Noninvasive Preimplantation Genetic Testing for Aneuploidy (niPGT-A): The first Brazilian baby.

Recently, a new technology known as the Noninvasive Preimplantation Genetic Testing for Aneuploidy (niPGT-A) emerged, using cell-free DNA present in the spent culture media of human blastocysts. Unlike PGT-A, in which only trophectoderm cells are used, niPGT-A reflects the ploidy state of these cells and internal cell mass, suggesting that this new technology may be less prone to error, being more reliable than the invasive test. The aim of the present study was to report the first occurrence of childbirth following niPGT-A in Brazil.

Association between estrogen receptor 1 (ESR1) and leukemia inhibitory factor (LIF) polymorphisms can help in the prediction of recurrent implantation failure.

OBJECTIVE: To investigate an association between polymorphisms related to the implantation process that together could help in the prediction of recurrent implantation failure (RIF). DESIGN: Cohort study. SETTING: Private fertility center and reproductive genetics laboratory. PATIENT(S): Forty-four women presenting RIF, who were included in study group (RIF group), and two control groups, one with 63 women who were attended at our service and became pregnant after the first IVF/intracytoplasmic sperm injection attempt (control group I) and other with 65 fertile women who had at least two children without any treatment and no history of miscarriage (control group II). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Genotyping was performed in the intron region of TP63, VEGFA, MMP2, ESR1, and ESR2 genes and in the 3' untranslated region of the LIF gene on genomic DNA using real-time polymerase chain reaction. RESULT(S): The presence of ESR1/AA (rs12199722) and LIF/GT (rs929271) genotypes was more frequent in the RIF group, leading to a 7.9-fold increase in the chance of women presenting with RIF when compared with women who became pregnant on their first cycle of IVF/intracytoplasmic sperm injection and a 2.8-fold increase when compared with women who became pregnant without treatment. CONCLUSION(S): The association between ESR1 and LIF polymorphisms can help in the prediction of RIF.

Cost-effectiveness comparison between pituitary down-regulation with a gonadotropin-releasing hormone agonist short regimen on alternate days and an antagonist protocol for assisted fertilization treatments.

OBJECTIVE: To compare cost-effectiveness between pituitary down-regulation with a GnRH agonist (GnRHa) short regimen on alternate days and GnRH antagonist (GnRHant) multidose protocol on in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcome. DESIGN: Prospective, randomized. SETTING: A private center. PATIENT(S): Patients were randomized into GnRHa (n = 48) and GnRHant (n = 48) groups. INTERVENTION(S): GnRHa stimulation protocol: administration of triptorelin on alternate days starting on the first day of the cycle, recombinant FSH (rFSH), and recombinant hCG (rhCG) microdose. GnRHant protocol: administration of a daily dose of rFSH, cetrorelix, and rhCG microdose. MAIN OUTCOME MEASURE(S): ICSI outcomes and treatment costs. RESULT(S): A significantly lower number of patients underwent embryo transfer in the GnRHa group. Clinical pregnancy rate was significantly lower and miscarriage rate was significantly higher in the GnRHa group. It was observed a significant lower cost per cycle in the GnRHa group compared with the GnRHant group ($5,327.80 ± 387.30 vs. $5,900.40 ± 472.50). However, mean cost per pregnancy in the GnRHa was higher than in the GnRHant group ($19,671.80 ± 1,430.00 vs. $11,328.70 ± 907.20). CONCLUSION(S): Although the short controlled ovarian stimulation protocol with GnRHa on alternate days, rFSH, and rhCG microdose may lower the cost of an individual IVF cycle, it requires more cycles to achieve pregnancy. CLINICAL TRIAL REGISTRATION NUMBER: NCT01468441.

[Contribution of hyperandrogenism to the development of metabolic syndrome in obese women with polycystic ovary syndrome]. / Contribuição do hiperandrogenismo para o desenvolvimento de síndrome metabólica em mulheres obesas com síndrome dos ovários policísticos.

PURPOSE: To assess the contribution of hyperandrogenism to the development of metabolic syndrome (MetS) in obese women with polycystic ovary syndrome (PCOS). METHODS: Retrospective cross-sectional study conducted on 60 obese women with classic PCOS phenotype - Rotterdam Consensus - and 70 non-PCOS obese women. MetS was diagnosed by the NCEP-ATP III criteria and obesity was defined by body mass index. The Ferriman-Gallwey score (mFG) was used to evaluate hirsutism. The following measurements were performed: total testosterone, dehydroepiandrosterone sulfate (DHEA-S), glucose and insulin, total cholesterol, HDL, and triglycerides. Insulin resistance was measured using the HOMA-IR and insulin sensitivity index of Matsuda and De Fronzo (ISI). Statistical analysis was performed using the Student's t-test, χ² test and multivariate logistic regression analysis (p<0.05). RESULTS: Obese women with PCOS had significantly higher mFG (15.4 ± 6.1), waist circunference (105.6 ± 11.4 cm), DHEA-S (200.8 ± 109.2 µg/dL), testosterone (135.8 ± 71.4 ng/dL), and HOMA-IR (8.4 ± 8.5) values and lower ISI values (2.0 ± 1.8) than non-obese PCOS women (3.2 ± 2.1; 101.4 ± 9.2 cm; 155.0 ± 92.7 µg/dL; 50.0 ± 18.2 ng/dL; 5.1 ± 4.7 and 3.3 ± 2.7, respectively) (p<0.05). The frequency of MetS was higher in PCOS obese (75%) than non-PCOS obese (52.8%) women (p=0.015). Multivariate analysis did not reveal the contribution of the variables IFG, testosterone, and DHEAS to the development of MetS (p>0.05). CONCLUSION: Obese women with PCOS have a higher frequency of metabolic syndrome than non-PCOS obese women, and hyperandrogenism does not contribute to the development of metabolic syndrome in this group of women.

Establishment of a Brazilian line of human embryonic stem cells in defined medium: implications for cell therapy in an ethnically diverse population.

Pluripotent human embryonic stem (hES) cells are an important experimental tool for basic and applied research, and a potential source of different tissues for transplantation. However, one important challenge for the clinical use of these cells is the issue of immunocompatibility, which may be dealt with by the establishment of hES cell banks to attend different populations. Here we describe the derivation and characterization of a line of hES cells from the Brazilian population, named BR-1, in commercial defined medium. In contrast to the other hES cell lines established in defined medium, BR-1 maintained a stable normal karyotype as determined by genomic array analysis after 6 months in continuous culture (passage 29). To our knowledge, this is the first reported line of hES cells derived in South America. We have determined its genomic ancestry and compared the HLA-profile of BR-1 and another 22 hES cell lines established elsewhere with those of the Brazilian population, finding they would match only 0.011% of those individuals. Our results highlight the challenges involved in hES cell banking for populations with a high degree of ethnic admixture.

Correlation between semen analysis by motile sperm organelle morphology examination and sperm DNA damage.

Regression analysis of 538 semen samples demonstrated that percentages of normal nuclear sperm and all spermatozoa with abnormalities of nuclear form at high magnification had significant negative correlation with percentages of DNA fragmentation. On the other hand, there was a positive correlation between percentages of spermatozoa with nuclear vacuoles and those with DNA fragmentation.

Artificial oocyte activation using calcium ionophore in ICSI cycles with spermatozoa from different sources.

The present study evaluated the effect of artificial oocyte activation (AOA) with calcium ionophore A23187 on intracytoplasmic sperm injection (ICSI) cycles using spermatozoa from different sources. The 314 cycles evaluated were divided into three groups according to sperm origin; the ejaculated group (n = 92), the epididymal group (n = 82), and the testicular group (n = 140). Each group was further split into experimental subgroups, depending on whether or not AOA was performed. In addition, the cycles of women younger than 36 years were evaluated separately. For each experimental group, ICSI outcomes were compared between subgroups. No significant difference was observed between subgroups for all sperm origin groups. When evaluating only the cycles of women younger than 36 years of age, AOA increased the percentage of high-quality embryos (74.5 versus 53.0%, P = 0.011) and the implantation rate (19.3 versus 10.5%, P = 0.0025) when it was used with ejaculated spermatozoa, and the percentage of high-quality embryos (64.4 versus 50.3%, P = 0.006) when epididymal spermatozoa were used. These results may suggest that both sperm maturity and oocyte quality play a role in oocyte activation. However, this study is to be continued to confirm these findings.

Artificial oocyte activation with calcium ionophore A23187 in intracytoplasmic sperm injection cycles using surgically retrieved spermatozoa.

OBJECTIVE: To evaluate the effect of artificial oocyte activation (AOA) on intracytoplasmic sperm injection (ICSI) cycles using surgically retrieved sperm. DESIGN: Laboratory study. SETTING: Fertility/assisted fertilization center. PATIENT(S): Couples undergoing surgical sperm retrieval for ICSI (n = 204). INTERVENTION(S): Application of calcium ionophore A23187 for AOA. MAIN OUTCOME MEASURE(S): Cycles were divided into experimental groups according to the origin of the sperm used for injection and the type of azoospermia: [1] testicular sperm aspiration in nonobstructive-azoospermic patients (TESA-NOA group, n = 58), [2] TESA in obstructive-azoospermic patients (TESA-OA group, n = 48), [3] and percutaneous epididymal sperm aspiration in obstructive-azoospermic patients (PESA-OA, n = 98). For each experimental group, cycles where AOA was applied (subgroup: activation) were compared with cycles in which AOA was not applied (subgroup: control). The fertilization, high-quality embryo, implantation, and pregnancy rates were compared among the subgroups. RESULT(S): For patients undergoing TESA, AOA did not improve ICSI outcomes for either type of azoospermia. However, for cases in which the injected sperm were retrieved from the epididymis, a statistically significantly increased rate of high-quality embryos was observed with AOA. CONCLUSION(S): Artificial oocyte activation may improve ICSI outcomes in azoospermic patients when epididymal, but not testicular spermatozoa, are injected.

Laser-assisted hatching of cryopreserved-thawed embryos by thinning one quarter of the zona.

Laser-assisted hatching is little documented in the literature regarding its efficacy in cryopreserved-thawed (CT) embryo transfer cycles. The aim of the present study was to evaluate in a randomized manner the efficacy of thinning one quarter of the zona pellucida of CT embryos to a depth of 50-80% of the original thickness, via laser treatment (the qLZT-AH procedure), in improving implantation and pregnancy rates. Two populations were studied: population I, patients who had all their supernumerary embryos cryopreserved, regardless of their morphology, and population II, patients at risk of ovarian hyperstimulation syndrome who had all their embryos cryopreserved. Artificial and natural protocols were used for the embryo transfers. A total of 350 laser-thinned CT embryos were compared with 352 intact zona embryos. No difference in implantation or pregnancy rate was found after using qLZT-AH in either population. These findings suggest that qLZT-AH should not be routinely performed in cryopreserved embryo programmes.

Effects of vaginal progesterone administration starting on the day of oocyte retrieval on pregnancy rates.

PURPOSE: Vaginal progesterone administration starting on the day of oocyte retrieval induced a decrease in uterine contraction frequency on the day of embryo transfer (ET) as compared with preovulatory values. Uterine relaxation before ET is likely to improve outcome by avoiding displacement of the embryo from the uterine cavity (Fanchin, Righini, de Ziegler, Oliviennes, Ledée, Frydman: Fertil Steril 2001;75:1136-1140). The objective of the present study was to determine whether the early use of vaginal progesterone on the day of oocyte retrieval may alter the embryo implantation and pregnancy rates. METHODS: A total of 103 patients were submitted for ovarian stimulation with GnRH-a and recombinant FSH (Puregon, Organon) for the application of invasive assisted reproduction techniques (ICSI). The patients were divided into two groups in a prospective and randomized manner: Group A (n = 51) where application of vaginal progesterone started (Utrogestan, Besins International) at the dose of 400 mg from the evening of the day of oocyte retrieval, and Group B (n = 52) started to apply vaginal progesterone at the same dose but from the evening of embryo transfer (2nd day). RESULTS: The age of Group A patients (34.2 +/- 4.6) was similar (p = 0.50) to that of Group B patients (34.8 +/- 4.9). The number of oocytes retrieved and at metaphase II from Group A patients (10.6 +/- 6.9 and 7.8 +/- 6.0; respectively) did not differ significantly (p = 0.84 and p = 0.49, respectively) from the number of oocytes retrieved and metaphase II from Group B patients (10 +/- 5.6 and 6.7 +/- 4.7, respectively). Also, there was no difference (p = 0.48) in number of embryos transferred to Group A patients (2.7 +/- 0.8) versus Group B patients (2.7 +/- 0.9). Embryo implantation and pregnancy rates for Group A patients (12.6 and 27.4%, respectively) were equal (p = 0.98 and p = 1.0, respectively) to those for Group B patients (13.4 and 28.8%, respectively). CONCLUSION: Vaginal progesterone at the dose of 400 mg started on the day of oocyte retrieval did not increase implantation or pregnancy rates when compared to the same dose started on the day of embryo transfer.

Psychological evaluation test for infertile couples.

PURPOSE: The infertility can lead to various emotional changes (anxiety, depression, somatization, aggressiveness, etc.). The objective of the present study was to develop a psychological evaluation test (PET) in an attempt to identify couples requiring psychological support when they face the problem of infertility. MATERIAL AND METHODS: A total of 251 infertile couples were submitted to the PET of the Center for Human Reproduction, "Sinhá Junqueira" Maternity Foundation. The causes of infertility were male-related in 45% of cases, female-related in 48%, and both male- and female-related in 7%. Infertility was primary in 74% of cases and secondary in 26%. The mean age of the women was 34 +/- 4.2 years and the mean age of the men was 36.8 +/- 6.5 years. The PET of the infertile couples was evaluated using a questionnaire with 15 questions selected in order to detect emotional reactions. The responses were assigned four grades with respect to frequency (1 = never or rarely; 2 = sometimes; 3 = many times, and 4 = always). The sum of the responses corresponded to a PET score ranging from 15 to 60 points. A PET score of >30 points was defined as cut-off point for necessity of specialized psychological evaluation. Data were analyzed statistically by the Student's t test and the Mann-Whitney and Fisher tests, with the level of significance set at 5%. The reliability of the questionnaires was determined on the basis of the alpha coefficient of Cronbach. RESULTS: The mean PET score for women (27 +/- 8) was significantly higher (p < 0.01, Mann-Whitney test) than the PET score for men (22 +/- 7). The alpha coefficient of Cronbach was 0.88, and was identical for the female and male questionnaires. CONCLUSIONS: The data demonstrate that one of the characteristics of Brazilian infertile couples is that women are habitually more affected by the situation of infertility than men. The PET is a simple and efficient tool for the identification of women and/or men requiring psychological support due to infertility. The team of the Center for Human Reproduction (employees, biologists, nurses, doctors etc.) has started to use the information provided by the PET in the daily routine, and all patients are informed and counseled about the factors generating emotional changes in infertility. Advice is provided (practicing sports, traveling, activating personal projects etc.) in order to help combat distress. A specialized psychological evaluation was indicated in selected cases (PET score >30 points).

Psychological evaluation test after the use of assisted reproduction techniques.

PURPOSE: The emotional changes provoked by the use of assisted reproduction techniques (ART) may trigger important psychological reactions. The objective of the present study was to develop a psychological evaluation test (PET-ART) in order to identify the occurrence of psychological problems and to facilitate their treatment. METHODS: A total of 128 women were submitted to PET-ART of the Center for Human Reproduction, "Sinhá Junqueira" Maternity Foundation, after application of IVF/ICSI program at least once. The causes of infertility were male-related in 45% of cases, female-related in 48%, and both male- and female-related in 7%. Infertility was primary in 79% of cases and secondary in 21%. The mean age of the women was 34.5 +/- 5.2 years and the mean age of the men was 37.9 +/- 6.8 years. The PET-ART was evaluated using a questionnaire with 15 questions selected in order to detect emotional reactions caused by infertility. The responses were assigned four grades with respect to intensity (1 = mild intensity; 2 = medium intensity; 3 = high intensity; and 4 = maximum or unbearable intensity). The sum of the responses corresponded to PET-ART score ranging from 15 to 60 points. The reliability of the questionnaire was evaluated by the alpha coefficient of Cronbach. RESULTS: The PET-ART identified five questions receiving 50% or more responses of the high/maximum intensity type (sum of the percentages of responses with a score of 3 and 4). The questions were the following: 1--The waiting time before being submitted to a pregnancy test (82.8% of the patients); 2--A negative result of the pregnancy test (77.3% of the patients); 3--The degree of anxiety in a new attempt to obtain pregnancy (76.5% of the patients); 4--Finding the money necessary for the repetition of the IVF/ICSI techniques (66.4% of the patients); 5--The possibility of collecting few eggs, or of forming or not an embryo in the laboratory is an expectation that makes me anxious (57.8% of the patients). The mean PET-ART was 33 +/- 6. The alpha coefficient of Cronbach was 0.757. CONCLUSIONS: The PET-ART was an efficient tool for the identification of women with emotional changes provoked by the application of ART and for the planning of their treatment. However, a general psychological approach was developed for each emotional factor regardless of PET-ART.

A uterine ultrasonographic scoring system as a method for the prognosis of embryo implantation.

PURPOSE: The objective of the present study was to evaluate an ultrasonographic uterine scoring system as a method for the prognosis of embryo implantation in patients submitted to ICSI. METHODS: A total of 562 patients submitted to an ICSI program were prospectively evaluated on the day of hCG administration in terms of the following ultrasonographic uterine parameters: A. Endometrial thickness (< 7.0 mm = 0; 7 a 14 mm = 3; > 14 mm = ); B. Endometrial layering (three lines = 2; absence of three lines = 0); C. Myometrial contractions in 2 min (< 3 = 0; > or = 3 = 3); D. Uterine artery Doppler flow (> 3 = 0; 2.2 a 3 = 22; > or = 2 .19 = 3); E. Endometrial power Doppler (The endometrium was divided into four equal quadrants and classified as grade I = 1; II = 2; III = 3; IV = 4, according to the visualization of the power Doppler in the quadrants). The colour Doppler signal was considered to be positive when it reached at least the basal layer of the endometrium; F. Myometrial power Doppler (absent = 0 weakly present 2; strongly present = 3); G. Myometrial echogenicity (homogeneous = 2; inhomogeneous = 0). The patients were divided into 4 groups according to total score: Group I, score < 10: Group II, score 10-14, Group III, score 15-17 and Group IV, score 18-20. RESULTS: The uterine parameters using an ultrasonographic scoring system are inversely correlated with patient age (p < 0.0001). The number of days of stimulation with FSH did not differ (p = 0.10) between groups. The number of follicles measuring >16 mm was different (p = 0.01) between groups. The number of metaphase II oocytes also did not differ significantly between groups (p = 0.45). The fertilization rate was also similar (p = 0.10) for all groups. The number of transferred embryos was different between groups (p = 0.02). The rate of embryo implantation did not differ (p = 0.60) between groups. Finally, the pregnancy rates did not differ significantly (p = 0.93) between groups. CONCLUSIONS: The ultrasonographic evaluation of uterine parameters on the day of hCG administration using a scoring system is inversely correlated with patient age. In the present study, the use of this ultrasonographic score method could not identify a population with greater uterine receptivity.