Objective way to support embryo transfer: a probabilistic decision.

STUDY QUESTION: Is it feasible to identify factors that significantly affect the clinical outcome of IVF-ICSI cycles and use them to reliably design a predictor of implantation? SUMMARY ANSWER: The Bayesian network (BN) identified top-history embryos, female age and the insemination technique as the most relevant factors for predicting the occurrence of pregnancy (AUC, area under curve, of 0.72). In addition, it could discriminate between no implantation and single or twin implantations in a prognostic model that can be used prospectively. WHAT IS KNOWN ALREADY: The key requirement for achieving a single live birth in an IVF-ICSI cycle is the capacity to estimate embryo viability in relation to maternal receptivity. Nevertheless, the lack of a strong predictor imposes several restrictions on this strategy. STUDY DESIGN, SIZE, DURATION: Medical histories, laboratory data and clinical outcomes of all fresh transfer cycles performed at the International Institute for Reproductive Medicine of Lugano, Switzerland, in the period 2006-2008 (n = 388 cycles), were retrospectively evaluated and analyzed. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients were unselected for age, sperm parameters or other infertility criteria. Before being admitted to treatment, uterine anomalies were excluded by diagnostic hysteroscopy. To evaluate the factors possibly related to embryo viability and maternal receptivity, the class variable was categorized as pregnancy versus no pregnancy and the features included: female age, number of previous cycles, insemination technique, sperm of proven fertility, the number of transferred top-history embryos, the number of transferred top-quality embryos, the number of follicles >14 mm and the level of estradiol on the day of HCG administration. To assess the classifier, the indicators of performance were computed by cross-validation. Two statistical models were used: the decision tree and the BN. MAIN RESULTS AND THE ROLE OF CHOICE: The decision tree identified the number of transferred top-history embryos, female age and the insemination technique as the features discriminating between pregnancy and no pregnancy. The model achieved an accuracy of 81.5% that was significantly higher in comparison with the trivial classifier, but the increase was so modest that the model was clinically useless for predictions of pregnancy. The BN could more reliably predict the occurrence of pregnancy with an AUC of 0.72, and confirmed the importance of top-history embryos, female age and insemination technique in determining implantation. In addition, it could discriminate between no implantation, single implantation and twin implantation with the AUC of 0.72, 0.64 and 0.83, respectively. LIMITATIONS, REASONS FOR CAUTION: The relatively small sample of the study did not permit the inclusion of more features that could also have a role in determining the clinical outcome. The design of this study was retrospective to identify the relevant features; a prospective study is now needed to verify the validity of the model. WIDER IMPLICATIONS OF THE FINDINGS: The resulting predictive model can discriminate with reasonable reliability between pregnancy and no pregnancy, and can also predict the occurrence of a single pregnancy or multiple pregnancy. This could represent an effective support for deciding how many embryos and which embryos to transfer for each couple. Due to its flexibility, the number of variables in the predictor can easily be increased to include other features that may affect implantation. STUDY FUNDING/COMPETING INTERESTS: This study was supported by a grant, CTI Medtech Project Number: 9707.1 PFLS-L, Swiss Confederation. No competing interests are declared.

[Male contraception]. / La contraccezione maschile.

The only safe method of male contraception is vasectomy, with high reversibility secured by microsurgery. Italy, however, suffers from a lack of regulations on this subject. Hormonal treatment (testosterone plus progestational hormones) is far from providing reliability and safety, while some perspectives, theoretical only for the time being, are offered by studies on functional infertility induced by either speeding up (ganglioplegic, sympathomimetic, parasympatholytic, oxytocin, endothelin, angiotensin) or inhibiting (sympatholytic) the sperm transport through the epididymis, or altering the epididymal environment (alpha-chloridin, chlorodeoxyglucose).

Semen cryopreservation from oncological patients: the Italian experience.

The aim of the study is to summarize official data on semen cryopreservation for oncological patients in Italy. The first private semen bank for oncological patients in Italy was founded by Colpi in 1983 in Milan. In 1987, the first public semen bank was established in "Macedonio Melloni" Hospital (Milan) by Ragni. Normal semen samples are usually present in only 40% of oncological patients. The rate of semen sample use for assisted reproduction techniques is similar to international data (5%). At present, semen cryopreservation is possible only in about 20 Italian centers.

[Management of infertility following treatment of testicular tumors]. / Gestione dell'infertilità conseguente a trattamento per tumore del testicolo.

Testis cancer mainly affects patients in a reproductive age. Since at the present time recovery can be achieved in 84% of cases within ten years, there has been an increasing demand for paternity by these patients. In most cases, the preventive cryopreservation of spermatozoa and their subsequent use for assisted reproductive techniques can solve the problems connected with secretory infertility (no always reversible) caused by chemotherapy or radiotherapeutic treatment. Cryopreservation also allows to avoid the surgical taking of germinal cells either from testes or from seminal ducts in cases of anajeculation due to retroperineal lymphoadenectomy (present in 23.5-80% of cases). Failing the preventive cryopreservation, the surgical or microsurgical extraction of testis spermatozoa can be performed with success rates equal to 50%. Their use for intracytoplasmic sperm injection (ICSI) procedures presently seems to provide some encouraging results both for fertilization and pregnancy rates.

Seminal tract washout: a new diagnostic tool in complicated cases of male infertility.

The diagnosis of azoospermia or severe oligospermia that is made using conventional techniques (testicular biopsy, epididymal exploration, and vasovesiculography) may in some cases remain a dilemma. In such circumstances, post-testicular causes of obstruction must be evaluated. Following the clinical experience acquired in a selected population of 150 severely infertile subjects, the total sperm count in the fluid obtained from the bladder after a seminal tract washout during vasovesiculography has proved to be a valid tool to diagnose the location of the (sub-)obstruction in the seminal tract in complicated cases. Some representative cases are presented. In particular, seminal tract washout (STW) helps to identify functional distal seminal tract emptying disturbances and epididymal incomplete obstruction.

Epididymal ultrasonographic findings in case of obstructive pathology.

Epididymal ultrasonography has proved effective in finding anatomic obstructive alterations affecting the epididymis. The authors investigated two groups: 1. Bilateral vas agenesia (20 epididymis)--(sensitivity of EUS--100%) 2. Normozoospermic noninfertile patients (before different surgical exploration)--(45 epididymis) EUS resulted "ideal" epididymis in 36 out of 45. EUS was "altered" in 9 cases. They call the attention for the impotence of EUS investigation in andrology.

Effectiveness mechanism of chlomipramine by neurophysiological tests in subjects with true premature ejaculation.

The effectiveness mechanism of the chlomipramine treatment was evaluated by sacral evoked response (SER) and dorsal nerve somatosensory cortical evoked potential (DN-SEP) testings in 15 patients with true premature ejaculation (TPE). We couldn't demonstrate any significant difference between the values of either latency times or amplitudes of the evoked responses determined just before and at the end of the treatment with chlomipramine in these patients. However, the sensory thresholds were 24.4 +/- 4.3 V in the pretreatment term and 30.2 +/- 7.3 V at the end of the treatment. This difference is statistically significant (P = 0.0031). Our results suggest that chlomipramine increases the sensory threshold for the stimuli in the genital area.