Sperm chromosome aneuploidy as related to male factor infertility and some ultrastructure defects.

Some men have elevated levels of sperm chromosome aneuploidy. In this study, we have evaluated and summarized sperm aneuploidy rates in male infertility patients and control groups. The mean aneuploidy rate for five chromosomes (X, Y, 13, 18, 21) was 1.2 +/- 0.1 for fertile controls, 1.4 +/- 0.1 for a general population control group, and 5.8 +/- 1.14 for the patients. When the patients were classified by the type of male factor infertility, the total aneuploidy rate was 2.6 +/- 0.3 in men with moderately diminished semen quality (n = 7), 4.0 +/- 0.3 patients with severe teratoasthenooligozoospermia, and 15.9 +/- 3.8 for men with rare ultrastructure defects such as round head only syndrome or severe tail agenesis. Some infertility patients have a severely elevated level of sperm chromosome aneuploidy, which may contribute to infertility or diminish the likelihood of a successful outcome from IVF/ICSI. The severity of sperm chromosome aneuploidy appears to be proportional to the severity of abnormal semen quality: in particular, abnormal morphology. The high rates of aneuploidy in patients with severe ultrastructure defects suggest that caution should be employed in counseling those patients prior to IVF/ICSI.

Sperm DNA fragmentation is increased in couples with unexplained recurrent pregnancy loss.

Previous studies have indicated that sperm quality may be related to unexplained recurrent pregnancy loss. This study evaluated the degree of sperm DNA fragmentation using the TUNEL assay on sperm from 24 couples with unexplained recurrent pregnancy loss (RPL) compared to sperm from 2 control groups: donors of known fertility and unscreened men from the general population. The percentage of sperm staining positive for DNA fragmentation was increased (p < .001) in the RPL group (38 +/- 4.2) compared to the donor (11.9 +/- 1.0) or general population (22 +/- 2.0) control groups. In the RPL group, no correlation was observed between semen quality parameters and the TUNEL data. These data indicate that some RPL patients have a significant increase of sperm DNA fragmentation, which may be causative of pregnancy loss in some patients.

Comparison of several one-step home urinary luteinizing hormone detection test kits to OvuQuick.

OBJECTIVE: To compare clinical accuracy and ease of use for several of the new rapid one-step home urinary LH detection kits compared with the preexisting OvuQuick brand LH detection kit (designated as the standard). DESIGN: Prospective cohort study. SETTING: University-based infertility clinic. PATIENT(S): All women undergoing intrauterine inseminations at the clinic, regardless of infertility diagnosis, were offered enrollment during a 28-month study period. INTERVENTION(S): Each participant was supplied three one-step test kits (OvuQuick One-Step, ClearPlan Easy, and SureStep) in addition to a multistep OvuQuick test kit and instructed to run the tests in parallel on the same urine sample and to record the results. Urine testing was performed every 12 hours, beginning 3 days before the anticipated onset of an LH surge, and continued with the one-step kits every 12 hours for 48 hours after the surge was first detected by OvuQuick. Subjects also completed questionnaires evaluating the use of each test kit. MAIN OUTCOME MEASURE(S): Correlation of LH surge detection by one-step kits in comparison to surge detection by OvuQuick. Satisfaction and ease of use questionnaires. RESULT(S): Sixty-three volunteers returned useable data, from which 81 evaluable cycles were analyzed. The majority of patients found the newer one-step kits to be easier to use and less time consuming than OvuQuick. The three one-step kits detected the LH surge within +/- one testing period (+/-12 hours) of detection by OvuQuick 68%-84% of the time. OvuQuick One-Step, with modified instructions allowing for an equal color intensity in the test and reference areas, had the highest correlation with OvuQuick (84%). However, with a study power (alpha = 0.05, beta = 0.10) sufficient to detect a 10% difference between Ovuquick and each one-step kit, all one-step kits were statistically equivalent to each other. There was no cycle in which a one-step kit detected a positive LH surge but OvuQuick did not. CONCLUSION(S): One-step urinary LH kits are easier for patients to use than a multistep home urinary LH kit and have reasonable correlation with the multistep kit when used clinically for timing artificial inseminations.

A simplified coculture system using homologous, attached cumulus tissue results in improved human embryo morphology and pregnancy rates during in vitro fertilization.

PURPOSE: This study was undertaken to evaluate simplified methods of human embryo coculture using either attached or nonattached autologous cumulus tissue. METHODS: Eight hundred one zygotes were cultured for 48 hr in a prospective, randomized trial comparing culture of embryos either with intact cumulus tissue, with cumulus tissue added to the droplet of culture medium, or without any cumulus tissue. In a follow-up study, embryo quality, pregnancy rates, and implantation rates were compared in 120 consecutive patients undergoing in vitro fertilization with a coculture system using cumulus tissue compared to a cohort of 127 patients undergoing IVF immediately preceding the institution of the coculture protocol. RESULTS: Embryo morphology was significantly improved (P < 0.05) following culture with attached cumulus tissue (5.61 +/- 0.29) and culture with added cumulus tissue (4.72 +/- 0.31) compared to that of embryos grown in culture medium without cumulus tissue (3.95 +/- 0.26). The clinical pregnancy rate improved from 39.4% (50/127) to 49.2% (59/120) following institution of a system of coculture with attached cumulus tissue. CONCLUSIONS: These data indicate that a simple coculture system using autologous cumulus tissue can result in improved embryo morphology, implantation rates, and clinical pregnancy rates during in vitro fertilization. This coculture system is simple, is non-labor intensive, and eliminates many of the risks which may be present in other embryo coculture systems.

Antiphospholipid antibodies and infertility: fact or fallacy.

Some clinicians are convinced that antiphospholipid antibodies, including antibodies to any one of five-to-seven phospholipid antigens, are associated with infertility. Additionally, some clinicians recommend that infertile women who have antiphospholipid antibodies and are undergoing in-vitro fertilization should be treated with heparin to improve the rate of pregnancy. However, experts disagree regarding the relationship between antiphospholipid antibodies and infertility. There is also substantial evidence that treatment with heparin does not alter the rate of pregnancy following in-vitro fertilization. Why the confusion? Probable culprits include variation in study design and the selection of infertile patients. Another important problem is that assays for antiphospholipid antibodies other than anticardiolipin are not standardized. Before the real relationship between antiphospholipid antibodies and infertility is discovered, assays for antiphospholipid antibodies other than anticardiolipin must be standardized and properly designed studies conducted. Randomized, controlled trials must be done to determine if heparin should be recommended as an adjunctive treatment for in-vitro fertilization in women with antiphospholipid antibodies.

A randomized, prospective analysis of five sperm preparation techniques before intrauterine insemination of husband sperm.

OBJECTIVE: To evaluate pregnancy rates (PRs) in women undergoing artificial insemination with sperm alternately prepared by one of five techniques: sperm washing, Percoll gradient centrifugation, swim-up, swim-down, or refrigeration/heparin treatment. DESIGN: Each treatment group alternated in a different order through the five sperm preparations. Pregnancy rates were compared for each sperm preparation. SETTING: Two infertility centers, one located in an academic institution and the other a regional hospital. PATIENT(S): Three hundred sixty-three women undergoing 898 artificial inseminations with husband semen with a progressive motile sperm count of >20 million sperm per mL were randomly placed in the five treatment groups. MAIN OUTCOME MEASURE(S): Pregnancy rates. RESULT(S): The overall ongoing PR per insemination was 9.7% (87/898), including 6.12% for natural cycles (n = 196), 12.8% for clomiphene citrate-stimulated cycles (n = 101), and 10.3% for gonadotropin-stimulated cycles (n = 601). The highest ongoing PRs for sperm preparations followed the swim-up technique (13.2%, 26/197) and the Percoll gradient centrifugation technique (12.7%, 26/204). CONCLUSION(S): These data suggest that the swim-up and Percoll gradient preparations result in higher PRs than the wash, swim-down, and refrigeration/heparin techniques.

Autoantibody screening for infertility: explaining the unexplained?

Several laboratories currently offer panels of serum autoantibody assays to screen women with unexplained infertility and those undergoing in vitro fertilization (IVF). Offering these tests implies that they have predictive value for the outcome of proposed infertility treatments such that the results of the testing would alter clinical management. Because screening for antiphospholipid antibodies adds expense to already costly procedures, it is an appropriate time to review the justification for the use of these panels.

Strategies for ovulation induction and oocyte retrieval in the lowland gorilla.

PURPOSE: Ovulation induction and oocyte retrieval were performed in a lowland gorilla in an attempt to propagate and potentially cryopreserve embryos from an infertile animal and to advance techniques to help preserve this endangered species. RESULTS: Following 34 days of leuprolide acetate suppression, human menopausal gonadotropins were administered for 14-days in a 32-year-old wild-born lowland gorilla. Ten oocytes were retrieved by transrectal ultrasound-guided aspiration. Other approaches to oocyte recovery were not feasible in this case. A serum estradiol concentration of 4700 pg/ml at the time of human chorionic gonadotropin administration did not induce ovarian hyperstimulation. Mature oocytes were recovered from follicles measuring 14 to 24 mm in diameter, with a corresponding average serum estradiol concentration of approximately 300 pg/ml for each mature follicle. Cryopreservation of a gorilla embryo was effected from cryopreserved gorilla spermatozoa. CONCLUSIONS: Parameters for monitoring ovulation induction in the gorilla appear to be similar to those for humans. The results indicate that the use of a gonadotropin releasing hormone agonist and higher doses of gonadotropins than previously used in gorillas appear to improve oocyte recovery.

Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia.

OBJECTIVE: This study was done to compare costs, operating and recovery times, safety, and patient acceptance between (a) minimally invasive laparoscopic tubal ligation under sedation and local anesthesia and (b) conventional laparoscopic operating-room-based tubal ligations under general anesthesia. METHODS: Fourteen women desiring sterilization were randomized between tubal ligation under sedation/local analgesia versus general anesthesia. Procedures were performed by supervised residents previously unfamiliar with the minimally invasive technique. Hospital charges were used as a surrogate for cost. Operating or procedure room times, surgical complications, and recovery times were recorded. Patient acceptance was assessed using satisfaction surveys administered in the recovery room and again 1 week postoperatively. RESULTS: The cost of minimally invasive tubal ligation was significantly lower than for the conventional technique ($1,615+/-$134 vs $2,820+/-$110, p < 0.001). Surgical times were not different between the two procedures: 40.4+/-15 min for the conventional technique versus 32.9+/-10 min for minimally invasive surgery. However, the total in-room time required in the operating room significantly exceeded that for the procedure room technique (84+/-10 min vs 60+/-2 min, p < 0.05). Likewise, recovery time for the general anesthesia technique was longer (48+/-6 min vs 14+/-7 min, p < 0.03). No complications were encountered with either surgical method. Patient satisfaction for pain, fatigue, and days of missed work was similar between the two groups. CONCLUSIONS: The use of minimally invasive surgery to perform tubal ligation is advantageous over conventional laparoscopic tubal ligation under general anesthesia with regard to cost and time utilization. The minimally invasive technique appears to be easy to learn, safe, and well tolerated.

Implantable levonorgestrel contraception: 4 years of experience with Norplant.

PIP: Thirty years ago, the International Committee for Contraceptive Research of the Population Council began sponsoring research into a long-acting implantable contraceptive device. Several progestins were considered for application in such a device, but levonorgestrel was ultimately chosen due to the nature of its pharmacodynamics, its high efficacy, and its low incidence of side effects. More than 60,000 women participated in worldwide clinical trials using levonorgestrel in implantable silastic rods, making Norplant the most thoroughly studied contraceptive agent prior to release upon the general market. US Food and Drug Administration approval was granted in December 1990, and since 1991, approximately one million US women have had the implants inserted and more than three million women worldwide have used Norplant. Norplant is marketed in the US by Wyeth-Ayerst Laboratories and the silastic component of the system is manufactured by Dow Corning. The author discusses Norplant's mechanism of action, pharmacokinetics, effectiveness, legal challenges, side effects, other specific concerns with Norplant, continuation rates, insertion, removal, removal techniques, patient selection and counseling, and the future, and notes that the device still faces challenges four years after its introduction.^ieng

A hook-traction technique for Norplant removal.

We describe a simple technique to facilitate the removal of difficult-to-remove Norplant implants. Through a standard skin incision for Norplant removal, the fibrous capsule surrounding the implant is secured using either a dermatologic skin hook or a 25-gauge hypodermic needle fashioned into a hook with a hemostat. Traction is applied to bring the fibrous sheath into the incision site, where the implant tip is dissected free using a scalpel. The precisely localized countertraction afforded by this technique provides increased accuracy and speed for the removal of difficult-to-extract implants. Tissue trauma is minimized and the need to extend the skin incision is reduced.

Metabolic parameter, bleeding, and weight changes in U.S. women using progestin only contraceptives.

Our objective was to determine the effect of progestin-only contraceptives on metabolic parameters, bleeding patterns, and weight changes during the first year of use. Seventy-one women (> 95% Caucasian), who were advised regarding contraception alternatives, self-selected levonorgestrel implants (n = 44), depo-medroxyprogesterone acetate (n = 22), or oral norethindrone (n = 5). One year later, 11 levonorgestrel implant and five depomedroxyprogesterone acetate patients were randomly selected to compare (pre- and post-progestin use) levels of cholesterol, triglycerides, low density lipoprotein (LDL), high density lipoprotein (HDL), very low density lipoprotein (VLDL), apolipoproteins A-1 and B-100, bilirubin, and sex hormone binding globulin. Monthly bleeding and spotting records were kept in each group. Body weights were also monitored in each group. No statistically significant differences in metabolic parameters were found between pre- and post-progestin use in the levonorgestrel implant and depo-medroxyprogesterone acetate groups. Continued bleeding patterns were more prominent in the levonorgestrel implant and oral norethindrone groups than in patients receiving depo-medroxyprogesterone acetate. No significant weight gain was detected in any group. No changes in metabolic parameters or weight were noted over the one year of use of levonorgestrel implants or depo-medroxyprogesterone acetate. Depo-medroxyprogesterone acetate had the highest incidence of amenorrhea.

PIP: During March 1991-April 1992, health workers recruited 71 women aged 16-43 (98% Caucasian) attending the University of Utah Obstetrics and Gynecology Clinic for a clinical study examining metabolic parameters, menstruation disorders, and changes in weight after 12 months of use of a progestin-only contraceptive. The progestin-only contraceptives (number of women using each) included Norplant contraceptive implants (44), Depo-Provera (22), and a mini-pill (norethindrone) (5). Metabolic parameters were total cholesterol, triglycerides, high density lipoprotein (HDL), low density lipoprotein (LDL), very low density lipoprotein (VLDL), sex hormone binding globulin, apolipoprotein A-1, apolipoprotein B-100, and total and direct bilirubin. The only groups investigated for metabolic parameters were Norplant users and Depo-Provera users. Metabolic parameters did not change significantly after progestin use. No group experienced significant weight gain. However, one woman gained more than 60 pounds in the Norplant group and one woman gained more than 40 pounds in the Depo-Provera group. Depo-Provera users had significantly fewer total days of blood loss than Norplant users during months 5-12 (p 0.02) and mini-pill users during months 6-10 (p 0.04). Mini-pill users and Norplant users had similar bleeding patterns, except during months 11-12, when Norplant users had more bleeding than mini-pill users (e.g., month 12, 9 vs. 0 days). The total days of blood loss was 8.7 for Norplant users, 3.5 for Depo-Provera users, and 10.2 for mini-pill users. Less than 10% of Norplant users and mini-pill users experienced amenorrhea, while amenorrhea increased after 120 days in Depo-Provera users (p 0.001). After 1 year, the Norplant and mini-pill groups had more excessive prolonged (10 days) bleeding than the Depo-Provera group (29% and 50%, respectively, vs. 11%).

Comparison of the ClearView uterine manipulator with the Cohen cannula in laparoscopy.

The ClearView Uterine Manipulator was compared with the Cohen acorn-tipped cannula for efficacy and safety in patients undergoing laparoscopy at the University of Utah Medical Center. Fifty consecutive patients were randomized by computer to have either the ClearView instrument or the Cohen cannula used as a uterine manipulator (25 patients each). The ClearView manipulator was statistically superior to the Cohen cannula for range of motion in the anterior and posterior sagittal plane (p <0.0001). The Cohen cannula was consistently inserted in less time (p <0.02). There was no statistically significant difference between the instruments in ease of uterine manipulation, ease of dye instillation, percentage of dye leakage from the cervix, overall ease of use, ease of device insertion, and ease of device removal. Two cervical perforations occurred during cervical dilatation in the ClearView manipulator group in patients with cervical stenosis requiring dilatation with metal dilators (os <2 mm). No patients in the Cohen cannula group had cervical stenosis. In that group two cervical lacerations occurred requiring suture ligation. The ClearView instrument provides a greater range of motion, does not require an assistant to maintain uterine position, and allows manipulation without a cervical tenaculum. Its insertion occasionally (36%) required tenaculum placement, uterine sounding, and cervical dilatation, increasing the time of insertion compared with placement of the Cohen cannula. In patients with cervical stenosis, use of a uterine sound and cervical dilatation increase the risk of perforation.

Recurrent pregnancy loss.

Recurrent pregnancy loss is a frustrating clinical dilemma for both patients and physicians because, in most cases, causes are nebulous and few treatments with proven benefit can be offered. Involved, expensive tests have frequently been proposed and their use has often filtered into clinical practice before their utility has been firmly demonstrated. Proposed causes of recurrent pregnancy loss include genetic and environmental etiologies, infectious agents, maternal congenital and acquired anatomic abnormalities, and immunologic and endocrinologic dysfunction. Appropriate management relies upon a realistic understanding of the often substantial limitations of currently available therapies.

Ovulation induction with gonadotropins and intrauterine insemination compared with in vitro fertilization and no therapy: a prospective, nonrandomized, cohort study and meta-analysis.

OBJECTIVES: To determine whether one to four cycles of ovulation induction with hMG and IUI or one cycle of IVF results in the highest pregnancy rate and is least expensive and whether published pregnancy rates for one to four cycles of hMG and IUI results in a higher pregnancy rate than rates for one cycle of IVF, zygote intrafallopian transfer (ZIFT), or GIFT. DESIGN: Prospective, nonrandomized, cohort study. Patients were excluded who were infertile for < 18 months, had a significant male factor, had greater than mild endometriosis, or had bilateral nonpatency of the fallopian tubes. Cohort groups included 47 hMG and IUI patients (99 cycles), 19 IVF patients (19 cycles), and 21 patients (210 cycles) receiving no treatment. A meta-analysis on accumulated hMG and IUI data using similar entry criteria was also performed. Theoretical calculations were performed and stable fecundity assumed to compare with national data on IVF, ZIFT, and GIFT. SETTING: Fertility Center, Division of Reproductive Endocrinology, University of Utah, Salt Lake City, Utah. RESULTS: A course of therapy with one to four cycles of hMG and IUI was just as effective as one cycle of IVF in achieving pregnancy. No significant difference in pregnancy rates was found between one IVF cycle and one to four cycles of hMG and IUI in our population. In vitro fertilization was more expensive than four cycles of hMG and IUI. Both IVF and hMG and IUI were more effective than no therapy. Published data also suggest that four cycles of hMG and IUI theoretically result in higher pregnancy rates than one cycle of IVF, ZIFT, or GIFT. CONCLUSION: Cost-benefit analysis comparing hMG and IUI, IVF, and no therapy in infertility patients may favor a course of four cycles of hMG and IUI as the first line of therapy. Using meta-analysis and theoretical assumptions, the pregnancy rate for one cycle of hMG and IUI is inferior to IVF, GIFT, or ZIFT; two cycles are comparable to IVF or ZIFT and inferior to GIFT; three cycles are superior to IVF or ZIFT and comparable to GIFT; and four cycles are theoretically superior to all techniques.

The response of the growth hormone and insulin-like growth factor I axis to medical castration in women with polycystic ovarian syndrome.

OBJECTIVE: To assess the impact of ovarian hormone deprivation on serum concentrations of GH and insulin-like growth factor I (IGF-I) in women with polycystic ovarian syndrome (PCOS). DESIGN: Growth hormone and IGF-I levels were measured before, during, and at the end of a 6-month period of treatment with leuprolide acetate (LA) depot. Normal cycling and ovariectomized women served as controls. SETTING: The Clinical Research Center of Northwestern University Medical School. PATIENTS: Six women with PCOS, seven normal cycling women, and six ovariectomized women. INTERVENTIONS: The PCOS and normal cycling subjects were treated with six consecutive monthly injections of LA depot 3.75 mg IM. MAIN OUTCOME MEASURES: Circulating concentrations of GH and IGF-I. RESULTS: After 3 months of treatment, GH levels decreased modestly in the PCOS group; however, these changes were not significant. No further decline was observed at 6 months. Growth hormone levels were unaffected in the normal cycling group. Levels of IGF-I remained unchanged in both groups. Mean baseline levels of both GH and IGF-I in the ovariectomized group were lower than those of the normal cycling and PCOS groups at all time points, but not significantly so. CONCLUSIONS: Medical castration fails to significantly alter serum GH and IGF-I levels in either normal cycling or women with PCOS. These data indicate that GH secretion is not modulated by hormones of ovarian origin in either group, at least over the period of time studied.

Tumor necrosis factor-alpha inhibits ovulation and steroidogenesis, but not prostaglandin production in the perfused rat ovary.

OBJECTIVE: We tested the null hypothesis that tumor necrosis factor-alpha (TNF-alpha) does not decrease ovulation, estradiol and progesterone production, or prostaglandin (PG) E2, PGF2alpha, or 6 keto-PGF1alpha production in the open bursa rat ovarian perfusion model. METHODS: Experimental animals were controlled for age, weight, litter, and pregnant mare's serum gonadotropin (PMSG) aliquot. Female Sprague-Dawley rats, 26-27 days old, were injected with 25 IU PMSG. Forty-eight hours later, the right ovary was dissected, the bursa removed, and the specimen placed in the perfusion chamber with defined media. Luteinizing hormone and isobutylmethylxanthine were given as an ovulatory trigger. Test perfusions also received TNF-alpha in 0.8-nmol/L, -pmol/L, and -fmol/L doses. Samples were collected at 0, 1, 3, 5, 7, 10, and 20 hours. Ovulations were counted at 20 hours. Steroids and PGs were measured. RESULTS: The addition of TNF-alpha to the rat ovarian perfusion model resulted in a dose-dependent decrease in ovulations (mean +/- standard deviation): 16.14 +/- 6.2 in controls (n = 7) versus 2.38 +/- 3.4 with TNF-alpha 0.8 nmol/L (n = 7), and 4.3 +/- 1.5 with TNF-alpha 0.8 pmol/L (n = 3), both P < .001. Tumor necrosis factor-alpha also inhibited estradiol (P < .005) and progesterone production (P < .05) throughout, but produced no significant changes in PG production. CONCLUSIONS: Tumor necrosis factor-alpha inhibits ovulation in a dose-dependent fashion, and inhibits estradiol and progesterone production without altering PG production in the open bursa rat ovarian perfusion model.

GnRH agonist therapy in human ovarian epithelial carcinoma (OVCAR-3) heterotransplanted in the nude mouse is characterized by latency and transience.

We have previously documented the responsiveness of a cell line of human ovarian epithelial carcinoma (Bowman Gray 1) heterotransplanted in nude mice to treatment with the GnRH agonist Lupron-SR. In this study we used another human ovarian epithelial carcinoma cell line, OVCAR-3, and the human endometrial carcinoma cell line HEC-1A. After a latent period, OVCAR-3 tumors showed significant inhibition of growth on Days 17, 21, and 24 (P < 0.03) compared to controls. The effect was transient and did not persist beyond Day 24. HEC-1A tumors showed no inhibition of growth. Radioreceptor assay studies utilizing native radiolabeled GnRH and [D-Lys6]-GnRH revealed no specific GnRH receptors in any of the tumor samples (BG-1, OVCAR-3, HEC-1A, University of Nebraska cell line, and two fresh human ovarian epithelial tumor samples) compared to male rat anterior pituitary cells. Binding studies and the latency and transience of effect would suggest that the mechanism of action in this animal model may be indirect. This activity may be via altered circulating steroids, gonadotropins, cell-cycle regulatory events, or some other as-yet-undefined action related to GnRH agonist administration or indirectly via effects of the metabolic products of degraded GnRH agonist such as D-amino acids, which are incorporated into the cells by constitutive or adsorptive pinocytosis. This study confirms latency and transience of effect of GnRH agonist therapy on an in vivo model of ovarian cancer.