Uroplakins play conserved roles in egg fertilization and acquired additional urothelial functions during mammalian divergence.

Uroplakin (UP) tetraspanins and their associated proteins are major mammalian urothelial differentiation products that form unique two-dimensional crystals of 16-nm particles ("urothelial plaques") covering the apical urothelial surface. Although uroplakins are highly expressed only in mammalian urothelium and are often referred to as being urothelium specific, they are also expressed in several mouse nonurothelial cell types in stomach, kidney, prostate, epididymis, testis/sperms, and ovary/oocytes. In oocytes, uroplakins colocalize with CD9 on cell-surface and multivesicular body-derived exosomes, and the cytoplasmic tail of UPIIIa undergoes a conserved fertilization-dependent, Fyn-mediated tyrosine phosphorylation that also occurs in Xenopus laevis eggs. Uroplakin knockout and antibody blocking reduce mouse eggs' fertilization rate in in vitro fertilization assays, and UPII/IIIa double-knockout mice have a smaller litter size. Phylogenetic analyses showed that uroplakin sequences underwent significant mammal-specific changes. These results suggest that, by mediating signal transduction and modulating membrane stability that do not require two-dimensional-crystal formation, uroplakins can perform conserved and more ancestral fertilization functions in mouse and frog eggs. Uroplakins acquired the ability to form two-dimensional-crystalline plaques during mammalian divergence, enabling them to perform additional functions, including umbrella cell enlargement and the formation of permeability and mechanical barriers, to protect/modify the apical surface of the modern-day mammalian urothelium.

What makes them split? Identifying risk factors that lead to monozygotic twins after in vitro fertilization.

OBJECTIVE: To identify the incidence, risk factors, and obstetric/perinatal outcomes associated with monozygotic twins (MZTs) after IVF. DESIGN: Nested case-control. SETTING: University-based center. PATIENT(S): The IVF cycles eventuating in pregnancy from 2000-2009. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The MZT incidence, chorionicity/zygosity, pregnancy/neonatal outcome. RESULT(S): Of 6,223 gestations, 131 MZTs were diagnosed (2.1% incidence; 2.0% in autologous and 2.7% in donor IVF cycles), 10 were dichorionic, and 121 were monochorionic. Controlling for all risk factors, young oocyte age, extended culture (noncleavage embryos transferred on/after day 4), and year of IVF treatment cycle were significantly associated with MZT. When assessing factors associated with specific MZT placentation, day 3 assisted hatching correlated more with dichorionic MZT, whereas extended culture and advanced day 5 embryonic stage correlated with monochorionic MZT. Comparing monozygotic to dizygotic multigestation outcomes, MZT fared worse; however, once controlling for triplet gestation, only gestational age at delivery remained significantly compromised in the monozygotic group. CONCLUSION(S): After IVF the incidence of MZT is high, with young oocyte age, year of treatment, and extended culture (or embryo stage at transfer) conferring greatest risk. Regarding MZT type, assisted reproductive technology (ART) procedures may influence the timing of embryonic splitting (i.e., division in early embryonic development may be influenced by zona pellucida [ZP] manipulation whereas later splitting may occur during delayed implantation). Poor obstetric/perinatal outcome is significantly impacted by the presence of an "extra" fetus, as high-order multiple gestation concurrent with an MZT conveyed the worst prognosis.

WITHDRAWN: What makes them split? Identifying risk factors that lead to monozygotic twins after in vitro fertilization.

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Treatment outcomes and quality-of-life assessment in a university-based fertility preservation program: results of a registry of female cancer patients at 2 years.

PURPOSE: To explore patient goals and quality of life (QOL) via a prospective registry and compare fertility preservation (FP) outcomes before, during, and after cancer therapy. METHODS: Of 35 patients entering the registry from 3/2008 to 3/2010, 29/35 completed the study survey and agreed to follow-up, and 31/35 completed treatment. Survey results and FP outcomes were analyzed. RESULTS: Most patients rated the impact of cancer treatment on fertility of highest importance at baseline and 1-year follow-up. QOL scores were overall positive at both intervals. Patients naïve to any cancer treatment (n = 12) had more gametes frozen than patients with prior cancer treatment (n = 19) with no difference in age or gonadotropin dosage. For patients awaiting cancer treatment, the median time from consultation to oocyte retrieval was 25 days. Cancer treatment sequalae posed challenges to optimal FP outcomes. CONCLUSIONS: Fertility preservation remains a significant issue for cancer patients. With early reproductive endocrinologist referral, cancer treatment delay is minimized and FP outcomes are optimized.

Effect of autoimmune thyroid disease in older euthyroid infertile woman during the first 35 days of an IVF cycle.

In this case-control study of euthyroid first-cycle IVF patients ≥ 38 years old with singleton baby, miscarriage, biochemical pregnancy, and no pregnancy outcomes from 2005-2008, we assayed frozen serum for autoimmune thyroid disease (AITD) and thyroid function at cycle start, trigger, and 4 and 5 weeks' gestation. AITD prevalence in older infertile women was similar across clinical outcomes, and although AITD was associated with a higher baseline TSH, TSH remained within acceptable ranges, suggesting that T(4) supplementation may not affect maternal outcomes in older euthyroid AITD patients through 5 weeks gestation.

Evaluating the necessity for universal screening of prospective oocyte donors using enhanced genetic and psychological testing.

BACKGROUND: To minimize the potential for harmful inheritable conditions, donors are rigorously screened according to standard guidelines, yet such guidelines may not be sufficient to exclude egg donors with certain known inheritable conditions. We compared universal screening of oocyte donors with Tay-Sachs, Fragile X, karyotype and Minnesota Multiphasic Personality Inventory-2 (MMPI-2) versus standard American Society of Reproductive Medicine (ASRM) guidelines that do not include such testing. METHODS: In this 12 year retrospective cohort study, results of enhanced universal screening of all anonymous oocyte donor candidates from 1997 to 2008 at a university hospital oocyte donation program were reviewed. Primary outcomes were the frequency of oocyte donor candidates excluded as a result of enhanced universal screening (Tay-Sachs, Fragile X, karyotypic analysis and MMPI-2) versus basic screening according to ASRM guidelines. RESULTS: Of 1303 candidates who underwent on-site evaluation, 47% passed the screening process, 23% were lost to follow-up and 31% were excluded. Genetic and psychological factors accounted for the most common reasons for candidate exclusion. Enhanced genetic screening excluded an additional 25 candidates (19% of all genetic exclusions) and enhanced psychological screening excluded an additional 15 candidates (12% of all psychological exclusions). Altogether enhanced screening accounted for 40 candidates (10%) of the total pool of excluded candidates. CONCLUSIONS: Although our study is limited by its retrospective nature and center-specific conclusions, we show that enhanced comprehensive screening can exclude a significant number of candidates from an oocyte donor program and should be encouraged to assure optimal short-term and long-term outcomes for pregnancies achieved through oocyte donation.

Monozygotic twinning: an eight-year experience at a large IVF center.

OBJECTIVE: To characterize incidence, chorionicity, amnionicity, and pregnancy outcome for monozygotic twin pregnancy (MZT) after IVF. DESIGN: Retrospective review. SETTING: University-based fertility center. PATIENT(S): Autologous and oocyte donation IVF cycles eventuating in 4,976 clinical gestations from 2000 to 2007. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): MZT incidence, chorionicity, zygosity, pregnancy outcome. RESULT(S): Ninety-eight MZTs were diagnosed after first-trimester ultrasound evaluation (2% incidence). The incidence in cycles transfering autologous oocytes was 1.7% but was 3.3% with donor oocytes; however, women <35 years old using their own oocytes displayed a similar rate (3.1%) to women using donor oocytes. Eighty MZTs occurred after fresh day-5 transfer; only 14 followed fresh day-3 transfer (2.6% vs. 1.2%). The MZT incidence in day-3 transfers without hatching was not different from those with hatching (1.3% vs. 1.1%). In addition, MZT incidence did not differ significantly whether or not ICSI was performed (2.4% vs. 2.0%). Four MZTs occurred after frozen-thawed embryo transfer (0.8% incidence). Ninety-five percent of all placental arrangements were confirmed as monochorionic-diamniotic on obstetric ultrasounds. CONCLUSION(S): These findings confirm a higher incidence of MZT after IVF. Monochorionic-diamniotic implantations were increased, whereas monochorionic-monoamniotic were not. The MZT risk factors included young age and extended culture, but not zona penetration or cryopreservation.

Comparison of pregnancy outcomes in elective single blastocyst transfer versus double blastocyst transfer stratified by age.

OBJECTIVE: To determine whether there is a difference in pregnancy outcomes, stratified by age, between women undergoing elective single blastocyst transfer (eSBT) versus those undergoing double blastocyst transfer (2BT). DESIGN: Retrospective analysis. SETTING: University IVF center. PATIENT(S): A total of 1,141 nondonor IVF cycles in women aged <40 years from January 2004-March 2007. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Eggs retrieved, embryos cryopreserved, implantation rates, clinical pregnancy rates (PR), live birth rates (LBR), spontaneous abortion rates (SAB). RESULT(S): Pregnancy outcomes in 52 cycles of women <40 years of age who underwent eSBT were compared with 1,086 cycles of women who underwent 2BT in fresh IVF cycles from January 2004-March 2007. Overall, the eSBT was associated with a statistically significant 92% reduction in the twinning rate (from 25%-2%) while maintaining a high clinical PR (63% in the eSBT group vs. 61% in the 2BT group). CONCLUSION(S): Women who are <40 years of age undergoing nondonor fresh IVF cycles can electively choose to transfer a single blastocyst for the purpose of significantly reducing their risk of multiples without compromising their PR.

Optimizing embryo selection with day 5 transfer.

OBJECTIVE: To compare rates of implantation, pregnancy, miscarriage, multiple gestation, and selective reduction between patients undergoing day 5 (d5) and day 3 (d3) ETs. DESIGN: Retrospective cohort study. SETTING: University-based IVF center. PATIENT(S): The first d5 ET cycle of patients 42 years of age from 2003 to 2006 was compared with a historical control of first cycle d3 ET patients 42 years of age from 1996 to 1999 who would have met current d5 ET criteria. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Rates of implantation, clinical pregnancy, miscarriage, live birth, high order multiple pregnancy (HOMP), and selective reduction. RESULT(S): D5 ET patients had higher implantation rates (39% vs. 30%), with no difference in the no-transfer rate. D5 ET patients had lower rates of HOMP (2.5% vs. 11%) and HOMP delivery (0.7% vs. 3.5%), multiple pregnancy (27% vs. 33%), multiple delivery (19% vs. 26%), and twin delivery (18% vs. 23%). There were fewer selective reductions of HOMP with d5 ET (1.7% vs. 3.8%). CONCLUSION(S): Extended culture improves embryo selection through increased implantation, facilitating fewer embryos per transfer, which lowers multiple gestation rates and the need for HOMP reduction.

Are gonadotropin-releasing hormone agonists losing popularity? Current trends at a large fertility center.

OBJECTIVE: To explore the long- and short-term trends in LH-suppression protocol use and patient profile characteristics. DESIGN: Descriptive study, retrospective cohort. SETTING: Large, university-based IVF center. PATIENT(S): Four thousand five hundred one fresh IVF cycles categorized by use of GnRH antagonist, luteal GnRH agonist, and follicular microdose GnRH agonist. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Frequency of use of LH-suppression protocol, patient and cycle characteristics, and outcomes at 10-year (1996-2005), 5-year (2001-5), and 3-year intervals (2004-6). RESULT(S): In both the <40 and >or=40 age groups, GnRH antagonist use increased from 2001 to 2005, while luteal GnRH agonist and microdose use decreased. The most recent luteal agonist patients were better responders and had higher implantation, clinical pregnancy, and delivery rates. Antagonist patients in the <40 and >or=40 age groups had a better response in 2005 than in 2001 with higher clinical pregnancy rates. Microdose patients responded worse in 2005 than in 2001, although pregnancy rates did not change significantly. Such trends were echoed from 2004 to 2006. CONCLUSION(S): The target population for GnRH antagonist has broadened to include younger, normal responders in addition to the traditional poor responder. Luteal agonist and microdose protocols are chosen less frequently and remain targeted toward good and poor responders, respectively.

Impact of developmental stage at cryopreservation and transfer on clinical outcome of frozen embryo cycles.

Although several early IVF successes were achieved after transferring fully formed blastocysts, the majority of embryos replaced worldwide over the past 30 years have been at the cleavage stage. The programme at this study centre has previously found that delaying an embryo transfer to day 5 can reduce the chance for a high-order multiple gestation without compromising the pregnancy rate because fewer embryos can be replaced. To evaluate the impact of transfer day and embryonic stage at cryopreservation on cycle outcome, 6069 fresh and 706 frozen transfers from 2000-2006 performed at this study centre were retrospectively analysed. Approximately half of the fresh transfers were performed on day 3, with a shift to day-5 transfer over the study period with no change in cryopreservation incidence. Implantation, clinical pregnancy and live birth rates were significantly higher following day-5 transfer. When frozen-thawed embryos (2-cell to day-6 blastocysts) were transferred, acceptable pregnancy and live birth rates were achieved at all stages but thawed embryos transferred as day-5 blastocysts generated consistently higher clinical pregnancy and live birth rates. Transfer of embryos frozen on day 6 had the highest miscarriage and lowest live birth rates. Barring government regulation, an IVF programme's day for cryopreservation generally depends on its management of and success with fresh embryo transfer.

Ectopic pregnancy rates after in vitro fertilization: a look at the donor egg population.

In an 8-year review of ectopic pregnancy (EP) rates in donor egg recipients and standard patients undergoing in vitro fertilization-embryo transfer (IVF-ET) at a large university-based program, we report an EP rate of 0.6% in donor egg recipients and 0.9% in standard IVF patients, a difference that is not statistically significant. Donor egg recipients were found to have a significantly lower incidence of tubal disease compared with standard IVF patients; however, tubal disease was not found to be an independent risk factor for EP in our practice, perhaps owing to aggressive management of tubal disease.

Women with cancer undergoing ART for fertility preservation: a cohort study of their response to exogenous gonadotropins.

Cancer patients produce similar numbers of oocytes after ovarian hyperstimulation compared with age-matched infertile controls, suggesting that malignancy does not adversely affect ovarian response.

Embryo biopsy: the fate of abnormal pronuclear embryos.

This study assessed 1908 embryos, including those with abnormal numbers of pronuclei, in IVF cycles from July 2001 to December 2006 in which preimplantation genetic screening (PGS) was performed on day 3 post-retrieval and 'euploid' embryos transferred the following day. PGS-intracytoplasmic sperm injection and PGS-translocation cycles were excluded. At 18 h post-insemination, the zygote distribution was 19% 0PN, 4% 1PN, 69% 2PN and 8% 3PN. No pregnancy occurred following 0PN or 1PN embryo transfers. A retrospective, blinded morphological ranking of all embryos on day 3 was performed and the results compared with PGS; no 0PN or 1PN embryo would have been chosen for transfer based on morphological superiority alone. Blastocyst formation occurred in 1PN embryos (29%) but not in 0PN embryos when evaluated on day 5. Euploid karyotypes were reported for biopsies of 0PN (3%), 1PN (5%) and 2PN (19%) embryos (P = 0.015, 1PN versus 2PN). A Y chromosome was observed in 0PN (17%) and 1PN (32%) embryos; surprisingly, 91% of these Y chromosome-bearing embryos were aneuploid. Many different meiotic and fertilization errors can result in 0PN or 1PN zygotes; these results indicate that the resultant embryos should not be transferred, especially when normally fertilized embryos are available.

Early serum interleukin-8 evaluation may prove useful in localizing abnormally implanted human gestations after in vitro fertilization.

OBJECTIVE: To determine whether early measurement of the serum cytokines interleukin-2 receptor (IL-2R), IL-6, and IL-8 along with human chorionic gonadotropin (hCG) and progesterone (P(4)) can differentiate an ectopic from an intrauterine gestation. DESIGN: Retrospective analysis. SETTING: University-based fertility center. PATIENT(S): 75 women who underwent treatment with in vitro fertilization (IVF) and subsequently had an ectopic gestation (n = 15), spontaneous abortion (SAB) (n = 30), or term delivery (TD) (n = 30). INTERVENTION(S): Serum samples were obtained 14 (day 28) and 21 (day 35) days after oocyte retrieval. MAIN OUTCOME MEASURE(S): Serum concentrations of IL-2R, IL-6, IL-8, P(4), and hCG. RESULT(S): Median hCG readings on day 28 and day 35 were statistically significantly lower in the ectopic gestation group than in those with spontaneous abortion or term delivery. On day 28, median IL-8 levels were lower in the ectopic gestation group when compared with all intrauterine gestations combined. No statistically significant differences in IL-2R or IL-6 levels were noted between groups. Despite P(4) supplementation, median day-35 P(4) levels were lower in ectopic gestation than in the spontaneous abortion and term delivery cycles. CONCLUSION(S): In the setting of a rise or plateau in hCG levels, low day-28 IL-8 and day-35 P(4) levels suggested an extrauterine implantation. This assay combination may facilitate earlier diagnosis of an ectopic gestation when pregnancy location is unclear.

Programmatic implementation of blastocyst transfer in a university-based in vitro fertilization clinic: maximizing pregnancy rates and minimizing triplet rates.

To assess whether the use of extended embryo culture can reduce the incidence of high-order multiple gestations, a retrospective analysis of 7,418 fresh ETs performed in a university-based IVF clinic from 1997-2003 was conducted, comparing program results before and after institution of a protocol to select patients for extended culture of in vitro fertilized embryos. The incidence of triplet pregnancies was significantly reduced in patients at highest risk for high-order multiple gestations, i.e., those at <35 years of age (16.8% versus 6.8%), those at 35-37 years of age (13.0% versus 5.6%), and recipients of donated oocytes (11.2% versus 4.5%).

Isolated teratozoospermia does not affect in vitro fertilization outcome and is not an indication for intracytoplasmic sperm injection.

OBJECTIVE: To reevaluate clinical management of isolated teratozoospermia, in couples initiating IVF. DESIGN: Retrospective analysis of fertility indices in 535 cycles. SETTING: A large, university-based fertility center. PATIENT(S): Consecutive couples (n = 495) who had a semen analysis using Kruger/Tyberberg strict criteria at our center within 12 months before undergoing their first and/or second IVF cycle in 2002-2004 with >2 million postwash, motile sperm on the day of egg retrieval. INTERVENTION(S): Eggs were fertilized either by conventional IVF or ICSI. Semen analysis and gamete/embryo manipulation was standardized in all cases. MAIN OUTCOME MEASURE(S): Fertilization, fertilization failure, pregnancy, and live birth rates. RESULT(S): There was no statistical difference in fertilization, fertilization failure, pregnancy, and live birth rates in the first or second IVF cycle when comparing couples with isolated teratozoospermia (<5% normal morphology) to those with a normal semen analysis. Furthermore, no improvement in these outcomes was noted when ICSI was used to treat these teratozoospermic couples. CONCLUSION(S): Because isolated teratozoospermia generally does not impact on the major indices of IVF, these patients need not be subjected to the unnecessary cost and potential risks of ICSI. Future studies, however, should focus on different sperm morphologic and biochemical parameters to determine if they are important for clinical management in IVF.

Increased risk of pregnancy-induced hypertension in young recipients of donated oocytes.

OBJECTIVE: To assess the rates of select obstetric outcomes in oocyte donation (OD) recipients aged <35 years and > or =40 years and compare them to similarly aged IVF patients. DESIGN: Retrospective anonymous questionnaire study. SETTING: University-based IVF center. PATIENT(S): Live-birth outcome was experienced by 199 OD recipients and 488 IVF patients <35 or > or =40 years. INTERVENTION(S): The OD or IVF cycles. MAIN OUTCOME MEASURE(S): Response rate, pregnancy outcome, and complications. RESULT(S): Response rate was 60%. The OD recipients had significantly higher rates of pregnancy-induced hypertension (PIH) than their IVF counterparts. The OD <35 years had the highest rate (42%), followed by OD > or =40 years (26%), IVF > or =40 years (14%), and IVF patients <35 years (12%). In twin pregnancies, the rates of PIH remained higher in the OD groups: OD <35 years (56%), OD > or =40 years (36%), IVF > or =40 years (25%), and IVF <35 years (22%). Twin pregnancy rate was lowest in IVF patients > or =40 years (19%) and a lower preterm delivery rate (16%) reflected this difference. The cesarean section rates were 50% for singleton and 78% for twin deliveries in the OD patients <35 year; in OD patients > or =40 years, the rates were 75% and 84%, respectively. CONCLUSION(S): The OD recipients are at higher risk for untoward obstetric outcomes than their IVF counterparts. Young OD recipients reported the highest rate of PIH, warranting further investigation into an association between early loss of ovarian function and PIH.

Transabdominal ultrasound-assisted embryo transfer and pregnancy outcome.

OBJECTIVE: To assess the clinical value of transabdominal ultrasound (TAS)--assisted embryo transfer on outcomes of in vitro fertilization--embryo transfer (IVF-ET) in comparison to the "clinical touch" method of transcervical embryo transfer by one physician and to determine if transabdominal ultrasound should be applied to all cases of embryo transfer in this practice. DESIGN: A retrospective comparison study. SETTING: A university-based IVF practice. PATIENT(S): Two hundred forty-nine patients who underwent transcervical transfer of fresh embryos created using autologous oocytes performed by the same physician from July 1, 2003, to June 30, 2004. INTERVENTION(S): On selected days, at time of embryo transfer, transabdominal ultrasound was performed to guide catheter placement depth approximately 1 cm from the uterine fundus. MAIN OUTCOME MEASURE(S): The presence of at least one gestational sac on ultrasound was compared in the two study groups; additionally, the clinical pregnancy rate (presence of fetal cardiac activity observed on ultrasound), the ectopic pregnancy rate, the biochemical pregnancy rate, and the implantation rate (number of gestational sacs identified on ultrasound per number of embryos transferred) between groups was evaluated. Characteristics of the two cohorts were analyzed to verify similarities between the treatment and control groups, including age of recipient, prior IVF history, day of transfer (day 3 or day 5 after retrieval), difficulty of transfer, the use of a tenaculum, and the quality and number of embryos transferred. RESULT(S): No statistical difference was seen in the presence or number of gestational sacs following embryo transfer with or without transabdominal ultrasound guidance. CONCLUSION(S): No additional advantage is conferred when using transabdominal ultrasound to perform embryo transfer. In experienced hands, the "clinical touch" method of embryo transfer yields equivalent results to transabdominal ultrasound-guided embryo placement. However, in patients with a prior history of difficult uterine sounding or embryo transfer, transabdominal ultrasound guidance may still play a role.

Evaluating the role of exogenous luteinizing hormone in poor responders undergoing in vitro fertilization with gonadotropin-releasing hormone antagonists.

OBJECTIVE: To evaluate the importance of exogenous LH in poor responders undergoing IVF with GnRH antagonists. DESIGN: Retrospective cohort study. SETTING: University-based IVF center. PATIENT(S): All patients with a history of poor response to ovarian stimulation undergoing IVF with GnRH antagonists between September 2000 and August 2001. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical pregnancy rates. RESULT(S): Two hundred forty GnRH-antagonist cycles were initiated in poor responders. One hundred fifty-three progressed to oocyte retrieval. Seventy-five patients received recombinant FSH (Rec) for ovarian stimulation, and 66 received hMG in combination with Rec. In patients aged <40 years, there were no significant differences in amount and duration of treatment, number of oocytes retrieved, and number of embryos between treatment groups. In patients aged > or =40 years, significantly fewer oocytes were retrieved in groups who received exogenous LH in their stimulation, resulting in significantly fewer fertilized embryos. Implantation and clinical pregnancy rates did not differ by treatment group. CONCLUSION(S): In poor responders undergoing IVF with GnRH antagonists, outcomes are comparable whether stimulation is achieved in the presence or absence of supplemental LH. Exogenous LH does not appear to be necessary to achieve pregnancy in these challenging patients and may be detrimental to older patients with a history of poor response.