Adenomyosis and endometriosis. Re-visiting their association and further insights into the mechanisms of auto-traumatisation. An MRI study.

PURPOSE: In a series of publications, we had developed the concept that uterine adenomyosis and pelvic endometriosis as well as endometriotic lesions at distant sites of the body share a common pathophysiology with endometriosis constituting a secondary phenomenon. Uterine auto-traumatization and the initiation of the mechanism of tissue injury and repair (TIAR) were considered the primary events in the disease process. The present MRI study was undertaken (1) to corroborate this concept by re-visiting, in view of discrepant results in the literature, the association of adenomyosis with endometriosis and (2) to extend our views concerning the mechanisms of uterine auto-traumatization. PATIENTS AND METHODS: MRI was performed in 143 women attending our center, in whom, on the basis of transvaginal sonography (TVS) and historical data, such as documented endometriosis and dysmenorrhea of various degrees of severity, the presence of uterine adenomyosis was suspected. In addition to the measurement of the diameter of junctional zone (JZ) of the anterior and posterior walls in the mid-sagittal plane, the diagnosis of adenomyosis was based on visualization, in that all planes were analyzed with scrutiny. By this method of "visualization" all transient enlargement of the JZ, such as peristaltic waves of the archimyometrium and sporadic neometral contractions that might mimic adenomyotic lesions could be excluded. At the same time, this method allowed to lower the limit of detection in terms of thickness of the JZ for assured diagnosis of adenomyosis. Furthermore, the localizations of the individual lesions, their shapes and patterns were described. RESULTS: With the method of 'visualization', the diagnosis of uterine adenomyosis could be verified in 127 of the 143 patients studied. The prevalence of endometriosis in adenomyosis was 80.6% and the prevalence of adenomyosis in endometriosis was 91.1%. As concluded from their localization within the uterine wall, the adenomyotic lesions predominantly developed in the median region of the upper two-thirds of the uterine wall. Cystic cornual angle adenomyosis was a distinct phenomenon that was only observed in patients suffering from extreme primary dysmenorrhea. Aside from this, the majority of the patients complained of primary dysmenorrhea (80%). On the basis of these findings and the fact that particularly extreme primary dysmenorrhea is associated with high intrauterine pressure, menstrual 'archimetral compression by neometral contraction' has to be considered as an important cause of uterine auto-traumatization in addition to uterine peristalsis and hyperperistalsis. Both mechanical functions of the non-pregnant uterus exert their strongest power in the upper region of the uterus, which is compatible with the predominant localization of the adenomyotic lesions. CONCLUSIONS: The data confirm our previous results of a high association of adenomyosis with endometriosis and vice versa. Our view of the mechanism of uterine auto-traumatization by mechanical functions of the non-pregnant uterus has to be extended, in that 'archimetral compression by neometral contractions' could be realized as the predominant cause of mechanical strain to the non-pregnant uterus. The data of this study confirm our concept of the etiology and pathophysiology of adenomyosis and endometriosis in that the process of chronic proliferation and inflammation is induced at the level of the archimetra by chronic uterine auto-traumatization. Furthermore, with respect to the diagnosis of uterine adenomyosis (and consequently endometriosis) this study shows a high degree of accordance between the findings in real-time TVS and MRI.

Validation of reference genes in human testis and ejaculate.

Beta-actin (ACTB), glyceraldehyde-3-phosphate-dehydrogenase (GAPD), Heat Shock Protein 1, beta (HSPCB) and Adenosine Triphosphate subunit 5 beta (ATP5B) with distinct functional characteristics and expression patterns were investigated as suitable references for gene expression studies. We determined the expression stability of the four reference genes in ejaculates, cryopreserved as well as fixed and paraffin-embedded testicular tissue (from fertile and subfertile men) applying real-time qRT-PCR and statistical analysis. The mean gene expressions (mean Ct value) were compared for each gene between the fertile and subfertile donors by using the Wilcoxon-Mann-Whitney test. We did not observe significant statistical differences between variability of genes. To detect random effects, we used the two-way analysis of variance with a hierarchical model. The results show no significant statistical differences between proband and repetition within the probands. Taken together, we concluded that ACTB, GAPD, HSPCB and ATP5B have a variable expression within these samples, but this variability is not statistically significant. This finding demonstrated that all these genes could be appropriated for further studies on gene expression in ejaculate and testis tissue. Therefore, the selection of the suitable reference genes is highly specific for a particular experimental model and validation for each situation, on an individual basis, is a crucial requirement.

Light retardance by human oocyte spindle is positively related to pronuclear score after ICSI.

Disturbed spindle assembly increases risks of chromosome mal-segregation. Non-invasive polarization microscopy (PolScope) was employed in two centres to assess spindle integrity for the first time quantitatively in human oocytes from consenting patients undergoing intracytoplasmic sperm injection (ICSI) with respect to pronuclear (PN) score after fertilization. In one centre oocytes were selected before ICSI, in another selection was after ICSI according to PN score. In both centres, mean retardance of light by birefringent spindles in oocytes forming a pre-embryo with good PN score after ICSI was significantly higher compared with spindles in oocytes developing into a lower PN score pre-embryo with limited developmental potential (P < 0.001). Transfers involving oocytes with high retardance and at least one good PN score embryo resulted more frequently in a conception than transfers from oocytes with spindles of lower mean retardance and lower PN score embryos. There was a trend for an inverse relationship between age and magnitude of retardance in a small oocyte cohort. The study suggests that quantitative evaluation of mean retardance of light by the oocyte spindle predicts oocyte health, is related to PN score of the embryo and may be especially useful to assess oocyte quality in countries with legal restrictions to select after fertilization.

Influence of motility and vitality in intracytoplasmic sperm injection with ejaculated and testicular sperm.

The vitality of spermatozoa used for intracytoplasmic sperm injection (ICSI) is a crucial factor for fertilization, establishment and outcome of a pregnancy in assisted reproductive technique cycles. The sperm origin may also be a limiting factor, although little is known about this issue. It is known that the motility of injected spermatozoa and their origin from ejaculate or testicular biopsies are important predictors in terms of fertilization, pregnancy and birth rates. Oocytes of patients in 2593 cycles were retrieved in our in vitro fertilization programme and inseminated via ICSI. We used motile (group 1, n = 2317) or immotile ejaculated spermatozoa (group 2, n = 79), motile sperm retrieved from testicular biopsies (group 3, n = 62) and immotile spermatozoa from testicular biopsies (group 4, n = 135). Female age and number of oocytes retrieved did not differ significantly among the groups. The fertilization rates were as follows: 67.1% in group 1, 49.8% in group 2, 68.3% in group 3 and 47.8% in group 4. The pregnancy rates in cases where three embryos had been transferred amounted to 35.7% in group 1, 17.3% in group 2, 38.3% in group 3 and 20.5% in group 4. The embryo quality showed no differences between groups 1 and 3 (14.5), and between groups 2 (11.8) and 4 (10.8). The abortion rate was similar in groups 1-3, but increased in group 4 (26.6%, 27.3%, 31.6% and 55.5%). Irrespective of their origin, the fertilization potential of injected spermatozoa was found to be influenced by motility. The resulting pregnancy and birth rates, i.e. the potential of the resulting embryos to implant and to achieve viable pregnancies, seem to be additionally dependent on the sperm origin. This was well shown by declining rates when spermatozoa in a relatively early stage of maturity had been used. We see increasing evidence that the degree of sperm maturity has an important impact on the outcome of ICSI. In obstructive azoospermia, spermatozoa retrieved from the epididymis should be used rather than testicular biopsy spermatozoa, or testicular sperm should be preincubated in culture medium before ICSI.

High magnitude of light retardation by the zona pellucida is associated with conception cycles.

BACKGROUND: Failures in expression of zona proteins correlate to subfertility in animals. Low expression of the zona proteins by the growing human oocyte may indicate reduced developmental potential. Therefore, we non-invasively analysed the thickness and the structure of the zona pellucida (ZP) of human oocytes with respect to embryo fate after ICSI. METHODS: Retardance magnitude and thickness of the inner, middle and outer layers of the ZP were quantitatively analysed by a Polscope in 166 oocytes selected for transfer after ICSI (63 patients; 32.8 +/- 4.4 years) on the basis of pronuclear score at day 1. Blastomere number was determined at day 2. Data were compared between conception cycles (CC; 65 oocytes/23 patients) and non-conception cycles (NCC; 101 oocytes/40 patients) and with respect to maternal age. RESULTS: The thickness was slightly elevated (P < 0.001), and the mean magnitude of light retardance was nearly 30% higher (P < 0.001) in the inner layer of the zona pellucida of oocytes contributing to CC compared to NCC. Embryos in the CC group tended to develop faster. CONCLUSIONS: The magnitude of light retardance by the zona pellucida inner layer appears to present a unique non-invasive marker for oocyte developmental potential.

Urogenital inflammation: changes of leucocytes and ROS.

The presence of excess leucocytes in the semen has been associated with male infertility. According to the WHO, concentrations of more than 106 leucocytes ml-1 are considered as leucocytospermia, indicating genital tract infections. Up to now, no consensus has been achieved on how leucocytes should be quantified in semen. Using the peroxidase staining and monoclonal antibodies to CD15, CD45 and CD68, we found significant differences between the detection methods. Only 47.4% of the semen samples that were assessed as leucocytospermic by CD45 were identified as such by peroxidase staining. The concentration of peroxidase-positive cells was significantly correlated with polymorphonuclear granulocyte (PMN) elastase (P < 0.0001). However, a negative correlation of peroxidase-positive cells with the sperm concentration was only found in oligozoospermic patients (P < 0.0001). Moreover, the slightly positive correlation with normal sperm morphology seems to be applicable only in cases of oligozoospermia. Significant negative correlation of the number of peroxidase-positive cells were found for both maximal inducible acrosome reaction (P = 0.0219) and the inducibility of acrosome reaction (P = 0.0370), indicating a rather deleterious effect of leucocytes on this important sperm function. Concerning the result in the in vitro fertilization programme, none of the examined parameters (PMN elastase, concentration of round cells and peroxidase-positive cells) showed a correlation with either fertilization or pregnancy. This result seems to be reasonable as severely damaged spermatozoa and leucocytes are eliminated from the ejaculate by different sperm separation methods. Interestingly, a significant negative correlation of the TUNEL assay as a measure of sperm DNA fragmentation was found only with pregnancy (P = 0.006) but not with fertilization. As DNA fragmentation can also be caused by ROS that are generated by leucocytes, this causality should not be neglected.

Different cumulative pregnancy rates in patients with repeated IVF- or ICSI cycles: possible influence of a male factor.

The low rate of ongoing pregnancies in IVF cycles leads to a high number of repeated cycles in couples with previously failed attempts. Therefore it would be helpful to have a prediction about the chance of becoming pregnant in a repeated cycle. In a retrospective study the data of about 4246 cycles were analysed. Because the pregnancy rates in IVF- and ICSI cycles are generally different, these two groups were distinguished between and the outcome in patients with one, two or more attempts was analysed. The rate of ongoing pregnancies per patient was lower after IVF (24.9%) than after ICSI (32.9%), but was similar or even slightly increased in patients with more than one attempt. On the other hand, there was a high pregnancy rate with ICSI in the first two cycles (35.9%), but patients with more than two ICSI cycles had a significantly lower chance of becoming pregnant (20.7%). Factors that are known to influence the pregnancy rate, such as stimulation protocol, oocyte quality or number of transferred embryos, were similar in all groups. However, significantly reduced embryo quality with successive cycles was only observed in ICSI patients. There might be a negative selection of patients with poor embryo quality and previously failed attempts after ICSI, possibly due to an andrological factor. The differences between IVF- and ICSI patients are based on treatment indications, and andrological diseases are the predominant indication for ICSI. Although no correlation was found between changes in conventional sperm parameters and number of treated cycles, there might be a subgroup of andrological patients selected by repeatedly failed ICSI cycles. Chromosomal or genetic disturbances in spermatozoa of this subgroup could be the reason for failure.

Use of failed-fertilized oocytes for diagnostic zona binding purposes after sperm binding improvement with a modified medium.

PURPOSE: Because the availability of prophase oocytes for zona binding testing is limited, we compared sperm binding to the zona of failed-fertilized intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF) oocytes after incubation in a standard IVF medium and a specially composed binding improvement medium. METHODS: Semen samples from nine patients and nine fertile donors were separated in parallel by the standard swim-up method in both media. Subsequently, hemizona assays were performed with prophase, failed-fertilized ICSI and IVF oocytes. RESULTS: Sperm separation resulted in a significantly higher sperm count (P < 0.01) and progressive motility (P = 0.018) in binding improvement medium. Moreover, spermatozoa coincubated with hemizonae (prophase, failed-fertilized ICSI and IVF oocytes) in binding improvement medium bound significantly more to hemizonae than in the controls (P < 0.01). However, the hemizona index did not differ. CONCLUSIONS: Thus, the limited number of human zonae can be increased by the use of oocytes that failed to fertilize during ICSI or IVF. This will lead to a qualitative improvement of the diagnostic spectrum in male-factor infertility.

Sperm selection methods for intracytoplasmic sperm injection (ICSI) in andrological patients.

PURPOSE: To improve the chances of successful in vitro fertilization, spermatozoa have to be separated from semen before insemination. Therefore, sperm preparation methods are of great importance. METHODS: To obtain sufficient numbers of spermatozoa from patients with cryptozoospermia or severe OAT syndrome, only Minipercoll centrifugation and migration-sedimentation (MS) are practicable methods. The present study was performed to compare these two methods with regard to sperm concentration, motility, vitality, morphology, and chromatin condensation. The number of spermatozoa obtained after minipercoll was higher than that after MS, but sperm quality in all parameters examined was clearly better after MS than after Minipercoll. In the second stage of this study, the MS method was used for preparation of the spermatozoa for intracytoplasmic sperm injection (ICSI). RESULTS: Over a period of 13 months, 159 cycles were treated by ICSI. Of 1045 aspirated oocytes, 790 were injected. The fertilization rate was 70.4% of injected oocytes (556 oocytes with clearly visible pronuclei). In 146 cases, embryonic transfer was achieved; 58 patients became pregnant (39.7% per transfer and 36.5% per cycle). CONCLUSIONS: Although the abortion rate was very high (18 women lost their embryos), the results demonstrate that the microinjection method can be successfully used in combination with a MS method for preparation of spermatozoa.

Andrological work-up of patients undergoing microsurgical epididymal sperm aspiration or testicular sperm extraction.

Microsurgical epididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) require close cooperation between andrologists, urologists and gynaecologists. Intracytoplasmic sperm injections were established in Giessen in March 1994 and embryo transfer (ET) was performed in 342 of 375 patients (91.2%). The percentage of pregnancies and ongoing pregnancies are 35.4% per ET (32.3% per cycle) and 25.1% per ET (22.9% per cycle), respectively. Microsurgical procedures such as epididymovasostomy or vasovasostomy and cryopreservation of human semen are also established methods. The purpose of the present study was to describe the andrological work-up for patients before MESA and TESE. Experiments demonstrate that incubation of testicular tissue samples in IVF medium and treatment with 1 mg ml-1 pentoxifylline increase the number of extracted motile spermatozoa. Centrifugation of the medium results in a further concentration of sperm cells. If no motile spermatozoa can be found in the supernatant medium, they may be extracted directly from the testicular tissue samples by means of a micromanipulator.

Pregnancy and birth after intracytoplasmic sperm injection with spermatozoa from a patient with tail stump syndrome.

Tail stump syndrome, which may be associated with primary ciliary dyskinesia, is also associated with morphological defects of the flagellum resulting in severe asthenozoospermia. Until recently, these morphological anomalies caused definite male infertility. Today, however, new methods such as micromanipulation techniques provide a rational therapy for this patient group. A pregnancy followed by living offspring was achieved following the intracytoplasmic injection of immotile spermatozoa from a patient with tail stump syndrome.

Outer dense fibres of human spermatozoa: partial characterization and possible physiological functions.

The outer dense fibres are accessory fibres in the spermatozoon. They represent up to 30% of the protein portion in human spermatozoa and are involved in sperm progressive motility. If outer dense fibres are missing or developed poorly, spermatozoa are only locally motile. For isolation of the outer dense fibres, human spermatozoa were sonicated at 25 kHz and the flagella were separated by density gradient centrifugation in Percoll. Thereafter, membranes and fibrous sheath were dissolved under reducing conditions in the cationic detergent cetyltrimethylammonium bromide for 30, 60 and 90 min, respectively. The isolation steps were monitored by phase contrast microscopy and electron microscopy. After SDS-polyacrylamide gel electrophoresis and silver staining of isolated outer dense fibres, two protein bands at 55 and 67 kDa could be detected. By means of rhodamine B staining, no phosphorus could be detected in the outer dense fibre proteins.

Isolation and partial characterization of the outer dense fiber proteins from human spermatozoa.

Flagella of human spermatozoa were separated from the sperm head by sonication at 25 kHz and subsequent density gradient centrifugation in Percoll. For isolation of the outer dense fibers (ODF), the flagellar membrane and fibrous sheath were dissolved under reducing conditions in the cationic detergent cetyltrimethylammonium bromide (CTAB) for 30, 60 and 90 min, respectively. The isolation steps were monitored by phase-contrast microscopy and electron microscopy. After SDS-PAGE and silver staining two protein bands at 55 and 67 kDa could be detected. An identification of these proteins as phosphoproteins, either with molybdate/methylgreen or rhodamine B, was not possible. The obtained results indicate that the ODF proteins might have more passive elastic than active function with respect to motility of spermatozoa.