Impact of the addition of Early Embryo Viability Assessment to morphological evaluation on the accuracy of embryo selection on day 3 or day 5: a retrospective analysis.

In this study we aimed at retrospectively assessing in a homogeneous group of IVF patients whether the addition of Early Embryo Viability Assessment (Eeva™) to standard morphology increases the accuracy of embryo selection in case of double embryo transfer (DET) on day 3 or single embryo transfer (SET) on day 5. Eeva™ is an algorhythm aimed at indicating on day 3, according to morphokinetic parameters observed in the first three days of embryo growth, which embryos are more likely to develop into viable blastocysts and implant. A total number of 328 patients were included in the study; IVF or ICSI were performed and 428 embryos were transferred, either with DET on day 5, or (when at least four top scored embryos were available on day 3) with SET of day 5. Four groups were considered: (a) patients receiving day 3 DET with embryos selected by standard morphology (DET-3 M, n = 106, receiving 212 embryos), (b) patients receiving day 3 DET with embryos selected by morphology plus Eeva™ (DET-3 ME group, n = 48, receiving 96 embryos), (c) patients receiving day 5 SET with a blastocyst selected by standard morphology (SET-5 M group, n = 126, receiving 126 embryos), and (d) patients receiving day 5 SET with a blastocyst selected by morphology plus Eeva™ (SET-5 ME group, n = 48, receiving 48 embryos). Overall, a clinical pregnancy rate of 49.1%, implantation rate of 40%, and ongoing pregnancy rate of 43.6% were observed. The implantation rate was significantly higher in DET-3 ME group than in DET-3 M group (44.8% vs. 30.2%, p < 0.02), whereas it was comparable in groups DET-3 ME, SET-5 M and SET-5 ME. Differently, the ultrasound-verified clinical pregnancy rate and the ongoing pregnancy rate at 12 weeks did not significantly differ in all four groups. Overall, our findings suggest that Eeva™ algorhythm can improve embryo selection accuracy of standard morphology when ET on day 3 is scheduled, leading to a higher implantation rate, but its impact on ongoing pregnancy and live birth needs to be further clarified.

Fertility preservation in BRCA mutation carriers.

According to enhanced long-term survival rates of these patients, interest in fertility preservation for young women facing gonadotoxic therapies is increasing. Women who carry a mutation in the BRCA1 or BRCA2 gene have a specifically increased lifetime risk of developing breast and tubo-ovarian cancer. Moreover, they are at high risk of undergoing premature infertility due to the medical interventions that are often performed in order to reduce cancer risk or treat an already existing malignancy. Fertility issues are relevant for healthy BRCA mutation carriers, whose family-planning decisions are often influenced by the need of prophylactic bilateral salpingo-oophorectomy at young age. In BRCA mutation carriers who have a breast cancer at young age, the oncostatic treatment is associated with a significant ovarian toxicity linked to chemotherapy as well as to the long lasting hormonotherapy and to the need of delaying pregnancy for several years. Prompt counselling about different fertility preservation options should be offered to all young girls and women at high risk of ovarian insufficiency and infertility. Validated techniques to preserve fertility include oocyte and embryo cryopreservation, while experimental techniques include ovarian suppression with GnRH-analogs during chemotherapy and ovarian tissue cryopreservation. The choice of the best strategy depends on age, type of chemotherapy, partner status, cancer type, time available for fertility preservation intervention and the risk of ovarian metastasis. All available options should be offered and can be performed alone or in combination. A crucial point is to avoid a significant delay to cancer treatment.

Fertility preservation in BRCA mutation carriers.

Interest in fertility preservation for young women facing gonadotoxic therapies is increasing according to enhanced long-term survival rates of these patients. Women who carry a mutation in the BRCA1 or BRCA2 gene have a specifically increased lifetime risk of developing breast and tubo-ovarian cancer. Moreover, they are at high risk of undergoing premature infertility due to the medical interventions that are often performed in order to reduce cancer risk or treat an already existing malignancy. Fertility issues are relevant for healthy BRCA mutation carriers, whose family-planning decisions are often influenced by the need of prophylactic bilateral salpingo-oophorectomy at young age. In BRCA mutation carriers who have a breast cancer at young age, the oncostatic treatment is associated with a significant ovarian toxicity linked to chemotherapy as well as to the long lasting hormonotherapy and to the need of delaying pregnancy for several years. Prompt counselling about different fertility preservation options should be offered to all young girls and women at high risk of ovarian insufficiency and infertility. Validated techniques to preserve fertility include oocyte and embryo cryopreservation, while experimental techniques include ovarian suppression with GnRH-analogues during chemotherapy and ovarian tissue cryopreservation. The choice of the best strategy depends on age, type of chemotherapy, partner status, cancer type, time available for fertility preservation intervention and the risk of ovarian metastasis. All available options should be offered and can be performed alone or in combination. A crucial point is to avoid a significant delay to cancer treatment.

Awareness of the effects of postponing motherhood among hospital gynecologists: is their knowledge sufficient to offer appropriate help to patients?

PURPOSE: The aim of this study is to ascertain the awareness of hospital gynecologists about the effects of woman's age on spontaneous fecundity and on the efficacy of assisted reproduction techniques (ARTs). METHODS: One hundred fifty-six gynecologists working in public or private Italian hospitals, without specific experience in reproductive medicine and ART, were administered a multiple-choice answer questionnaire addressing (a) the effect of age on woman's spontaneous fecundity, (b) the tools to estimate the ovarian follicular reserve, and (c) the outcome of ART in women above 40 years. RESULTS: Approximately half of the interviewed gynecologists indicated the woman's age limit for successful reproduction between 44 and 50 years; fertility lifespan was believed to be prolonged by oral contraception, pro-fertility medical treatments, or ART. The correct meaning of serum FSH measurement was known by approximately one third of the interviewed doctors. The effectiveness of ART for women of advanced age was overestimated by half of the gynecologists, especially in case of patients having regular cycles and/or small follicles at ultrasound. CONCLUSIONS: Overall, the survey clearly showed that the knowledge of hospital gynecologists about the effects of age on woman's fertility and ART effectiveness is largely insufficient to offer scientifically correct, helpful information to patients. Properly targeted corrections to academic and periodical educational programs for Ob/Gyn specialists are warranted.

150 years of congenital adrenal hyperplasia: translation and commentary of De Crecchio's classic paper from 1865.

In 1865, Luigi De Crecchio, a Neapolitan pathologist, published a detailed autopsy description of Giuseppe Marzo, who lived as a man, had nearly-normal appearing male external genitalia, female internal reproductive organs, and massively enlarged adrenals. This report is widely cited as the first report of non-salt-losing congenital adrenal hyperplasia (CAH), but a complete English translation has not been available. Via interlibrary loan, we obtained the original volume containing De Crecchio's paper. The complete 39-page publication was translated by two reproductive endocrinologists (L.D.P. and P.F.R.) who are native speakers of Italian. A pediatric endocrinologist conversant with CAH (W.L.M.) summarizes and comments on De Crecchio's observations. Anatomically, the external genitalia were characterized by labio-scrotal fusion and a 10-cm curved phallus with hypospadias. Internally, the ovaries, tubes, and uterus were hypoplastic but otherwise normal, except that the uterus inserted into a utricle. The adrenals were massively enlarged, but this observation was dismissed as unimportant. De Crecchio's exposition of Marzo's life shows many of the issues affecting patients today: family ill-ease regarding genital ambiguity at birth, social pressure following reversed sex assignment in childhood, adult embarassment about genital appearance, difficulties with a legal sex assignment on a birth certificate, and substantial efforts to exhibit maleness to self and associates. De Crecchio was an astute observer who provides insight into both nineteenth-century endocrinology and continuing twenty-first-century difficulties in the care of patients with disordered sex development.

A critical review of bi-dimensional and three-dimensional ultrasound techniques to monitor follicle growth: do they help improving IVF outcome?

BACKGROUND: This review focuses on the possibility of improving the outcome of human IVF by studying the follicles where oocytes grow by ultrasound techniques. A comprehensive analysis of bi-dimensional (2D) and three-dimensional (3D) ultrasound (US) assessment of the follicle size and volume is presented. METHODS: Published reports from the year 1999 to 2014 analyzing the relationship between oocyte competence, IVF outcome and ultrasound assessment of the follicle size and volume have been critically analyzed. RESULTS: US assessment of growing follicles has been performed mainly by 2D-US, and while overall very useful, it has been found to be of limited usefulness in predicting oocyte competence, recognize which follicles will release a mature metaphase II oocytes and decide the ideal time to trigger ovulation. In fact, a quite wide follicle size range (16-22 mm) has been reported to be associated with mature oocytes with good competence toward fertilization and embryo development. It has been also shown that smaller follicles sometimes contain mature, fertilizable oocytes. However, embryos derived from smaller follicles have probably a lower implantation potential, while follicles larger than 22 mm often contain post-mature eggs. CONCLUSIONS: The study of follicular size by 2D-US is of limited usefulness in helping in the identification of follicles containing the best oocytes and in choosing the best moment to trigger ovulation. Possibly the value of US in this area will be improved by large prospective studies in which automated 3D-US will be used.

Fertility preservation program before ovarotoxic oncostatic treatments: role of the psychological support in managing emotional aspects.

Fertility preservation programs (FPPs) based on oocyte or ovarian tissue cryostorage may be offered to women facing oncostatic treatments at risk of precocious ovarian insufficiency. The way in which FPPs are presented to patients affects their decision to join them. We studied herein 48 young women to whom a FPP was proposed, aiming at clarifying the emotional aspects involved. A psychologist attended the consultations in which the FPP was offered to patients; at the end of the talk, a questionnaire was administered and a semi-structured interview was carried out. Finally, the STAI test was administered to measure trait (TAI) and state (SAI) anxiety, both immediately after consultation, and later on, when patients returned home. We observed that the possibility to join a FPP implied important emotional aspects, and that the presence of a psychologist was helpful to integrate technical information and emotions as well as to reduce trait and state anxiety levels. Our study suggests that the presence of a psychologist during the meeting in which a FPP is offered improves communication between doctors and patients, and helps these women to get a full awareness before choosing to join the FPP.

Comparative analysis of fetal and neonatal outcomes of pregnancies from fresh and cryopreserved/thawed oocytes in the same group of patients.

OBJECTIVE: To analyze the fetal and neonatal outcomes of pregnancies achieved with fresh and/or frozen oocytes in the same group of patients. DESIGN: Observational study and comparative analysis. SETTING: Research unit of an academic medical center. PATIENT(S): A group of 855 women with cryopreserved oocytes and their resulting 954 assisted reproductive technology clinical pregnancies were enrolled and followed up during the same time period and in the same clinical setting; the outcomes of 197 pregnancies from frozen/thawed oocytes were compared with 757 obtained from fresh sibling oocyte cycles. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Pregnancies were followed until delivery, and neonatal data (up to 28 days after delivery) were collected. RESULT(S): No significant differences were found between the use of fresh and frozen oocytes in the rates of therapeutic abortions for fetal anomaly (1.5% vs. 0.8%) and ectopic pregnancies (3.6% vs. 2.9%), but a significantly higher rate of spontaneous abortions at ≤ 12 weeks (17.6% vs. 26.9%) was observed in the frozen/thawed oocytes group. No statistical differences were found in major anomalies at birth (2.8% vs. 4.6%). Despite no difference in gestational age at delivery, the mean birth weights were significantly lower with fresh oocyte pregnancies, both in singleton (2,725 ± 727 g) and twins (2,128 ± 555 g), than with frozen-thawed oocytes (3,231 ± 615 g and 2,418 ± 492 g, respectively). However, the analysis of the 63 patients who obtained pregnancies both in fresh and thawed cycles (138 pregnancies) showed no differences in the abortion rate and in the mean birth weight. CONCLUSION(S): These results provide strong support to the notion that fetal and perinatal complications and congenital anomalies do not differ between pregnancies from frozen-thawed and fresh oocytes. The significantly lower mean birth weight observed with pregnancies from fresh oocytes supports similar observations reported for pregnancies from embryo cryopreservation and requires further prospective studies.

Live birth after orthotopic grafting of autologous cryopreserved ovarian tissue and spontaneous conception in Italy.

OBJECTIVE: To describe a live birth obtained in Italy after autologous orthotopic transplantation of cryopreserved ovarian cortical tissue. DESIGN: Case report. SETTING: University department of gynecology and obstetrics, reproductive medicine and IVF unit. PATIENT(S): A 29-year-old patient affected by ß-thalassemia (intermedia phenotype) who underwent chemotherapy and bone marrow transplantation at age 21 years, resulting in a complete precocious ovarian failure. INTERVENTION(S): Before being treated with chemotherapy (busulfan, cyclophosphamide, and cyclosporine) for bone marrow transplantation, the patient underwent laparoscopic sampling of ovarian cortical tissue that was frozen and cryopreserved in liquid nitrogen. Eight years later, the ovarian tissue was thawed and grafted during laparoscopy at an orthotopic site. MAIN OUTCOME MEASURE(S): Ultrasound and endocrine monitoring of the postgrafting restoration of ovarian function; conception, pregnancy, and live birth. RESULT(S): Three months after grafting, the decrease of circulating FSH levels and the parallel increase of E(2) levels demonstrated ovarian function restoration, which was confirmed by bidimensional ultrasound and color Doppler examinations. After some ovulatory cycles, the patient spontaneously conceived 16 months after transplantation. After 39 weeks of uneventful gestation, a healthy girl weighing 3,970 g was born. CONCLUSION(S): Autologous grafting of cryopreserved ovarian cortex at an orthotopic site may allow ovarian function restoration, spontaneous conception, and birth of a healthy baby.

Oocyte cryostorage to preserve fertility in oncological patients.

Thanks to the progress in oncostatic treatments, young women affected by cancer have a fairly good chance of surviving the disease and leading a normal post-cancer life. Quite often, however, polychemiotherapy and/or radiotherapy can induce ovarian damage and significantly reduce the content of follicles and oocytes inside the ovary, thus predisposing the patient to menstrual disorders, infertility, and precocious menopause. Several techniques have been proposed to preserve fertility in these patients; among them oocyte collection and cryopreservation prior to the oncostatic treatment has been widely applied in the last decade. The proper indications, the permitting conditions, the available hormonal stimulation protocols, as well as the effectiveness and limits of this option will be discussed herein, with a comprehensive and up-to-date review of the two techniques commonly used to cryostore oocytes, the slow-freezing technique and the vitrification technique.

Ovarian endometriomas and IVF: a retrospective case-control study.

We performed this retrospective case-control study analyzing 428 first-attempt in vitro fertilization (IVF) cycles, among which 254 involved women with a previous or present diagnosis of ovarian endometriosis. First, the results of these 254 cycles were compared with 174 cycles involving patients with proven non-endometriotic tubal infertility having similar age and body mass index. Women with ovarian endometriosis had a significantly higher cancellation rate, but similar pregnancy, implantation and delivery rates as patients with tubal infertility. Second, among the women with ovarian endometriosis, the women with a history of laparoscopic surgery for ovarian endometriomas prior to IVF and no visual endometriosis at ovum pick-up (n = 112) were compared with the non-operated women and visual endometriomas at ovum pick-up (n = 142). Patients who underwent ovarian surgery before IVF had significantly shorter period, lower antral follicle count and required higher gonadotropin doses than patients with non-operated endometriomas. The two groups of women with a previous or present ovarian endometriosis did, however, have similar pregnancy, implantation and live birth rates. In conclusion, ovarian endometriosis does not reduce IVF outcome compared with tubal factor. Furthermore, laparoscopic removal of endometriomas does not improve IVF results, but may cause a decrease of ovarian responsiveness to gonadotropins.

Milder is better? Advantages and disadvantages of "mild" ovarian stimulation for human in vitro fertilization.

In the last decades, several steps have been made aiming at rendering human IVF more successful on one side, more tolerable on the other side. The "mild" ovarian stimulation approach, in which a lower-than-average dose of exogenous gonadotropins is given and gonadotropin treatment is started from day 2 to 7 of the cycle, represents a significant step toward a more patient's friendly IVF. However, a clear view of its virtues and defects is still lacking, because only a few prospective randomized trials comparing "mild" vs. conventional stimulation exist, and they do not consider some important aspects, such as, e.g., thawing cycles. This review gives a complete panorama of the "mild" stimulation philosophy, showing its advantages vs. conventional ovarian stimulation, but also discussing its disadvantages. Both patients with a normal ovarian responsiveness to exogenous gonadotropins and women with a poor ovarian reserve are considered. Overall, we conclude that the level of evidence supporting the use of "mild" stimulation protocols is still rather poor, and further, properly powered prospective studies about "mild" treatment regimens are required.

IVF twins have similar obstetric and neonatal outcome as spontaneously conceived twins: a prospective follow-up study.

Studies comparing the outcome of spontaneous versus IVF twin pregnancies report heterogeneous results. This may depend on differences in the studied populations and/or in the management approach to twin pregnancy. The aim of the present study was to compare both maternal and perinatal outcomes in dichorionic diamniotic twin pregnancies who where spontaneously conceived or originated by successful homologous IVF. In order to get homogeneous observations, monochorionic twin pregnancies and triplet pregnancies were excluded. Moreover, to avoid any possible bias deriving from differences in the obstetric management, all pregnancies were managed by the same team applying fixed obstetric protocols. The study included 223 twin pregnancies, 84 conceived by IVF and 139 spontaneously conceived. Overall, maternal and perinatal outcomes were similar in the two groups: no significant differences were observed as far as gestational age at delivery, birthweight, perinatal morbidity and mortality, and rate of malformations were concerned. The rate of Caesarean section was slightly, but not significantly, higher in IVF pregnancies. In conclusion, the outcome of IVF twin pregnancies is comparable to that of spontaneously conceived twin pregnancies, provided that the same management criteria are applied.

Superfetation after ovulation induction and intrauterine insemination performed during an unknown ectopic pregnancy.

This report describes the first case of superfetation after ovarian stimulation with gonadotrophins and intrauterine insemination (IUI) that were performed in the presence of an undiagnosed tubal pregnancy. A 32-year-old woman who underwent repeated attempts of ovarian stimulation and IUI was hospitalized for severe pelvic pain and submitted to laparoscopic salpingectomy because of ruptured salpynx containing a 6-week pregnancy. Transvaginal ultrasound examination showed a simultaneous intrauterine 2-week pregnancy that had been conceived by ovarian stimulation and IUI while the tubal pregnancy was already ongoing and still undiagnosed. The intrauterine pregnancy went on until term and ended with the spontaneous delivery of a healthy baby. This report demonstrates that human superfetation may occur after gonadotrophin treatment and IUI in the presence of an ongoing tubal pregnancy. It is recommended to perform a pregnancy test before starting ovulation induction even when an apparently normal blood discharge appeared.

Slow-freezing-induced changes of birefringent structures in human oocytes are related to responsiveness to ovulation induction.

The slow-freezing method is widely used to freeze human oocytes, both for fertility preservation and in routine IVF programmes. Slow freezing damages some of the cell's structures, including the meiotic spindle (MS) and the zona pellucida (ZP). Polarized light microscopy was used to study the variations induced by slow freezing on the MS and the ZP of human oocytes and to analyse the relationship between slow-freezing effects on the gamete and some clinical characteristics, such as age, body mass index and ovarian responsiveness to ovulation induction (expressed as total follicle-stimulating hormone dose/retrieved oocyte). Both the MS and the ZP (particularly its inner layer) underwent significant changes during slow-freezing procedure. The MS became thinner and structurally less organized (lower retardance) (P<0.001 and P<0.05, respectively), whereas the ZP became thicker and its inner layer lost structural organization (both P<0.05). These morphological changes were unrelated to the patient's age or body mass index, but ZP variations in thickness and retardance were significantly related to ovarian responsiveness (P=0.033 and P=0.026, respectively), suggesting that patients with a higher response to gonadotrophins produce oocytes better able to preserve their characteristics after freezing-thawing.

Follicular fluid content and oocyte quality: from single biochemical markers to metabolomics.

The assessment of oocyte quality in human in vitro fertilization (IVF) is getting increasing attention from embryologists. Oocyte selection and the identification of the best oocytes, in fact, would help to limit embryo overproduction and to improve the results of oocyte cryostorage programs. Follicular fluid (FF) is easily available during oocyte pick-up and theorically represents an optimal source on non-invasive biochemical predictors of oocyte quality. Unfortunately, however, the studies aiming to find a good molecular predictor of oocyte quality in FF were not able to identify substances that could be used as reliable markers of oocyte competence to fertilization, embryo development and pregnancy. In the last years, a well definite trend toward passing from the research of single molecular markers to more complex techniques that study all metabolites of FF has been observed. The metabolomic approach is a powerful tool to study biochemical predictors of oocyte quality in FF, but its application in this area is still at the beginning. This review provides an overview of the current knowledge about the biochemical predictors of oocyte quality in FF, describing both the results coming from studies on single biochemical markers and those deriving from the most recent studies of metabolomics.