Intracytoplasmic sperm injection: what are the risks?

UNLABELLED: Intracytoplasmic sperm injection, a relatively new technique used at the time of in vitro fertilization to fertilize human oocytes, has provided couples with very severe male factor infertility the ability to conceive their own biologic children. Many men with severe oligospermia or azoospermia can now pass their genes on to their progeny, an event that might not have been possible for them just a few years ago. Recent studies now suggest that there may be genetic and developmental differences in some children conceived through intracytoplasmic sperm injection. It is likely that genetic testing and counseling will be recommended for all couples with male factor infertility in the near future. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to describe the various indications for the use of ICSI in the treatment of infertility, to identify the potential long-term risks associated with the use of ICSI, and to estimate the rate of chromosomal abnormalities in this population of infertile patients.

Testis sperm extraction and intracytoplasmic sperm injection guided by prior fine-needle aspiration mapping in patients with nonobstructive azoospermia.

OBJECTIVE: To evaluate intracytoplasmic sperm injection (ICSI) outcomes in a cohort of men with nonobstructive azoospermia who underwent prior fine-needle aspiration (FNA) "maps" to localize sperm and guide testis sperm extraction (TESE). DESIGN: Retrospective clinical study. SETTING: University-based infertility practice. PATIENT(S): A consecutive cohort of 19 infertile, azoospermic men. INTERVENTION(S): Couples underwent IVF-ET in which TESE procedures were informed and directed by prior FNA maps of the testis. MAIN OUTCOME MEASURE(S): Sperm retrieval and pregnancy rates. RESULT(S): In 21 IVF-ET and ICSI cycles, sufficient sperm for all oocytes were retrieved in 20 TESE attempts (95%). A mean of 3.1 biopsies per patient were required, with an average size of 72 mg. Mean operative time for the TESE procedure was 88 minutes. Overall, the two-pronuclear fertilization rate was 66%; ongoing clinical pregnancies were obtained in 10 of 21 initiated cycles (48%). CONCLUSION(S): In an effort to reduce IVF-ET cancellation rates in cases of nonobstructive azoospermia, diagnostic testis FNA can define those patients who are good candidates for TESE. It also directs sperm retrieval and minimizes tissue removal from nonobstructed testes.

The mini-micro-epididymal sperm aspiration for sperm retrieval: a study of urological outcomes.

Epididymal sperm aspiration and in-vitro fertilization (IVF) with intracytoplasmic sperm injection is an established treatment for obstructive azoospermia. Sperm aspiration is performed with either an incision or percutaneously. To control costs, minimize morbidity and retain the advantages of both approaches, we developed a mini-incision technique for epididymal aspiration and here report sperm retrieval and procedure-related outcomes. Twenty-six consecutive patients with obstructive azoospermia underwent epididymal sperm retrieval through a 1 cm incision with local anaesthesia to provide spermatozoa for concurrent IVF cycles. The quality of retrieved spermatozoa, the quantity of spermatozoa cryopreserved as well as anaesthetic requirement, recovery time and patient satisfaction were evaluated. Fresh epididymal spermatozoa were retrieved in 25 of 26 (96%) patients. In one patient, testicular sperm extraction was necessary. Excess motile spermatozoa were cryopreserved in 24 of 26 (92%) patients; a mean total motile count of 4.8x10(6) motile spermatozoa were banked. The procedure was performed with 62% of patients receiving minimal i.v. sedation. Post-procedure recovery was rapid, with a median time to return to work of 2.0 days with a median of 2.0 pain pills taken. Procedure-related satisfaction was high. The mini-micro-epididymal sperm aspiration achieves the goals of reliable retrieval of abundant epididymal spermatozoa with a single, minimally morbid procedure. It appears to combine the advantages of the incision and percutaneous approaches.

Elevated ovarian follicular fluid stem cell factor concentrations are associated with improved pregnancy rates in in-vitro fertilization cycles.

OBJECTIVE: To determine whether ovarian follicular fluid (FF) stem cell factor concentrations are associated with successful IVF pregnancies. DESIGN: Nested case-control design evaluation of stem cell factor levels from the FF of oocytes fertilized and transferred after controlled ovarian hyperstimulation. SETTING: University-based ART program. PATIENT(S): Infertile women undergoing IVF in a university-based ART program. INTERVENTION(S): Fifty-seven FF samples from a cohort of patients (n = 13) with tubal factor and unexplained infertility were stored at -80 degrees C and subsequently evaluated for stem cell factor concentration. Patients with endometriosis, polycystic ovary disease, and male factor infertility were excluded. Stem cell factor concentrations were measured using a commercially available ELISA kit according to the manufacturer's specifications. The groups were analyzed using a one-way analysis of variance, and significance was determined using the chi2 analysis of contingency table, the unpaired t-test, or the Mann-Whitney rank-sum test. MAIN OUTCOME MEASURE(S): FF stem cell factor concentration, pregnancy. RESULT(S): Stem cell factor concentrations were significantly higher in the FF of the patients who achieved successful pregnancies than in those who did not (641.7+/-75.2 pg/mL versus 475.5+/-50.58 pg/mL). CONCLUSION(S): Elevated FF stem cell factor concentrations are associated with an increased likelihood of IVF success. Therefore, stem cell factor may play a role in human follicular and oocyte development, and increasing infrafollicular stem cell factor concentrations may improve pregnancy rates after oocyte retrieval, fertilization, and ET.

Transvaginal reduction of an interstitial heterotopic pregnancy with preservation of the intrauterine gestation.

With use of transvaginal ultrasonographic guidance, cardiac activity in an interstitial heterotopic pregnancy at 7 weeks' gestation was terminated. The interstitial pregnancy resolved, and a healthy term infant was delivered. If an early diagnosis of an interstitial heterotopic pregnancy is made, selective reduction may allow preservation of the intrauterine gestation without surgery.

Cytochrome P450 17 alpha-hydroxylase gene expression in differentiating rat trophoblast cells.

Trophoblast giant cells of the rat placenta express cytochrome P450 17 alpha-hydroxylase (P450c17) and synthesize androgens. The purpose of this study was to investigate androgen production and expression of P450c17 in the Rcho-1 trophoblast cell line. These cells are capable of differentiating along the trophoblast giant cell lineage. Androstenedione production increased approximately 70-fold as Rcho-1 trophoblast cells progressed from the proliferation to the differentiation state. P450c17 enzyme activity and mRNA also showed significant increases associated with trophoblast giant cell differentiation. To study the transcriptional regulation of the P450c17 gene, the activities of a series of P450c17 promoter-luciferase reporter constructs were evaluated following transient transfection into Rcho-1 trophoblast cells. A DNA region located-98 bp upstream of the P450c17 gene transcriptional start site was the shortest promoter DNA construct consistently possessing activity in Rcho-1 trophoblast cells. Activities of longer constructs (-156 to -1560 bp) in this population of cells were significantly greater than the -98 bp promoter-reporter construct. The -476 bp P450c17 construct showed maximal promoter activity in transiently transfected Rcho-1 trophoblast cells and was developmentally activated in stably transfected Rcho-1 trophoblast cells. Activation of the cyclic AMP/protein kinase A pathway did not significantly affect P450c17 promoter activity in Rcho-1 trophoblast cells, in contrast to its effects in mouse MA-10 Leydig cells. In summary, Rcho-1 trophoblast cells are capable of endocrine differentiation and are a useful in vitro system for studying the regulation of trophoblast androgen production and P450c17 gene expression.

Transcriptional regulation of rat cytochrome P450c17 expression in mouse Leydig MA-10 and adrenal Y-1 cells: identification of a single protein that mediates both basal and cAMP-induced activities.

Cytochrome P450c17, 17 alpha-hydroxylase/17,20 lyase, is a key enzyme in the steroidogenic pathway leading to the production of corticosteroids and androgens from the adrenal gland and sex steroids from the gonads. Both enzymatic activities of the protein are encoded by a single gene, CYP17, which is expressed in both the human adrenal and gonad but not in the placenta, and in the rodent gonad and placenta but not the rodent adrenal. We isolated and sequenced a full-length rat genomic clone (7,553 bases) containing the entire coding region of the rat P450c17 gene, and all intronic sequences and 1,560 bp of 5'-flanking DNA (EMBL Acc#X69816). To determine which sequences in the rat P450c17 promoter may be responsible for basal and cAMP-stimulated gene transcription, deletion constructs containing between -1,560 and -53 base pairs of 5'-flanking DNA from the rat P450c17 gene were ligated to plasmids expressing the reporter gene luciferase and transfected into two mouse cell lines, adrenal Y-1 cells, and testicular Leydig MA-10 cells. Highest basal and cAMP-stimulated luciferase activity were found in constructions containing 156 bp of 5'-flanking DNA. This construction contains a sequence very similar to the consensus cis element reported to be responsible for cAMP enhancement of the rat somatostatin gene and also overlaps a sequence similar to the consensus element for the orphan steroid receptor SF-1. Gel mobility-shift analysis, using a 30-bp oligonucleotide containing this region incubated with cellular extracts from cultured mouse adrenal Y-1 and mouse Leydig MA-10 cells, revealed all the extracts to contain two proteins that bind to this sequence. Neither DNA-protein complex was further retarded by co-incubation with an anti-CREB antibody, suggesting that cAMP regulation of this gene occurs via a non-CREB protein. Mutation of this oligonucleotide resulted in loss of binding of only one of these proteins, but resulted in loss of both basal and cAMP stimulation of rat P450c17 promoter-regulated gene transcription. Southwestern analysis suggests that one of these proteins is larger than SF-1. This study suggests that a protein that binds to an SF-1 like sequence regulates both basal and cAMP-stimulated rat P450c17 gene expression in rodent cells.

Elevated serum progesterone levels on the day of human chorionic gonadotropin administration do not predict outcome in assisted reproduction cycles.

OBJECTIVE: To determine if the level of serum P drawn on the day of hCG administration predicts assisted reproductive technology (ART) outcome in patients undergoing stimulation with hMG under GnRH agonist (GnRH-a) suppression. DESIGN: Retrospective P assay of stored serum. PATIENTS: One hundred seventy-one patients (189 cycles) who had undergone GnRH-a suppression (leuprolide acetate or nafarelin) and stimulation with hMG for an ART procedure. MAIN OUTCOME MEASURES: Progesterone RIA of serum obtained on the day of hCG administration. Measurement of sequential serum LH values by RIA in those patients with the highest P levels. RESULTS: Pregnancy rates per oocyte retrieval were not correlated with the P level before hCG administration. There were 18 of 54 (33.3%) clinical pregnancies in those cycles with P < 0.9 ng/mL (conversion factor to SI unit, 3.180) and 42 of 135 (31.1%) clinical pregnancies in cycles with a P > or = 0.9 ng/mL. Significantly higher serum E2 levels and numbers of of follicles and oocytes obtained were observed in the high P cycles. There were no differences in the number of oocytes fertilized, the number of embryos transferred, or the implantation rate. However, a significantly higher percentage of mature oocytes were fertilized in the low P cycles (73%), as compared with the high P cycles (60%). CONCLUSIONS: Serum P levels before hCG administration do not predict the outcome of ART cycles in patients suppressed with GnRH-a before hMG stimulation. Lower fertilization rates observed in the high P cycles did not have an effect on clinical outcome.

The choice of a gonadotropin-releasing hormone analog influences outcome of in vitro fertilization treatment.

OBJECTIVE: Our purpose was to determine if there is a difference in outcome associated with choice of gonadotropin-releasing hormone analog in in vitro fertilization treatment cycles. STUDY DESIGN: A retrospective analysis of 510 consecutive in vitro fertilization cycles with patient-selected use of either nafarelin (Synarel) or leuprolide (Lupron) was performed. RESULTS: Of 510 consecutive patient cycles, 284 patients (56%) chose nafarelin and 226 (44%) chose leuprolide. In the nafarelin group 64 cycles (34% of retrievals) resulted in deliveries. In the leuprolide group 37 (24%) resulted in delivery (p < 0.05). There were 260 patients in their first cycle of treatment, with 157 (60%) choosing nafarelin, resulting in 33 deliveries (34% per retrieval). Leuprolide, used in 103 (40%) of first cycles, resulted in 12 deliveries (20% per retrieval), (p = 0.052). CONCLUSIONS: In a large population of unselected patients undergoing in vitro fertilization the choice of nafarelin was associated with a significantly better outcome in terms of successful pregnancies achieved.

Constraints on Mueller matrices of polarization optics.

The issue of physical realizability constraints on depolarizing scattering or imaging systems is addressed. In particular, the overpolarization problem, i.e., the problem of ensuring that the output degree of polarization is always smaller than (or equal to) unity, is discussed in detail. A set of necessary conditions for the elements of a Mueller matrix is derived. These conditions can be used to test the accuracy of polarimetric measurements and computations. Several recent experimental examples from polarization optics and radar are discussed.