Promoting Best Practices in Assisted Human Reproduction.

OBJECTIVES: Assisted human reproduction (AHR) is a complex process of clinical, laboratory, and organizational activities that involve risk and safety. The regulation of the Canadian fertility industry is a mix of federal and provincial/territorial responsibility. Oversight of care is fragmented as patients, donors, and surrogates may each live in different jurisdictions. The Canadian Medical Protective Association (CMPA) undertook a retrospective analysis of CMPA medico-legal data to identify the contributing factors to medico-legal risks for Canadian physicians providing AHR services. METHODS: Experienced CMPA medical analysts, reviewed information from closed cases. A previously reported medical coding methodology was applied to a 5-year retrospective descriptive analysis of CMPA cases closed between 2015 and 2019, involving physicians caring for patients with infertility seeking AHR. Class action legal cases were excluded. All contributing factors were analyzed using the CMPA Contributing Factor Framework.1 Cases were de-identified and reported at the aggregate level for analysis to ensure confidentiality for both patients and health care providers. RESULTS: There were 860 gynaecology cases with comprehensive information and peer expert review. Of these, 43 cases involved patients seeking AHR. Due to the small sample size, the results presented are for descriptive purposes only. AHR cases had an unfavourable outcome for the physician in 29 cases. Diagnostic error was noted in 10 cases. The most common patient allegations were related to a breakdown in communication. Peer experts were critical of patient care in 34 cases. These were divided among provider, team, and system factors. CONCLUSIONS: Diagnostic error was the most common clinical concern. Deficient clinical decision-making and communication breakdown with the patient contributed to these errors. Enhanced clinical decision-making, through heightened situational awareness, strengthened diagnostic test follow-up, and improved communication with the health care team may reduce medico-legal complaints related to AHR and improve patient safety.

Gene expression analysis of follicular cells revealed inflammation as a potential IVF failure cause.

PURPOSE: Hormonal stimulation prior to IVF influences the ovarian environment and therefore impacts oocytes and subsequent embryo quality. Not every patient has the same response to the same treatment and many fail for unknown reasons. Knowing why a cycle has failed and how the follicles were affected would allow clinicians to adapt the treatment accordingly and improve success rate. This study examines the hypothesis that transcriptomic analysis of follicular cells from failed IVF cycles reveals potential reasons for failure and provides new information on the physiological mechanisms related to IVF failure. METHODS: Follicular cells (granulosa cells) were obtained from IVF patients of four Canadian fertility clinics. Using microarray analysis, patients that did not become pregnant following the IVF cycle were compared to those that did. Functional analysis was performed using ingenuity pathway analysis and qRT-PCR was used to validate the microarray results in a larger cohort of patients. RESULTS: The microarray showed 165 differentially expressed genes (DEGs) in the negative group compared to the pregnancy group. DEGs include many pro-inflammatory cytokines and other factors related to inflammation, suggesting that this process might be altered when IVF fails. Overexpression of several factors, some of which act upstream from vascular endothelial growth factor (VEGF), also indicates increased permeability and vasodilation. Some DEGs were related to abnormal differentiation and increased apoptosis. CONCLUSIONS: Our results suggest that failure to conceive following IVF cycles could be associated with an imbalance between pro-inflammatory and anti-inflammatory mediators. The findings of this study identify potential failure causes and pathways for further investigation. Stimulatory protocols personalized according to patient response could improve the chances of later success.

Can peri-ovulatory putrescine supplementation improve egg quality in older infertile women?

The aging-related decline in fertility is an increasingly pressing medical and economic issue in modern society where women are delaying family building. Increasingly sophisticated, costly, and often increasingly invasive, assisted reproductive clinical protocols and laboratory technologies (ART) have helped many older women achieve their reproductive goals. Current ART procedures have not been able to address the fundamental problem of oocyte aging, the increased rate of egg aneuploidy, and the decline of developmental potential of the eggs. Oocyte maturation, which is triggered by luteinizing hormone (LH) in vivo or by injection of human chorionic gonadotropin (hCG) in an in vitro fertilization (IVF) clinic, is the critical stage at which the majority of egg aneuploidies arise and when much of an egg's developmental potential is established. Our proposed strategy focuses on improving egg quality in older women by restoring a robust oocyte maturation process. We have identified putrescine deficiency as one of the causes of poor egg quality in an aged mouse model. Putrescine is a biogenic polyamine naturally produced in peri-ovulatory ovaries. Peri-ovulatory putrescine supplementation has reduced egg aneuploidy, improved embryo quality, and reduced miscarriage rates in aged mice. In this paper, we review the literature on putrescine, its occurrence and physiology in living organisms, and its unique role in oocyte maturation. Preliminary human data demonstrates that there is a maternal aging-related deficiency in ovarian ornithine decarboxylase (ODC), the enzyme responsible for putrescine production. We argue that peri-ovulatory putrescine supplementation holds great promise as a natural and effective therapy for infertility in women of advanced maternal age, applicable in natural conception and in combination with current ART therapies.

Comparing Maternal Serum Screening Markers Among IVF and Spontaneous Conceptions in Ontario Through Registry Data.

OBJECTIVE: The objectives of this study were as follows: (1) to investigate the accuracy of IVF identification on the prenatal screening record from prenatal screening laboratories; (2) to compare the screening markers in IVF and non-IVF pregnancies in the population of Ontario; and (3) to propose more appropriate IVF adjustment factors for the Ontario population. METHODS: Two years of IVF treatment, data from all fertility clinics in Ontario were merged with the corresponding prenatal screening data from all five prenatal screening labs. New adjustment factors for IVF were developed for each maternal serum screening marker and nuchal translucency measurement. Means and SDs and linear regression models were reported for all prenatal screening records, as well as for records that had IVF identified through the prenatal screening requisition and records that were identified through the Canadian Assisted Reproductive Technologies Register (CARTR) Plus database. RESULTS: Significant differences between IVF and non-IVF groups on the basis of the prenatal screening requisition information and CARTR Plus information were found among the ethnicity-adjusted mean multiple of the medians for alpha fetoprotein, first trimester pregnancy-associated plasma protein A, second trimester unconjugated estradiol, first trimester human chorionic gonadotropin, total human chorionic gonadotropin, and dimeric inhibin A. CONCLUSION: This study proposed alternate IVF adjustment factors that will produce more accurate screening results within the population of Ontario.

Polycystic ovary syndrome: possible involvement of androgen-induced, chemerin-mediated ovarian recruitment of monocytes/macrophages.

Polycystic ovary syndrome (PCOS) is a continuum of endocrine and reproductive disorders characterized by hyperandrogenism, antral follicle growth arrest, and chronic inflammation. Macrophages play key role in inflammation, and the balance between M1 (inflammatory) and M2 (anti-inflammatory) macrophages determines physiological/pathological outcomes. Here, we investigated if hyperandrogenism increases ovarian chemerin altering the balance of M1 and M2 macrophages and the granulosa cell death. Ovarian chemerin was upregulated by 5α-dihydrotestosterone (DHT) in lean and overweight rats; while increased serum chemerin levels were only evident in overweight rats, suggesting that the serum chemerin may be reflective of a systemic response and associated with obesity, whereas increased ovarian chemerin expression is a localized response independent of the metabolic status. DHT altered follicle dynamics while increased the M1: M2 macrophages ratio in antral and pre-ovulatory follicles. While ovarian M1 macrophages expressing chemokine-like receptor 1 (CMKLR1) were increased, CMKLR1+ monocytes, which migrated toward chemerin-rich environment, were markedly decreased after 15 days of DHT. Androgen-induced granulosa cell apoptosis was dependent on the presence of macrophages. In humans, chemerin levels in follicular fluid, but not in serum, were higher in lean PCOS patients compared to BMI-matched controls and were associated with increased M1: M2 ratio. Our results support the concept that in PCOS, hyperandrogenemia increases chemerin expression while promotes CMKLR1+ monocytes recruitment and deregulates the immunological niche of ovaries. This study established a new immunological perspective in PCOS at the ovarian level. Hyperandrogenism is associated with upregulation of chemerin and macrophage unbalance in the ovaries.

Research on Human Embryos and Reproductive Materials: Revisiting Canadian Law and Policy.

Research involving human embryos and reproductive materials, including certain forms of stem cell and genetic research, is a fast-moving area of science with demonstrated clinical relevance. Canada's current governance framework for this field of research urgently requires review and reconsideration in view of emerging applications. Based on a workshop involving ethics, legal, policy, scientific and clinical experts, we present a series of recommendations with the goal of informing and supporting health policy and decision-making regarding the governance of the field. With a pragmatic and principled governance approach, Canada can continue its global leadership in this field, as well as advance the long-term health and well-being of Canadians.

Maternal serum screening markers and nuchal translucency measurements in in vitro fertilization pregnancies: a systematic review.

OBJECTIVE: To study the current literature on the association between IVF treatment and maternal serum screening marker levels and nuchal translucency thickness. DESIGN: Systematic review. SETTINGS: Not applicable. PATIENT(S): Eligible studies included those with an exposed group of pregnant women that used IVF with or without intracytoplasmic sperm injection to conceive and a control group of pregnant women who conceived spontaneously. INTERVENTION(S): IVF treatment to conceive. MAIN OUTCOME MEASURE(S): Outcomes evaluated included maternal serum screening markers (pregnancy-associated plasma protein A [PAPP-A], alpha-fetoprotein, hCG, unconjugated estriol, dimeric inhibin-A) and nuchal translucency thickness. RESULT(S): Database searches identified 4,118 titles and abstracts that were independently screened, which resulted in 76 articles that were assessed for eligibility. Additionally, one study was added for consideration based on expert knowledge. There were 29 cohort and 11 case-control studies in the descriptive review. The most commonly reported markers were PAPP-A and free ß-hCG, which were reported in 28 and 26 studies, respectively. The studies that reported effect sizes for PAPP-A and free ß-hCG were not statistically significant. CONCLUSION(S): A decrease in PAPP-A and an increase in total hCG was consistently reported among the included studies. However, owing to the variability in the levels of the other maternal serum screening markers reported and the inability to conduct a meta-analysis, we were unable to generalize about the differences between prenatal screening results in the IVF population.

Hysteroscopic resection in the management of early-stage endometrial cancer: report of 2 cases and review of the literature.

Although endometrial cancer, the most common gynecologic malignancy, is most often diagnosed in postmenopausal women, it affects young women who wish to preserve fertility. The purpose of this article is to describe 2 cases of stage IA endometrial cancer managed conservatively by a combination of hysteroscopic surgery and medical therapy for fertility-sparing purposes, one of which achieved successful pregnancy using assisted reproductive technology, and review the existing literature on the use of hysteroscopic resection in conservative management of endometrial cancer to preserve fertility. The addition of hysteroscopic resection to conservative management of early-stage endometrial carcinoma may be a way to improve response and recurrence rates in women wishing to preserve fertility and can offer other additional benefits, such as a shorter time period to remission and a faster return to fertility. Key factors to success with this approach include an interdisciplinary approach, thorough patient counseling, and the availability of a team experienced in hysteroscopic resection.

Does an intraabdominally placed LNG-IUS have an adverse effect on fertility? A case report.

This case of secondary infertility with an associated intraabdominal levonorgestrel intrauterine system (LNG-IUS) demonstrates the importance of adequate imaging in women with a missing intrauterine contraceptive device and the possible fertility implications of an extrauterine LNG-IUS.

Corifollitropin alfa or rFSH treatment flexibility options for controlled ovarian stimulation: a post hoc analysis of the Engage trial.

BACKGROUND: We sought to determine the impact of treatment flexibility on clinical outcomes in either a corifollitropin alfa or recombinant follicle-stimulating hormone (rFSH) protocol. METHODS: Post hoc analysis of a prospective, multicenter, randomized, double-blind, double-dummy non-inferiority clinical trial (Engage). Efficacy outcomes were assessed on patients from the Engage trial who started treatment on menstrual cycle day 2 versus menstrual cycle day 3, patients who received rFSH step-down or fixed-dose rFSH, patients who received rFSH on the day of human chorionic gonadotropin (hCG) compared with those who did not, and patients who received hCG when the criterion was reached versus those with a 1-day delay. RESULTS: The effect of each of the treatment flexibility options on ongoing pregnancy rate was not significant. The estimated difference (95% confidence interval) in ongoing pregnancy rate was -4.3% (-9.4%, 0.8%) for patients who started ovarian stimulation on cycle day 2 versus day 3, 1.8% (-4.1%, 7.6%) for patients who received hCG on the day the hCG criterion was met versus 1 day after, 3.2% (-2.1%, 8.6%) for patients who received rFSH on the day of hCG administration versus those who did not, and -5.8% (-13.0%, 1.4%) for patients who received a reduced versus fixed-dose of rFSH from day 8. CONCLUSIONS: Treatment flexibility of ovarian stimulation does not substantially affect the clinical outcome in patients' treatment following initiation of ovarian stimulation with either corifollitropin alfa or with daily rFSH in a gonadotropin-releasing hormone antagonist protocol. TRIAL REGISTRATION: Trial was registered under ClinicalTrials.gov identifier NCT00696800.

Chemerin suppresses ovarian follicular development and its potential involvement in follicular arrest in rats treated chronically with dihydrotestosterone.

In the present study, we have investigated the cellular mechanisms of androgen-induced antral follicular growth arrest and the possible involvement of chemerin and its receptor chemokine-like receptor 1 (CMKLR1) in this process, using a chronically androgenized rat model. We hypothesize that hyperandrogenism induces antral follicle growth arrest via the action of chemerin and ovarian structural changes, resulting from granulosa cell and oocyte apoptosis and theca cell survival. Dihydrotestosterone (DHT) treatment resulted in increased expression of chemerin and CMKLR1 in antral follicles, absence of corpus luteum, and increased atypical follicles. Addition of chemerin to follicle cultures induced granulosa cell apoptosis and suppressed basal, FSH- and growth differentiation factor-9-stimulated follicular growth. DHT down-regulated aromatase expression and increased active caspase-3 content and DNA fragmentation in granulosa cells in vivo. These changes were accompanied by higher phosphatase and tensin homolog and lower phospho-Akt (Ser473) content in antral follicles and higher calpain expression and down-regulation of cytoskeletal proteins in atypical follicles, which were constituted predominantly of theca cells. DHT also activated granulosa cell caspase-3, decreased X-linked inhibitor of apoptosis protein, poly(ADP-ribose) polymerase, and phospho-Akt contents and induced apoptosis in vitro, responses readily attenuated by forced X-linked inhibitor of apoptosis protein expression. These findings are consistent with our hypothesis that antral follicular growth arrest in DHT-treated rats results from increased chemerin expression and action, as well as changes in follicular cell fate and structure, which are a consequence of dysregulated interactions of pro-survival and pro-apoptotic modulators in a cell-specific manner. Our observations suggest that this chronically androgenized rat model may be useful for studies on the long-term effects of androgens on folliculogenesis and may have implications for the female reproductive disorders associated with hyperandrogenism.

Follicular stage-dependent regulation of apoptosis and steroidogenesis by prohibitin in rat granulosa cells.

BACKGROUND: Follicular growth and atresia are tightly regulated processes, which involve the participation of endocrine, autocrine and paracrine factors at the cellular level. Prohibitin (PHB) is a multifunctional intracellular protein playing an important role in the regulation of proliferation, apoptosis and differentiation. Here we examined the expression of PHB and its regulation by FSH in vitro and studied the role of PHB in the regulation of apoptosis and steroidogenesis in response to the apoptosis inducer staurosporine (STS) and to FSH, respectively. METHODS: Undifferentiated and differentiated granulosa cells were collected from diethylstilbestrol (DES)- and equine chronic gonadotropin (eCG)-primed immature rats, respectively and then cultured with various treatments (FSH, adenovirus infection, STS) according to experimental design. The apoptosis rate, the production of estradiol and progesterone, and the expression of distinct proteins (PHB, caspase-3, phospho- and total Akt) were assessed. RESULTS: PHB is anti-apoptotic and its action is dependent on the differentiated state of the granulosa cells. Data from gain- and loss-of-function experiments demonstrate that PHB inhibited STS-induced caspase-3 cleavage and apoptosis in undifferentiated granulosa cells, but was ineffective in differentiated cells. In contrast, PHB suppresses FSH-induced steroidogenesis and this response is evident irrespective of the differentiated state of granulosa cells. CONCLUSION: These findings suggest that PHB regulates granulosa cell apoptosis and steroidogenesis in a follicular stage-dependent manner and that the dysregulation of PHB expression and action may be relevant to ovarian dysfunction.

Personalized prediction of first-cycle in vitro fertilization success.

OBJECTIVE: To test whether the probability of having a live birth (LB) with the first IVF cycle (C1) can be predicted and personalized for patients in diverse environments. DESIGN: Retrospective validation of multicenter prediction model. SETTING: Three university-affiliated outpatient IVF clinics located in different countries. PATIENT(S): Using primary models aggregated from >13,000 C1s, we applied the boosted tree method to train a preIVF-diversity model (PreIVF-D) with 1,061 C1s from 2008 to 2009, and validated predicted LB probabilities with an independent dataset comprising 1,058 C1s from 2008 to 2009. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Predictive power, reclassification, receiver operator characteristic analysis, calibration, dynamic range. RESULT(S): Overall, with PreIVF-D, 86% of cases had significantly different LB probabilities compared with age control, and more than one-half had higher LB probabilities. Specifically, 42% of patients could have been identified by PreIVF-D to have a personalized predicted success rate >45%, whereas an age-control model could not differentiate them from others. Furthermore, PreIVF-D showed improved predictive power, with 36% improved log-likelihood (or 9.0-fold by log-scale; >1,000-fold linear scale), and prediction errors for subgroups ranged from 0.9% to 3.7%. CONCLUSION(S): Validated prediction of personalized LB probabilities from diverse multiple sources identify excellent prognoses in more than one-half of patients.

Inhibitory roles of prohibitin and chemerin in FSH-induced rat granulosa cell steroidogenesis.

Follicular differentiation is a tightly regulated process involving various endocrine, autocrine, and paracrine factors. The biosynthesis of progesterone and estradiol in response to FSH involves the regulation of multiple steroidogenic enzymes, such as p450 cholesterol side-chain cleavage enzyme and aromatase. Here we demonstrated that prohibitin (PHB), a multifunctional protein, inhibits FSH-induced progesterone and estradiol secretion in rat granulosa cells. The mRNA abundances of cyp11a (coding p450 cholesterol side-chain cleavage enzyme) and cyp19 (coding aromatase) were also suppressed by PHB in a time-dependent manner. It is known that a novel adipokine chemerin suppresses FSH-induced steroidogenesis in granulosa cells. Chemerin up-regulates the content of PHB, and PHB knockdown attenuates the suppressive role of chemerin on steroidogenesis. In addition, inhibition of phosphatidylinositol 3-kinase/Akt pathway enhances the suppressive action of PHB, whereas expression of constitutively active Akt attenuates this response. These findings suggest that PHB is a novel negative regulator of FSH-induced steroidogenesis, and its action with chemerin may contribute to the dysregulation of steroidogenesis in the pathogenesis of polycystic ovarian syndrome.