Testicular fine-needle aspiration in infertile men with absolute non-obstructive azoospermia: A single-centre cohort study.

BACKGROUND: The methodology of surgically extracted sperm cells in fertility treatments remains debated, mainly due to the lack of data evaluating its predictive value on treatment outcomes. AIM: To gain insight into the effectiveness of testicular fine-needle aspiration (TEFNA) in a cohort of infertile men with absolute non-obstructive azoospermia and to examine whether the number of retrieved sperm cells affects the fertilisation rate. MATERIALS AND METHODS: A total of 89 infertile men, aged 26-47, meticulously diagnosed with non-obstructive azoospermia, participated in the study. All participants underwent TEFNA. The primary outcome measure was the TEFNA success rate in retrieving mature sperm. The secondary outcome measures included fertilisation rate, clinical pregnancy rates, and live births associated with the retrieved sperm. RESULTS: Sperm cells were successfully retrieved from 40 out of 89 patients (45%) with no significant postoperative complications. Retrieval of up to ten sperm cells occurred in 11 procedures (25%); ten procedures (22.7%) resulted in producing dozens of sperm cells, and 100s to 1000s of sperm cells were obtained from the remainder of 23 procedures (52.3%). Patients whose TEFNA resulted in only a few sperm cells had a much lower fertilisation rate (16.6%) than the other two groups (40.1% and 47.2%, respectively, P = 0.003). CONCLUSIONS: The utilisation of TEFNA for sperm extraction in men with non-obstructive azoospermia is a simple, fast-learning, effective, and safe treatment option. In cases where sperm retrieval was successful, the fertilisation rate was strongly related to the number of sperm cells obtained.

Use of complementary medical therapies by Israeli patients undergoing in vitro fertilization.

OBJECTIVE: To evaluate the prevalence and characteristics of complementary medical therapy (CMT) use among Israeli couples undergoing in vitro fertilization (IVF). METHODS: In a cross-sectional study, men and women undergoing treatment at four IVF units in Israel were invited to complete an anonymous questionnaire between May 2010 and December 2011. Patients were considered users of CMT if they reported that either partner used at least one type of CMT for treating infertility. Stepwise backward logistic regression was used to assess the independent effects of variables on CMT utilization. RESULTS: Of 511 patients approached, 400 (78.1%) completed the survey and 159 (39.8%) indicated that CMT for infertility was used by one or both partners. Higher CMT use was significantly associated with the treating hospital, post high-school education, more than three previous IVF trials, being employed, and using psychosocial support (all P<0.05). Most users (75/129; 58.1%) did not notify the IVF clinic medical staff about concurrent use of CMT. CONCLUSION: Use of CMTs was widely reported by Israeli patients undergoing IVF, particularly those with higher education, and those undergoing repeated IVF trials and receiving psychosocial support. IVF staff ought to be aware of the widespread utilization of CMTs because the impact of these therapies on IVF outcomes is inconclusive.

Prospective evaluation of early follicular ovarian stromal blood flow in infertile women undergoing IVF-ET treatment.

BACKGROUND: To evaluate the role of early follicular stromal flow studies in predicting ovarian response during IVF-ET treatment and to assess their correlation with ovarian reserve parameters and clinical pregnancy achievement. MATERIALS & METHODS: One hundred and sixty-eight consecutive and unselected infertile women undergoing their first IVF-ET treatment were included in the study. Basal ovarian reserve and stromal Doppler flow studies were performed in a natural cycle before starting treatment. Four Doppler indices were measured; peak systolic velocity (PSV), pulsatility index (PI), resistance index (RI) and systole/diastole ratio (S/D). Following completion of IVF-ET treatment Pearson's correlation analysis was performed to examine the correlation between Doppler indices, ovarian response, basal ovarian reserve parameters and clinical pregnancy achievement. RESULTS: A positive correlation was found between the number of ≥14 mm follicles on hCG day and PSV. The number of ≥14 mm follicles and retrieved oocytes had a significant negative correlation with RI and S/D ratio. As well, the number of fertilized oocytes had a significant negative correlation with S/D ratio. Absence of a Doppler signal in one or both ovaries was significantly higher in the women with poor response (31%) as compared to women with normal response (16%). In addition, RI correlated positively with basal FSH as well as FSH/LH ratio and negatively with AFC. The S/D ratio had a negative correlation with AFC (p = 0.027). A significant positive correlation between PSV, total ovarian volume (p = 0.011) and mean ovarian volume (p = 0.019) was detected. However, no correlation between all four Doppler indices and age was detected. Moreover, Doppler indices did not differ significantly between conception and non-conception cycles following IVF-ET treatment. CONCLUSIONS: Early follicular stromal Doppler signals is correlated with ovarian response as well as basal ovarian reserve parameters, but have no correlation with age neither with clinical pregnancy achievement in infertile women undergoing IVF-ET treatment.

Successful monozygotic twin pregnancy fathered by a male 46,XY true hermaphrodite.

This report presents an unusual case of absolute non-obstructive azoospermia revealed to be a male 46,XY true hermaphrodite who was successfully treated to father healthy monozygotic twins. A 27-year-old infertile male with non-obstructive azoospermia previously underwent an unsuccessful testicular sperm extraction procedure and refused donor sperm insemination.Revising the patient's old records revealed that he was born with ambiguous genitalia. He had a 46,XY karyotype and was raised as a male. During childhood he underwent ambiguous genitalia reconstruction, right orchiopexy and left salpingo-oophorectomy that revealed a gonadoblastoma. A new treatment was employed performing testicular fine needle aspiration leading successfully to a monozygotic twin pregnancy. As far as is known, this is the first reported case of healthy twins fathered by a male 46,XY true hermaphrodite.

A simple multivariate score could predict ovarian reserve, as well as pregnancy rate, in infertile women.

OBJECTIVE: To find a simple multivariate score that has the potential to predict ovarian reserve, as well as pregnancy rate, in infertile women. DESIGN: A prospective study. SETTING: A university-affiliated reproductive medicine unit. PATIENT(S): One hundred sixty-eight consecutive women undergoing their first IVF-ET treatment at our unit. INTERVENTION(S): Basal ovarian reserve studies, endocrine and sonographic, were performed before starting therapy. After completion of treatment, a logistic regression analysis was performed to examine which parameters significantly determined low ovarian reserve. These parameters were incorporated thereafter in a multivariate score to predict ovarian reserve, as well as clinical pregnancy rate. MAIN OUTCOME MEASURE(S): Low ovarian reserve defined as 14 was shown to be more accurate in predicting low ovarian reserve than age, day 3 FSH, or antral follicle count separately. Moreover, a score of >14 was shown to have a sensitivity of 88% and a specificity of 69% in predicting low ovarian reserve. More important, women with a score of >14 had significantly lower clinical implantation and pregnancy rates relative to women with a score of

Early and short follicular gonadotropin-releasing hormone antagonist supplementation improves the meiotic status and competence of retrieved oocytes in in vitro fertilization-embryo transfer cycles.

OBJECTIVE: To investigate whether early and short follicular administration of GnRH antagonist using the flexible protocol has the potential to improve IVF-ET clinical results. DESIGN: Prospective, controlled, randomized study. SETTING: University-affiliated assisted reproductive technology unit. PATIENT(S): Fifty-three consecutive infertile women were enrolled to the study and control groups. INTERVENTION(S): Both groups were treated with recombinant FSH and the flexible GnRH antagonist protocol. Women in the study group were additionally supplemented with three injections of GnRH antagonist (0.25 mg/d on days 1, 2, and 3 of the menstrual cycle). MAIN OUTCOME MEASURE(S): Hormonal milieu, oocyte meiotic status, competence for normal fertilization, cleavage, and clinical pregnancy rate. RESULT(S): Both groups had comparable baseline characteristics. The duration of recombinant FSH treatment was significantly longer in the study group as compared with the control group (10.9+/-3.1 and 9.7+/-1.3 days, respectively). The number of follicles>or=14 mm and E2 level on the day of hCG administration, number of retrieved oocytes, and endometrial thickness were similar between the two groups. However, the fertilization rate was significantly higher in the study as compared with the control group (85%+/-16% and 69%+/-24%, respectively). Moreover, the cumulative rate of mature first polar body oocytes was significantly higher in the study group as compared with the control group (93% and 85%, respectively). Concomitantly, day-3 FSH and LH levels after initiation of treatment were significantly lower in the study as compared with the control group (6.1+/-2.4 mIU/mL vs. 7.2+/-1.9 mIU/mL and 2.4+/-1.6 mIU/mL vs. 5.6+/-2.7 mIU/mL, respectively). CONCLUSION(S): Early and short follicular GnRH antagonist supplementation using flexible GnRH antagonist treatment improves the meiotic status and competence of retrieved oocytes. It seems that early and short pituitary shutdown has the potential to improve clinical results in IVF-ET GnRH antagonist cycles.

Does first polar body morphology predict oocyte performance during ICSI treatment?

PURPOSE: To gain insight into the morphology of the first polar body (1 PB) in ICSI patients and to explore whether it could predict mature oocyte viability and performance in this setting. METHODS: Seventy two consecutive women planned to perform ICSI treatment were prospectively recruited for this study. All oocytes retrieved underwent evaluation for nuclear maturity and accurate assessment of 1 PB morphology. MII oocytes were cultured in separate groups in each woman in accordance with two different categories of 1 PB morphology. Category A included normal intact round or ovoid 1 PB and category B included abnormal fragmented 1 PB. Each oocyte was followed throughout fertilization, embryo cleavage and embryo transfer. Cycles that reached embryo transfer, were divided into three groups in accordance with 1 PB morphology. Group I included only category A 1 PB embryos, group II included categories A and B 1 PB embryos, whereas group III included only category B 1 PB embryos. RESULTS: A total of 687 oocytes were aspirated and 553 MII oocytes underwent ICSI leading to 410 zygotes showing normal fertilization on day one. Three hundred ninety seven embryos cleaved on day two and a total of 176 embryos were replaced into the uterus. Clinical implantation and pregnancy rates were significantly correlated with the morphology of the 1 PB corresponding to 31%, 9% and 2% and 61%, 24% and 5%, in groups I, II and III respectively. CONCLUSIONS: Our findings demonstrate that 1 PB morphology is related to mature oocyte viability and it has the potential to predict oocyte performance and pregnancy achievement in infertile women undergoing ICSI treatment.

First polar body and nucleolar precursor body morphology is related to the ovarian reserve of infertile women.

This study was undertaken in order to gain insight into the morphology of the first polar body (PB1) and the two pronuclei (2PN) in ICSI patients, specifically the nucleolar precursor bodies (NPB). Whether early abnormalities in these structures are related to the ovarian reserve of infertile women was also studied. Eighty consecutive infertile women were prospectively investigated throughout their first ICSI cycles. Basal ovarian reserve studies were performed in all women. Cycles were evaluated with respect to PB1 and 2PN morphology of the transferred embryos. Cycles that had at least one transferred embryo with normal PB1 and 2PN morphology had significantly better basal ovarian reserve parameters compared with cycles in which all transferred embryos had abnormal PB1 and 2PN morphology. Moreover, the normal morphology group performed significantly better throughout the ovarian stimulation, compared with the abnormal morphology group. Furthermore, the clinical implantation and pregnancy rates were significantly higher in the normal compared with the abnormal morphology group, corresponding to 20.7% versus 10.6% and 42.4% versus 18.2%, respectively. The study concluded that the morphology of the PB1 in metaphase II oocytes as well as that of the NPB within the 2PN zygotes seems to be related to the ovarian reserve in infertile women.

Undetectable basal ovarian stromal blood flow in infertile women is related to low ovarian reserve.

To gain insight into the physiological significance of basal ovarian stromal blood flow and to assess whether its detection ability is related to ovarian reserve in infertility patients undergoing in vitro fertilization (IVF) - embryo transfer (ET) treatment. Thirty two consecutive infertile women scheduled for IVF-ET treatment were prospectively evaluated. Basal ovarian hormonal, ovarian volume and stromal blood flow studies were performed on day 3 of a natural cycle before treatment. The performer of the ultrasound studies was blinded to the clinical data. Women in the study were divided into two groups in accordance with estradiol level on the day of administration of human chorionic gonadotropin. Day-3 follicle-stimulating hormone and ovarian volume were significantly poorer in the women with low (group A) as compared with good (group B) ovarian reserve. Likewise, the numbers of follicles > or =14 mm in diameter, oocytes retrieved and embryos achieved were significantly lower in group A than group B. Six clinical pregnancies were obtained in group B, whereas no pregnancy was obtained in group A. Nine out of the 15 (60%) women in group A had undetectable basal stromal blood flow in at least one of the ovaries, whereas only one of the 17 (6%) women in group B had undetectable flow (p < 0.002). Basal stromal peak systolic blood flow velocity, pulsatility index and resistance index mean values did not differ significantly between the two groups. We conclude that undetectable basal ovarian stromal blood flow in at least one ovary is related to low ovarian reserve in infertile women undergoing IVF-ET. It seems that undetectable basal stromal blood flow is not solely a technical issue, but rather linked to the pathophysiology of ovarian aging.

Poor oocyte retrieval is a manifestation of low ovarian reserve.

Women with complete absence of oocytes during retrieval, as well as those with less than the 10th percentile of the expected number of oocytes retrieved, have clear manifestations of low ovarian reserve. It seems that this occurrence is a gradual biological phenomenon related to the basic pathophysiology of ovarian aging.