Routine double-ovarian-stimulation (DuoStim) in poor responders lacks rationale, evidence, and follow-up.

Double ovarian stimulation (DuoStim), initially only suggested for fertility preservation in cancer patients, is now increasingly also used in routine clinical IVF, especially in poor responders. The claimed rational for this is the alleged existence of multiple follicular waves in a single intermenstrual interval, allowing for retrieval of more oocytes in a single IVF cycle. This commentary argues that this expansion of purpose lacks rationale, evidence, and follow-up. Consequently, we suggest that, unless valid clinical indications have been established, DuoStim be only subject of controlled clinical trials with appropriate experimental consents.

Why double ovarian stimulation in an in vitro fertilization cycle is potentially unsafe.

The occurrence of two antral follicle recruitment waves in a single inter-ovulatory interval has been detected in ovaries of normal women. This data supports the claim that a double ovarian stimulation in the same cycle may benefit poor responder patients with an increased recovery of mature oocytes and good quality embryos per single cycle. The double stimulation protocol was the object of several published studies in which, surprisingly, the mechanism and the safety of the double stimulation in the same cycle were poorly addressed. We propose that in the double stimulation protocol, the first stimulation impacts more committed oocytes progenitors ready to differentiate into mature oocytes. Conversely, the protracted exposure of developmentally earlier less-committed ovarian stem cells to FSH, which occurs in the double stimulation protocol, impacts the less differentiated stem cells which take longer to differentiate into oocytes. The proposed mechanism has broad implications for the safety of the double stimulation strategy.

The safety of VASApos presumptive adult ovarian stem cells.

Isolation and characterization of presumptive human adult ovarian stem cells (OSC) has broken the long standing dogma of the absence of postnatal neo-oogenesis. Human adult OSC have been immunosorted by antibodies reacting against the RNA helicase VASA and have been reported to engraft into appropriate stem cell niches to promote neo-oogenesis. Analysis of published research, however, questions some of the findings on isolation, characterization, in-vitro self-renewal and clinical safety of the presumptive human adult OSC. In the present study, human VASApos embryo-fetal primordial germ cells and presumptive adult OSC are shown to share several pluripotency and early germ cell markers not ascertained in the initial characterization of adult OSC. A new hypothesis is made that the restoration of fertility claimed to result from presumptive human adult OSC may be attributed instead to VASApos embryo-fetal primordial germ cell remnants in the adult ovary, or alternatively to earlier VASAneg germ cells generated by in-vitro de-differentiation of the presumptive OSC. The suggested hypotheses have extensive implications for the practice and safety of adult OSC in the development of new treatments aimed at rescuing the ovarian reserve.

Hypothesis: human trophectoderm biopsy downregulates the expression of the placental growth factor gene.

Preeclampsia (PE) and intrauterine growth retardation (IUGR) are the results of defective placentation associated with the downregulation of different genes in the human trophoblast including the Placental Growth Factor (PGF). TrophEctoderm (TE) biopsy is increasingly performed for Pre-implantation Genetic Testing of Aneuploidies and it involves the traumatical removal of an unpredictable number of mural TE cells from the human blastocyst. We observed strikingly similar obstetrical and neonatal complications in pregnancies where the placenta bears PGF downmodulation or a TE biopsy has been done. In both groups, the risk of PE, IUGR, congenital cardiac ventricular septal defects, caesarean section, sex ratio in favour of males and preterm birth is significantly increased compared to controls. Given the high degree of correlation, the observation may not be a casual one. We postulate herein that the TE biopsy may induce persistent dysregulation of different genes in the placenta including PGF. The mechanism proposed is the disruption of tight junctions caused by the TE biopsy.

The unknown human trophectoderm: implication for biopsy at the blastocyst stage.

Trophectoderm biopsy is increasingly performed for pre-implantation genetic testing of aneuploidies and considered a safe procedure on short-term clinical outcome, without strong assessment of long-term consequences. Poor biological information on human trophectoderm is available due to ethical restrictions. Therefore, most studies have been conducted in vitro (choriocarcinoma cell lines, embryonic and pluripotent stem cells) and on murine models that nevertheless poorly reflect the human counterpart. Polarization, compaction, and blastomere differentiation (e.g., the basis to ascertain trophectoderm origin) are poorly known in humans. In addition, the trophectoderm function is poorly known from a biological point of view, although a panoply of questionable and controversial microarray studies suggest that important genes overexpressed in trophectoderm are involved in pluripotency, metabolism, cell cycle, endocrine function, and implantation. The intercellular communication system between the trophectoderm cells and the inner cell mass, modulated by cell junctions and filopodia in the murine model, is obscure in humans. For the purpose of this paper, data mainly on primary cells from human and murine embryos has been reviewed. This review suggests that the trophectoderm origin and functions have been insufficiently ascertained in humans so far. Therefore, trophectoderm biopsy should be considered an experimental procedure to be undertaken only under approved rigorous experimental protocols in academic contexts.

Comparison of intrafollicular sperm injection and intrauterine insemination in the treatment of subfertility.

PURPOSE: To compare the efficacy of intrafollicular sperm injection (IFI) versus intrauterine insemination (IUI) in the treatment of subfertility. METHODS: 38 couples suffering primary or secondary subfertility contributed a total of 47 IUI or IFI cycles, 26 by IUI and 21 by IFI. Folliculogenesis, ovulation triggering, and IUI or IFI were performed. Motile spermatozoa were inseminated into the uterine cavity for IUI or injected into pre-ovulatory follicles for IFI. The rate of biochemical and clinical pregnancy was assessed. RESULTS: The rate of biochemical pregnancy/cycle for IUI was 11 % as compared to 38 % for IFI (p = 0.04). The rate of clinical pregnancy/cycle for IUI was 11 % as compared to 29 % for IFI (p = 0.26). The rate of twin pregnancy and miscarriage was low and no high order multiple gestation was observed. The rate of ectopic tubal pregnancy/cycle for IUI was 0 % as compared to 9 % for IFI (p = 0.19); no ovarian pregnancy was observed. When the analysis was confined to IFI cycles in which 2.68-6.65 million motile spermatozoa were injected/follicle (n = 10), a rate of 60 % clinical pregnancy/cycle was observed, of which 2 were ectopic. CONCLUSION: Under the conditions described herein, IFI was more effective than IUI at achieving pregnancy.

Negligible serum anti-müllerian hormone: pregnancy and birth after a 1-month course of an oral contraceptive, ovarian hyperstimulation, and intracytoplasmic sperm injection.

OBJECTIVE: To describe a patient with isolated negligible (<0.5 ng/mL or <3.6 pmol/L) anti-müllerian hormone (AMH) levels who underwent intracytoplasmic sperm injection (ICSI) for severe oligoasthenoteratozoospermia, displayed ovarian hyperstimulation after a 1-month course of an oral contraceptive (OC), had a singleton pregnancy and delivered a healthy boy. DESIGN: Case report. SETTING: Reproductive center at a private hospital. PATIENT(S): A 34-year-old woman with isolated negligible (<0.5 ng/mL or <3.6 pmol/L) AMH level and poor response to controlled ovarian hyperstimulation (COH) and her 38-year-old partner with severe oligoasthenoteratozoospermia. INTERVENTION(S): A 1-month course of an OC, modified minimal stimulation cycle with recombinant FSH, antagonist (cetrorelix) administration to inhibit LH surge, triggered ovulation using 10,000 U of hCG and ICSI. MAIN OUTCOME MEASURE(S): Level of AMH, pregnancy, and birth. RESULT(S): Three high quality embryos were obtained and transferred 48 hours after ICSI. Transvaginal ultrasound at 8 weeks' gestation showed a vital singleton pregnancy. The pregnancy continued uncomplicated. The patient gave birth to a healthy boy, weighing 3,280 g, by caesarean section at 39 weeks' gestation. CONCLUSION(S): Ovarian hyperstimulation, pregnancy, and birth may occur after a short course of an OC and ICSI in poor responder, normogonadotropic, regularly menstruating young women with isolated negligible AMH.

Adenomyosis and 'endometrial-subendometrial myometrium unit disruption disease' are two different entities.

The diagnosis of adenomyosis is feasible on pathological specimen examination, while it is unreliable on clinical findings, biopsy, hysteroscopy, sonohysterography, and routine ultrasound or magnetic resonance imaging. Several patterns of 'abnormality' described on imaging have been linked to adenomyosis, but the correlation is weak and the diagnostic accuracy is low outside of a research context. Nevertheless, thickening or abnormality of the subendometrial myometrium, the outer part of the 'endometrial-subendometrial myometrium unit' (thought to be important in human fertility) has been repeatedly documented on imaging, called 'adenomyosis' and linked to infertility. This paper discusses the value of the physiological endometrial-subendometrial myometrium unit in human fertility, reviews the current criteria for its imaging, and reports on its relationship to fertility. It is proposed that endometrial-subendometrial myometrium unit disruption disease is considered as a new entity (distinguished from adenomyosis), the diagnosis of which is feasible and straightforward on imaging and expressed mainly by pathological thickening or abnormality of the subendometrial myometrium (myometrial halo or junctional zone). The study also reports on the influence of abnormal thickening or disruption on human fertility and outcome of assisted reproduction techniques, and demonstrates that this new entity is epidemiologically different from adenomyosis.

Mesenchymal stem cell: use and perspectives.

Studies on hematopoiesis have focused on the function and composition of human bone marrow stroma. Stroma function gives hematopoietic stem cells the microenvironment appropriate for self-renewal and/or prompt differentiation into hematopoietic progenitor cells, then into terminal specialized cells. Human bone marrow stroma has been dissected into hematopoietic and nonhematopoietic components. The former includes hematopoietic-derived cells, mainly macrophages, while the latter, still poorly characterized, is composed mainly of endothelial and mesenchymal stem cells and their derivatives (adipocytes, chondrocytes, cells of the osteogenic lineage). Isolation of bone marrow mesenchymal stem cells has made available a population of adherent cells, belonging to the non-hematopoietic stroma, which are morphologically and phenotypically homogeneous. This review will focus on: (i) definition of bone marrow stroma and mesenchymal stem cells; (ii) methods of mesenchymal stem cell isolation, morphological and phenotypic characterization; (iii) mesenchymal stem cell functional and differentiation properties and (iv) therapeutic applications of mesenchymal stem cells.

CD34+ cells from first-trimester fetal blood are enriched in primitive hemopoietic progenitors.

OBJECTIVE: The purpose of this study was to investigate whether purified CD34(+) cells from first-trimester fetal blood are a source of primitive and committed hemopoietic progenitors. STUDY DESIGN: CD34(+) cells from first-trimester fetal blood and term cord blood were assayed for committed hemopoietic progenitor cells, high proliferative potential colony-forming cells, and long-term culture-initiating cells. RESULTS: First-trimester CD34(+) cells that were compared with cells at term generated fewer hemopoietic progenitor cells and fewer high proliferative potential colony-forming cells with lower recloning efficiency(P <.001). First-trimester CD34(+) cells tended to contain more long-term culture-initiating cells, both in bulk cultures and by limiting dilution analysis. The ratio between committed and primitive progenitors was 3 in the first-trimester and 20 in the term cord blood, respectively. CONCLUSION: First-trimester fetal blood is enriched in primitive (compared with committed) hemopoietic progenitors and may be an advantageous source of stem cells for prenatal therapy.