Decreased fertility in poor responder women is not related to oocyte morphological status

Introduction: In women showing impaired fertility, a decreased response to ovarian stimulation is a major problem, limiting the number of oocytes to be used for assisted reproduction techniques (ART). Despite the several definitions of poor response, it is still a matter of debate whether young poor responder patients also show a decrease in oocyte quality. The objective in this study was to investigate whether poor ovarian response to the superstimulation protocol is accompanied by impaired oocyte quality.Material and methods: This study included 313 patients younger than 35 years old, undergoing intracytoplasmic sperm injection. Patients with four or fewer MII oocytes (poor-responder group, PR, n = 57) were age-matched with normoresponder patients (NR, n = 256).Results: A higher rate of oocyte retrieval and a trend towards an increase in MII oocyte rate were observed in the NR group when compared to the PR group (71.6 +/- 1.1% and 74.1 +/- 1.0% vs. 56.3 +/- 2.9% and 66.5 +/- 3.7%; p < 0.0001 and p = 0.056, respectively). A trend toward increased implantation rates was observed in the NR group when compared to the PR group (44 and 24.5 +/- 2.0% vs. 28.8 and 16.4 +/- 3.9%; p = 0.0305 and p = 0.0651, respectively).Conclusions: Low response to ovarian stimulation is apparently not related to impaired oocyte quality. However, embryos produced from poor responder oocytes show impaired capacity to implant and to carry a pregnancy to term.

Are poor responders patients at higher risk for producing aneuploid embryos in vitro?

Purpose To test the hypothesis that aged women with poor ovarian response express an increase on embryo chromosomal alterations when compared to aged women who presented normal response.Methods Couples undergoing intracytoplasmic sperm injection cycles with preimplantation genetic screening, were subdivided into two groups: Poor Responder group (n = 34), patients who produced a parts per thousand currency sign4 oocytes; and Normoresponder group (n = 50), patients who produced a parts per thousand yen5 oocytes. Groups were compared regarding cycles' outcomes and aneuploidy frequency.Results There were no significant differences between and groups regarding the fertilization rate (p = 0.6861), clinical pregnancy (p = 0.9208), implantation (p = 0.6863), miscarriage (p = 0.6788) and the percentage of aneuploid embryos (p = 0.270). Embryo transfer rate was significantly lower on poor responder group (p = 0.0128) and logistic regression confirmed the influence of poor response on the chance of embryo transfer (p = 0.016).Conclusions Aged females responding poorly to gonadotrophins are not at a higher risk for producing aneuploid embryos in vitro.

Agonistas do GnRH, antagonistas do GnRH e a reprodução assistida: Análogos do GnRH x fertilização in vitro

The agonists of gonadotropin-releasing hormone (GnRH) were introduced in ovarian stimulation for in vitro fertilization to avoid a premature surge of luteinizing hormone. Although they are accompanied by some disadvantages, GnRH agonists have become well accepted in clinical practice, and their use is associated with increased rates of pregnancy. The development of GnRH antagonists capable of blocking the pituitary immediately offered a therapeutic option. Comparative studies between the two analogs have suggested that the use of antagonists is associated with a shorter duration of ovulatory stimulus and a decreased incidence of ovarian hyperstimulation syndrome, while the type of GnRH analogues used show no significant effects on the rates of pregnancy and live birth. However, GnRH agonists have other applications in assisted reproductive technology cycles than the pituitary downregulation.

Estimulação ovariana, recuperação e maturação de oócitos de veado-catingueiro (Mazama gouazoubira)

Pós-graduação em Medicina Veterinária - FCAV

Eficácia da motilidade espermática pós-capacitação e encubação na predição de gravidez

Pós-graduação em Ginecologia, Obstetrícia e Mastologia - FMB

Sistema eletrônico para geração e avaliação de movimentos em paraplégicos

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Aspiração folicular videolaparoscópica em ovelhas recém-desmamadas submetidas à estimulação ovariana

Pós-graduação em Medicina Veterinária - FCAV

Efficacy of sperm motility after processing and incubation to predict pregnancy after intrauterine insemination in normospermic individuals

Background: Intrauterine insemination (IUI) is widely used to treat infertility, and its adequate indication is important to obtain good pregnancy rates. To assess which couples could benefit from IUI, this study aimed to evaluate whether sperm motility using a discontinuous gradient of different densities and incubation in CO2 in normospermic individuals is able to predict pregnancy.Methods: A total of 175 couples underwent 175 IUI cycles. The inclusion criteria for women were as follows: 35 years old or younger (age range: from 27 to 35 years) with normal fallopian tubes; endometriosis grades I-II; unexplained infertility; nonhyperandrogenic ovulatory dysfunction. Men with normal seminal parameters were also included. All patients underwent ovarian stimulation with clomiphene citrate and human hMG or r-FSH. When one or (at most) three follicles measuring 18 to 20 mm were observed, hCG (5000 UI) or r-hCG (250 mcg) was administered and IUI performed 36-40 h after hCG. Sperm processing was performed using a discontinuous concentration gradient. A 20 microliters aliquot was incubated for 24 h at 37 degrees C in 5% CO2 following a total progressive motility analysis. The Mann-Whitney and Chi-square tests, as well as a ROC curve were used to determine the cutoff value for motility.Results: Of the 175 couples, 52 (in 52 IUI cycles) achieved clinical pregnancies (CP rate per cycle: 29.7%). The analysis of age, duration and causes of infertility did not indicate any statistical significance between pregnancy and no pregnancy groups, similar to the results for total sperm count and morphology analyses, excluding progressive motility (p < 0.0001). The comparison of progressive motility after processing and 24 h after incubation between these two groups indicated that progressive motility 24 h after incubation was higher in the pregnancy group. The analysis of the progressive motility of the pregnancy group after processing and 24 h after incubation has not shown any motility difference at 24 h after incubation; additionally, in couples who did not obtain pregnancy, there was a statistically significant decrease in progressive motility 24 h after incubation (p < 0.0001). The ROC curve analysis generated a cutoff value of 56.5% for progressive motility at 24 h after incubation and this cutoff value produced 96.1% sensitivity, 92.7% specificity, 84.7% positive predictive value and 98.3% negative predictive value.Conclusions: We concluded that the sperm motility of normospermic individuals 24 h after incubation at 37 degrees C in 5% CO2, with a cutoff value of 56.5%, is predictive of IUI success.

Der Einfluss assistierter Reproduktionstechniken auf die epigenetische Reprogrammierung in der fruehen Embryogenese und Gametogenese im Mausmodell

Seit der Geburt von Louise J. Brown (1978) als erstem künstlich erzeugtem Kind hat sich die Nachfrage nach assistierten Reproduktionstechniken (ART) stark erhöht. Der Anteil der nach In-vitro-Fertilisation (IVF) oder Intrazytoplasmatischer Spermieninjektion (ICSI) geborenen Kinder macht mittlerweile abhängig vom betrachteten Industrieland zwischen 1-4% an der Gesamtgeburtenzahl aus. In zahlreichen Studien korreliert eine erhöhte Prävalenz für seltene Imprinting-Erkrankungen, wie z.B. Beckwith-Wiedemann oder Angelman-Syndrom, mit der Geburt nach assistierten Reproduktionstechniken. Es ist bekannt, dass die medizinischen Interventionen zur Behandlung von Sub- und Infertilität in sehr sensitive Phasen der epigenetischen Reprogrammierung des Embryos und der Keimzellen eingreifen. In der vorliegenden Arbeit wurde untersucht, ob die ovarielle Stimulation einen Einfluss auf die epigenetische Integrität von geprägten Genen in murinen Präimplantationsembryonen hat. Die in diesem Zusammenhang entwickelte digitale Bisulfitpyrosequenzierung gewährleistet die Analyse der DNA-Methylierung auf Einzelallelebene durch eine adäquate Verdünnung der Probe im Vorfeld der PCR. Die ovarielle Induktion führte zu einem erhöhten Rate an Epimutationen des paternalen H19-Allels, sowie des maternalen Snrpn-Allels. Zudem konnte festgestellt werden, dass die Expression von drei potentiellen Reprogrammierungsgenen (Apex1, Polb, Mbd3) in Embryonen aus hormonell stimulierten Muttertieren dereguliert ist. Whole-Mount Immunfluoreszenzfärbungen für APEX1 korrelierten dessen differentielle Genexpression mit dem Proteinlevel. Anzeichen früher apoptotischer Vorgänge äußerten sich in Embryonen aus hormonell induzierten Muttertieren in der hohen Rate an Embryonen, die keines der drei Transkripte exprimierten oder weniger APEX1-positive Blastomeren aufwiesen.In einer weiteren Fragestellung wurde untersucht, ob die Kryokonservierung muriner Spermatozoen den epigenetischen Status geprägter Gene in den Keimzellen beeinflusst. Die Analyse von F1-Zweizellembryonen, die durch IVF mit den jeweiligen Spermatozoen eines Männchens generiert wurden, diente der Aufklärung möglicher paternaler Transmissionen. Insgesamt konnten keine signifikanten Auswirkungen der Kryokonservierung auf den epigenetischen Status in Spermatozoen und F1-Embryonen ermittelt werden.

Der prognostische Wert des Anti-Müller-Hormons in der Reproduktionsmedizin

In der Arbeit wurde sich mit der Frage beschäftigt inweit das Anti-Müller-Hormon als prognostischer Faktor in der Reproduktionsmedizin gewertet werden kann. Parameter die von Bedeutung waren, sind Alter der Patientin, AMH-Wert im Serum, Menge an rekombinanten FSH das zur ovariellen Stimulation benötigt wurde, Tage an den denen mit FSH stimuliert wurde, Anzahl der gewonnenen und befruchteten Eizellen, Abbruchraten und Schwangerschaftsraten. rnDiese Parameter wurden mit dem AMH-Wert im Serum der Frau in Zusammenhang gebracht. Es konnte ein Zusammenhang zwischen dem Alter der Patientin, der Menge an rekombinanten FSH das zur ovariellen Stimulation benötigt wurde, der Anzahl der gewonnenen und befruchteten Eizellen, der Abbruchraten und Schwangerschaftsraten in Abhängigkeit vom AMH-Wert nachgewiesen werden.

Anti-Müllerian hormone and inhibin B as predictors of pregnancy after treatment by in vitro fertilization/intracytoplasmic sperm injection

OBJECTIVE: To evaluate anti-Müllerian hormone (AMH) as a marker of reproductive outcome after IVF/intracytoplasmic sperm injection (ICSI). DESIGN: Longitudinal study. SETTING: University hospital. PATIENT(S): Two hundred seventy-six consecutive women undergoing IVF/ICSI. INTERVENTION(S): Ovarian stimulation, oocyte retrieval, IVF, ICSI, embryo transfer, AMH, and inhibin B determinations in serum and follicular fluid (FF). MAIN OUTCOME MEASURE(S): The AMH and inhibin B concentrations in 276 matched FF/serum pairs have been determined. Different outcome groups have been compared and set in relation to the oocyte count, morphological parameters, and steroid hormone levels. RESULT(S): The concentrations of AMH and inhibin B in both serum and FF were significantly higher in the group of women who became pregnant in the corresponding treatment cycle than in those who did not conceive. Positive correlations were observed between serum inhibin B concentrations and embryo morphology (r = 0.126, 95% confidence interval 0.026-0.284). Serum and FF AMH or inhibin B correlated positively with the oocyte count and negatively with the pretreatment cycle day 3 FSH level and the total administered gonadotropin dose. CONCLUSION(S): The AMH and inhibin B levels on the day of oocyte retrieval are correlated to reproductive outcome.

Fertility preservation options in breast cancer patients.

The purpose of this review is to analyse current options for fertility preservation in young women with breast cancer (BC). Considering an increasing number of BC survivors, owing to improvements in cancer treatment and delaying of childbearing, fertility preservation appears to be an important issue. Current fertility preservation options in BC survivors range from well-established standard techniques to experimental or investigational interventions. Among the standard options, random-start ovarian stimulation protocol represents a new technique, which significantly decreases the total time of the in vitro fertilisation cycle. However, in patients with oestrogen-sensitive tumours, stimulation protocols using aromatase inhibitors are currently preferred over tamoxifen regimens. Cryopreservation of embryos and oocytes are nowadays deemed the most successful techniques for fertility preservation in BC patients. GnRH agonists during chemotherapy represent an experimental method for fertility preservation due to conflicting long-term outcome results regarding its safety and efficacy. Cryopreservation of ovarian tissue, in vitro maturation of immature oocytes and other strategies are considered experimental and should only be offered within the context of a clinical trial. An early pretreatment referral to reproductive endocrinologists and oncologists should be suggested to young BC women at risk of infertility, concerning the risks and benefits of fertility preservation options.

Twenty years' experience with the Swiss data registry for assisted reproductive medicine: outcomes, key trends and recommendations for improved practice.

QUESTIONS UNDER STUDY The impact of assisted reproductive technology (ART) on Swiss demography was quantified. From 1993 to 2012 the number of deliveries, including multiples, generated by ART was compared with overall delivery numbers. Swiss experts in ART collaborated in a consensus to increase successful outcomes, to reduce the incidence of complications of ART and to validate recommendations through statistical review of available data. METHODS Data generated between 1993 and 2012 and published by the Federal Office of Statistics (BfS) were compared with the Swiss database on ART (FIVNAT-CH) as organised by the Swiss Society of Reproductive Medicine (SGRM). From these analyses a panel of Swiss experts in ART extracted recommendations to improve current practice, to prevent complications related to ART and to recommend changes in current Swiss legislation dealing with ART. RESULTS Since 1993 the age of women giving birth rose together with the number of women asking for ART. This demographic trend was reflected in a rise in the number of deliveries generated by ART (in 2012: 2.2%) and the proportion of multiple births (in 2012: 17.6%). The outcome of ART was most negatively influenced by the age of the treated patient. The number of retrieved oocytes decisively impacted the likelihood of delivery, the risk of multiple births and the incidence of ovarian hyperstimulation syndrome. CONCLUSIONS Optimal ovarian stimulation should be designed for the retrieval of 10 to 15 oocytes per treatment. Swiss legislation should enable and stimulate a policy of elective single embryo transfer to avoid multiple births.

Exercise during chemotherapy for ovarian cancer (Echo) : study design features and outcomes of a Cancer Australia and Cancer Council Australia funded randomised, controlled trial

Ovarian cancer is the most common cause of gynaecological cancer death, with an overall 5-year relative survival of 43%. Impaired physical wellbeing and overall quality of life (QoL) represent major concerns for women during and following ovarian cancer treatment, predict survival and are amenable to change through interventions. Exercise, now considered an important part of overall management of a number of cancers, improves short-term outcomes (e.g., function, fatigue, QoL) during chemotherapy...