Immunology: Serum markers of immune activation in women undergoing in-vitro fertilization and embryo transfer

We evaluated serum concentrations of two early and sensitivemarkers of immune activation, interleukin-2 receptor (sIL-2R)and intercellular adhesion molecule-1 (ICAM-1) in two age-matchedgroups of in-vitro fertilization (IVF)-embryo transfer women,group I (n = 26) without and group II (n = 40) with methylprednisolone(MPD) supplementation of the luteal phase, on the days of oocyteretrieval (sample A) and embryo transfer (B), and second (C)and 13th (D) days post-transfer and in 20 normally cycling women(controls) on the day of luteinizing hormone (LH) peak. No differencein the outcome of the IVF-embryo transfer was observed betweengroups I and II. In sample A, both immunomarker concentrationsshowed no significant difference between the two groups of IVFwomen, while they were significantly higher (P < 0.01) thanvalues in controls. In cycles in which conception occurred,significantly higher immunomarker concentrations were observedin sample A of both groups I and II compared with those in unsuccessfulcycles of the same group. A significant decrease of both sIL-2Rand ICAM-1 was noticed in sample B only in group II (P <0.0001 and P < 0.001 respectively; paired t-test) that continuedfurther in the late luteal phase only hi the case of conception,independently of MPD supplementation. These data suggest that(i) due to multiple ovulations, IVF-embryo transfer women showelevated concentrations of sIL-2R and ICAM-1 at oocyte retrieval;(ii) since, even at oocyte retrieval stage, high concentrationsof immunomarkers are associated with IVF-embryo transfer success,sEL-2R and ICAM-1 could be used as early indicators for conceptioncycles; (iii) transient suppression of T cell activity by MPDsupplementation following IVF-embryo transfer does not improvepregnancy rate.     

体外受精-胚胎移植妇女的焦虑、抑郁情绪

目的:了解体外受精-胚胎移植(IVF-ET)妇女的焦虑、抑郁情绪及相关因素。方法:2009年4月-2010年3月,在湖南省妇幼保健院生殖中心选取来自全国各地符合本研究筛选标准的妇女连续入组,共入组IVF-ET妇女538例,采取现场询问的方式,在胚胎移植术后2小时内进行问卷调查,内容包括社会人口学特征、生育情况、治疗情况、社会心理因素及情绪症状的评定。结果:焦虑评分(39.6±3.1)分,焦虑症状检出率38.5%;抑郁评分(35.8±4.5)分,抑郁症状检出率12.3%。居住在城市(OR=1.66)、不孕年限长(OR=1.34)、夫妻交流少(OR=2.25)、积极应对评分低(OR=4.30)、生理健康(OR=3.24)评分低、心理健康(OR=5.36)评分低的IVF-ET妇女焦虑倾向危险比高;既往治疗费用多(OR=3.02),取卵个数少(OR=2.24)及性生活(OR=1.13)、积极应对(OR=6.08)评分低,应激性生活事件评分高(OR=1.83)的IVF-ET妇女抑郁倾向危险比高。结论:体外受精-胚胎移植妇女存在不同程度的焦虑、抑郁情绪,社会心理变量是其主要相关因素。     

Multiple attempts at embryo transfer: does this affect in-vitro fertilization treatment outcome?

In this study, we retrospectively analysed data from 877 patients who had 1204 embryo transfer procedures following in-vitro fertilization (IVF) at Midland Fertility Services, UK, between January 1991 and December 1995 to investigate the factors contributing to failure of embryo transfer at first attempt and the impact of immediate retransfer of retained embryos on the treatment outcome. Embryos were significantly more likely to be retained when the embryo transfer catheter was contaminated with mucus (3.3 versus 17.8%, P = 0.000001) or blood (3.3 versus 12%, P = 0.00001) and when the transfer procedure was difficult compared with when it was easy (20.3 versus 0.8%, P = 0.00001). There was no significant difference in the clinical pregnancy rate between those who had all their embryos transferred at the first attempt (24.7%) and those who required more than one attempt (23.2%). The types of embryo transfer catheter used in the unit did not show any difference in terms of embryo retention. Although we recommend aspiration of cervical mucus in order to reduce the rate of retained embryos, there is no evidence from our study to suggest that pregnancy rate is compromised when embryos are retained, provided they are discovered and immediately retransferred into the uterine cavity. Immediate retransfer is more convenient to the patients and reduces the laboratory workload without compromising the treatment outcome.      

Serum follicle-stimulating hormone inhibition is a marker for preovulatory oocytes in in-vitro fertilization and embryo transfer

A retrospective analysis was performed on 64 cycles stimulated with human menopausal gonadotrophin and/or pure follicle-stimulating hormone (FSH) and oestrogen (E2) levels. The increase in serum E2 on the day of HCG administration did not correlate (r = 0.05) with the number of preovulatory oocytes (preovs) or with an increase or decrease in serum FSH (r = 0.31). However, the change in serum FSH showed a significant correlation with the number of preovs (r = -0.95, P = 0.013). The probability of obtaining two or more preovs was relatively greater (1.47x) than that of other IVF patients, when there was a drop in FSH of 5% on the day of human chorionic gonadotrophin administration.     

Influence of antiphospholipid antibodies on pregnancy outcome in women undergoing in vitro fertilization and embryo transfer

PROBLEM: Antiphospholipid antibodies (APA) are thought to be involved in recurrent pregnancy loss. Therefore, we investigated the impact of APA on pregnancy outcome in women undergoing in vitro fertilization and embryo transfer (IVF-ET). METHOD OF STUDY: Blood samples taken from 54 Korean women referred for IVF were tested for the presence of APA, anticardiolipin antibody IgG and IgM and lupus anticoagulant. The standard gonadotropin-releasing hormone agonist long protocol was used for ovarian stimulation. RESULTS: Nine patients (16.7%) were positive and 45 (83.3%) were negative for APA. There were no significant differences between the two groups in clinical characteristics such as age, infertility duration, and response to controlled ovarian hyperstimulation. However, pregnancy outcome significantly differed between the two groups (p < 0.05). The APA positive group and APA negative group had abortion rates of 62.5% and 20.0%, respectively and delivery rates of 37.5% and 80.0%, respectively. CONCLUSION: The presence of APA in women undergoing IVF-ET was associated with a poor pregnancy outcome.     

Serum relaxin and the major endometrial secretory proteins in in-vitro fertilization and down-regulated hormone-supported and natural cycle frozen embryo transfer

Relaxin has been postulated to be a modulator of the expressionof the endometrial secretory proteins, insulin-like growth factorbinding protein (IGFBP-1) and placental protein 14(PP14). Thisstudy evaluated the expression of relaxin in relation to concentrationsof these secretory proteins along with oestradiol, progesteroneand human chorionic gonadotrophin in groups of pregnant andnon-pregnant patients who underwent differing assisted conceptiontreatments. Serum samples were taken from 88 patients at 8 and12 days after embryo transfer. At 12 days after embryo transfer,relaxin concentrations in the pregnant patients who had undergonein-vitro fertilization (IVF) or natural cycle frozen embryotransfer were significantly higher than those who did not conceivein these groups (mean concentrations 8334 versus 28 and 2608versus 62 pg/ml respectively, P <0.001). However concentrationsin the pregnant patients who had hormone support and transferof frozen embryos were not significantly different from thepatients who did not conceive after the same treatment. Althoughrelaxin expression was associated with corpus luteum activity,it was not related to the number of corpora lutea in IVF patients.A wide range of relaxin concentrations was seen to be compatiblewith a healthy pregnancy. These serum relaxin concentrationswere not found to be directly related to the serum concentrationsof IGFBP-1, PP14 or the other factors assessed in this study.     

Endometriosis: The relationship of endometriosis to endometrial sonographic studies prior to administration of human chorionic gonadotrophin in patients undergoing in-vitro fertilization and embryo transfer

The objective of this prospective comparative study was to investigatethe relationship of endometriosis to endometrial thickness andsonographic echo pattern prior to the administration of humanchorionic gonadotrophin (HCG). Patients were matched by ageand ovarian stimulation protocol. A total of 210 patients undergoingin-vitro fertilization (IVF) and embryo transfer at a university-relatedIVF centre were enlisted. Of these, 105 women with laparoscopicconfirmation of endometriosis were compared to an equal numberof patients with laparoscopic confirmation of no endometriosis.Mean endometrial thickness did not differ between the groups(12.7 ± 2.9 versus 12.2 ± 2.5 mm). The distributionof echo patterns was also the same, irrespective of diagnosis.Evaluation of clinical pregnancy rates showed no reduction inpatients with endometriosis, regardless of stage, nor when comparingpatients to controls. Endometriosis has no effect on the endometrialthickness or echo pattern measured by sonography prior to administrationof HCG or the pregnancy rates following IVF and embryo transfer.     

Ovarian stimulation in women undergoing in-vitro fertilization and embryo transfer using recombinant human follicle stimulating hormone (Gonal-F) in non-down-regulated cycles

In order to assess the efficacy and safety of recombinant humanfollicle stimulating hormone (FSH) in routine clinical use,ovarian stimulation with recombinant human FSH was performedin 71 patients prior to in-vitro fertilization (IVF) withoutgonadotrophin-releasing hormone (GnRH) analogues in a multicentre,non-comparative study. Human chorionic gonadotrophin (HCG) wasadministered to 58 patients (81.7%), 15 of whom underwent 19cycles with an initial dosage of three ampoules daily of recombinantFSH and 43 of whom underwent 152 cycles with four ampoules dailyfrom day 3 onwards. No significant differences were detectedbetween these two groups in all test parameters. The mean durationof treatment was 9.06 and 8.86 days respectively with a meannumber of 24.06 and 23.25 vials of recombinant human FSH administered.A mean number of 6.26 and 5.88 oocytes respectively was collected.The number of transferred embryos was 2.4 and 2.2. A clinicalpregnancy rate of 23.8% (10 out of 42) per transfer was achieved(30.9 and 20.6% respectively). Local tolerance of s.c. administrationwas excellent. Mild pain at the injection site was the dominantfinding in <20% of patients. Two cases of ovarian hyperstimulationsyndrome were noted. Recombinant human FSH is very attractiveto patients because it can be self-administered s.c. and thepreparation does not come from a human source. In conclusion,these data support the safety and efficacy of recombinant humanFSH in routine use for IVF.     

Anticardiolipin antibody levels in women undergoing first in vitro fertilization/embryo transfer

BACKGROUND: The clinical relevance of antiphospholipid antibodies (aPL) in women undergoing in vitro fertilization/embryo transfer (IVF/ET) and the role of IVF treatment in affecting antiphospholipid levels are controversial. The aim of this study was to evaluate anticardiolipin antibody (aCL) levels and the effect of IVF treatment on aCL in women undergoing their first IVF/ET cycle. METHODS: Immunoglobulin G (IgG)- and IgM-aCL were determined by enzyme-linked immunosorbent assay in 50 women undergoing IVF/ET, 18 due to endometriosis, 16 to tubal factor (TF) and 16 to male factor, before starting treatment (T0), on the day of oocyte retrieval (T1) and 14 days after ET (T2). A group of 31 age-matched fertile women served as controls. RESULTS: aCL levels detected at T0 in patients were not significantly different compared with the control group. IgG- but not IgM-aCL significantly increased at T2 in comparison with T0 (P < 0.001) and T1 (P < 0.05). The difference between T2 and T0 reached statistical significance in patients with endometriosis (P = 0.003) or TF (P = 0.018). No relationship was found between aCL and pregnancy. CONCLUSIONS: Our results indicate that IVF treatment increases IgG-aCL levels in patients with endometriosis and TF, but their presence seems to have no clinical relevance.     

Antiphospholipid antibodies and the outcome of pregnancy after the first in-vitro fertilization and embryo transfer cycle

Increased antiphospholipid antibody prevalence has been demonstrated by a number of recent studies in in-vitro fertilization (IVF) patients but the potential effects of antiphospholipid antibodies on the different components of the reproductive process and the consideration of whether to test IVF patients for antiphospholipid antibodies are controversial. The present study was undertaken to investigate the possible association between the presence of circulating antiphospholipid antibodies (namely the lupus anticoagulant and anticardiolipin antibodies), among a series of 21 consecutive IVF patients having a clinical spontaneous abortion after their first embryo transfer. As a control group (n=42), the nearest IVF cycle resulting in an ongoing pregnancy before and after each miscarried IVF cycle (i.e. the closest cycles in temporal relationship to the index cycle) was used. One patient (4.8%) in the study group and two women (4.8%) among controls were seropositive for antiphospholipid antibodies. These low and similar seropositivity rates found in the two groups studied lead us to conclude that antiphospholipid antibodies testing in IVF patients should be considered only in those women having repeated failures of implantation/clinical abortion after embryo transfer but not in an infertile general population reaching an IVF programme.      

A prospective randomized study comparing the outcome of in-vitro fertilization and embryo transfer following culture of human embryos individually or in groups before embryo transfer on day 2.

A prospective randomized trial of in-vitro fertilization and embryo transfer was undertaken to investigate the reported beneficial effects of culturing preimplantation human embryos in groups, rather than individually. A total of 159 treatment cycles, in which the women were matched for age, basal gonadotrophin concentrations and number of previous attempts, were included in the study. Of these, 78 cycles were randomized to the 'individual culture' group, and 81 cycles were randomized to the 'group culture' group. The groups did not differ in terms of the median number of oocytes or embryos obtained per cycle. There was no statistically significant difference between the two groups in terms of treatment outcome, as assessed by pregnancies or clinical pregnancies.     

Is the outcome of in-vitro fertilization and embryo transfer treatment improved by spontaneous or surgical drainage of a hydrosalpinx?

A pilot study was designed to examine whether the outcome of embryo transfer in women with a hydrosalpinx might be improved by surgical drainage of the hydrosalpinx at the time of oocyte collection for in- vitro fertilization treatment. A comparative, controlled but retrospective analysis of the results was performed of all women with infective tubal damage aged <40 years old, who had ovulatory cycles, a normal uterus and a partner with normal spermatozoa. A standardized treatment regimen was used. A maximum of three embryos were transferred. Hydrosalpinx was defined by prior hysterosalpingography and/or laparoscopy with transcervical dye injection. A total of 237 embryo transfer cycles in women with hydrosalpinges (tubal distension not visible in 151, visible but not drained in 30 and drained in 56) were compared with 705 embryo transfer cycles in women with tubal disease but no hydrosalpinx. Results were analysed in the first three cycles but also separately in the first cycle to check for bias. Success rates were higher in the first cycle, but did not significantly influence overall differences. Implantation rates were significantly reduced overall in the hydrosalpinx group (8.0 versus 13.2% for controls; P < 0.001), being 8.3% (P < 0.01) in the subgroup without evident tubal distension and 7.5% (not significant) in the drained hydrosalpinx group. This study shows that tubal damage with distal occlusion is associated with a marked reduction in embryo implantation, even in the absence of obvious fluid distension. Surgical drainage of distended hydrosalpinges appears to offer no benefit.      

Problems related to the laboratory part of treatment by in vitro fertilization and embryo transfer

The successive stages leading to fertilization in mammals are reviewed in this article. Methods of human sperm preparation for IVF are described and the "ideal" delay between oocyte pick-up and insemination time is discussed, as well as methods to reduce the incidence of polyspermy. Different culture media and their supplementation are mentioned, as well as a semi-quantitative embryonic scoring system, defined by the IVF team of the Saint-Pierre Hospital in Brussels. Finally the optimal transfer time, and the handling of embryos at replacement are discussed.     

Assisted fertilization in infertile women with patent Fallopian tubes. A comparison of in-vitro fertilization, gamete intra-Fallopian transfer and tubal embryo stage transfer

A comparison of the relative efficacy of in-vitro fertilizationwith uterine embryo transfer (TVF), tubal embryo stage transfer(TEST) and gamete intra-Fallopian transfer (GIFT) was performedin infertile patients with patent Fallopian tubes. A total of150 couples with unexplained infertility, peritoneal endometriosisor reduced semen quality were included in the study. The threegroups were comparable with regard to age distribution, indications,semen parameters, stimulation regimens, response to stimulationand numbers of oocytes retrieved. In the IVF and TEST groupsthere was no cleavage in 24% and a cleavage rate of only 47.6%.The highest cleavage rate was obtained in the endometriosispatients. The pregnancy rate was highest in the two groups inwhich in-vitro fertilization was performed, IVF = 45.7%, TEST= 37.9%, GIFT = 26.2%. To obtain one live intrauterine fetus,more oocytes had to be transferred in the GIFT group comparedtothe number of embryos in the IVF group, 14.4 versus 6.2, P <0.05. Due to a high success rate of IVF but at the same timea high frequency of no cleavage in cases of unexplained infertilityor male subfertility, we recommend FVF as the primary procedurein infertile couples with patent Fallopian tubes.     

Progesterone supplementation increases luteal phase endometrial thickness and oestradiol levels in in-vitro fertilization.

Luteal phase supplementation with natural progesterone appears to increase the pregnancy rate in in-vitro fertilization (IVF). The objective of this investigation was to examine the effect of intravaginal progesterone on endometrial thickness and hormonal parameters 7-9 days after embryo transfer. IVF patients receiving progesterone supplementation (Prog +, n = 64), who did not conceive, were compared to patients not receiving progesterone (Prog -, n = 23) because of failed fertilization. These two groups were also compared to 20 women (Preg) who conceived and to 16 women (control) in the mid-luteal phase of natural cycles. Endometrial thickness was greater (P < 0.01) in the Prog + (0.88 +/- 0.04 cm) and Preg (0.92 +/- 0.02 cm) groups compared to the Prog - (0.71 +/- 0.05 cm) and control (0.65 +/- 0.05 cm) groups. Mean luteal phase serum oestradiol levels were also higher (P < 0.05) in the Prog + (1118 +/- 112 pmol/l) and Preg (2267 +/- 757 pmol/l) groups than in the Prog - (574 +/- 70 pmol/l) and control (468 +/- 38 pmol/l) groups. These findings suggest that progesterone supplementation may affect pregnancy rates in IVF by increasing endometrial thickness, thereby enhancing receptivity for implantation. The mechanism through which this effect occurs is unclear but may involve serum oestradiol elevation.     

Transfusion-dependent homozygous {beta}-thalassaemia major: successful twin pregnancy following in-vitro fertilization and tubal embryo transfer

Homozygous -thalassaemia (thalassaemia major) is a severe, transfusion-dependentanaemia that also causes infertility due to endocrine impairment.Very few pregnancies are reported among such patients and thereis only one report in the literature referring to a pregnancyachieved with ovulation induction and intra-uterine insemination.We report here the first successful twin pregnancy followingin-vitro fertilization and tubal embryo transfer in a transfusion-dependenthomozygous -thalassaemic woman with an oligoastheno-zoospermicpartner. Prior to ovarian stimulation, desferrioxamine was discontinueddue to potential fetotoxicity. Pre-gestational transfusionaland chelating therapies were resumed after delivery. In suchpatients, ovulation induction and assisted reproductive techniquesappear crucial in achieving pregnancy with concurrent haematologicalbalance without desferrioxamine administration.     

Infertility: Human decidua-associated protein hDP200 in menstrual fluid: comparison between fertile women and women after failed in-vitro fertilization/embryo transfer treatment

The concentration of human decidua-associated protein (hDP)200 was measured in 238 menstrual fluid samples obtained fromnormal fertile women and in 26 menstrual fluid samples obtainedfrom infertile women who failed to conceive and menstruatedfollowing in-vitro fertilization (IVF)/embryo transfer treatment.A significant association was observed between the concentrationof hDP200 and the age of the women. A maximal concentrationof hDP200 was observed in women aged 28–30 years, withsignificantly lower concentrations in those aged 18–20and 39–41 years. The presence of an intra-uterine devicehad no effect on menstrual fluid hDP200 concentrations. A significantlylower mean concentration of hDP200 (82 U/ml) was measured inmenstrual fluid samples obtained from failed IVF/embryo transferpatients as compared with that in menstrual fluid samples fromnormal fertile women (191 U/ml). These findings support theconcept that adequate endometrial function, as evaluated bymenstrual fluid concentration of hDP200, is important for thesuccess of the fertility process.     

Implantation: Endometrial thickness appears to be a significant factor in embryo implantation in in-vitro fertilization

To evaluate the role of endometrial thickness and pattern inin-vitro fertilization (IVF), these parameters were prospectivelymeasured in 516 cycles of IVF with embryo transfer at our clinic.Pregnancy and embryo implantation rates were assessed for eachmm of endometrial thickness and for each of three endometrialpatterns. Embryo implantation, clinical and ongoing pregnancyrates were significantly higher in the patients with an endometrialthickness >9 mm (24.4, 48.6 and 42.2% respectively) comparedwith those of <9 mm (14.3, 16.0 and 11.7% respectively; P< 0.005). Endometrial thickness was negatively influencedby age and positively influenced by oestradiol concentration.The majority of patients (69.8%) exhibited a ‘ring’endometrial pattern. Embryo implantation and clinical pregnancy(statistically significant), as well as ongoing pregnancy rates(not statistically significant), were lower in patients exhibitingthe ‘solid’ pattern. Endometrial thickness is independentof pattern in its effect on pregnancy outcome. In conclusion,endometrial thickness >9 mm as well as ring and intermediateendometrial patterns denoted a more favourable prognosis forpregnancy in IVF but thinner endometrium and those exhibitinga solid configuration had an acceptable pregnancy outcome.     

Serum progesterone at the time of human chorionic gonadotrophin does not predict pregnancy in in-vitro fertilization and embryo transfer

Controversy exists as to whether the serum concentration ofprogesterone on the day of human chorionic gonadotrophin (HCG)administration following ovarian stimulation for in-vitro fertilization(IVF) and embryo transfer can be used to predict the likelihoodof success. This retrospective study was undertaken to answerthis question by analysing a large population of IVF and embryotransfer cycles (n = 756). In addition to the concentrationof progesterone on the day of HCG administration, all variablesknown to impact on IVF and embryo transfer success (such aspatient age), indication for IVF and embryo transfer, numberof oocytes retrieved and the number of embryos generated andtransferred were examined. There was a significant increasein the number of oocytes retrieved with increasing progesteroneconcentration at the time of HCG administration. However, therewas no correlation of progesterone concentration at HCG administrationwith pregnancy and implantation rates. It is concluded thatprevious reports associating a slight elevation of progesteronein gonadotrophin- releasing hormone agonist ovarian stimulationcycles for IVF and embryo transfer may be misleading becauseof a small sample size or the presence of confounding variablesthat affect IVF and embryo transfer success.     

The relationships between endometrial thickness, and blood flow and pregnancy rates in in-vitro fertilization

To establish whether endometrial blood flow and thickness can predict the success rate of in-vitro fertilization, 156 cycles were evaluated. The parameters were: endometrial colour and power Doppler pulsatility index (PI), resistance index (RI), systolic/diastolic ratio (S/D) and endometrial thickness. Each patient was studied: on the day of ovum retrievalpickup, and on the day of embryo transfer. Non-endometrial parameters studied were: age, oestrestrogen and progesterone concentrations, number of oocytes, and number of embryos. Pregnancy was achieved in 31 cycles. On the day of ovum retrieval, patients who conceived had PI, RI, and S/D values of 0.997, 0.563, and 2.403, respectively. Patients who did not conceive had values of 0.994, 0.584, and 2.477 respectively. The power Doppler technique provided similar results. On the day of embryo transfer, pregnant patients had PI, RI and S/D values of 1.096, 0.590 and, 2.597 respectively, while in the non-pregnant patients the values were 1.104, 0.603 and, 2.723 respectively. Power Doppler showed similar numbers. The differences between pregnant and non-pregnant patients were not statistically significant in any of the parameters. Endometrial thickness and blood flow does not seem to correlate with pregnancy rate in IVF.