Human embryonic stem cell methyl cycle enzyme expression: modelling epigenetic programming in assisted reproduction?

To investigate a possible mechanism for inducing epigenetic defects in the preimplantation embryo, a human embryonic stem cell model was developed, and gene expression of the key methyl cycle enzymes, MAT2A, MAT2B, GNMT, SAHH, CBS, CGL, MTR, MTRR, BHMT, BHMT2, mSHMT, cSHMT and MTHFR was demonstrated, while MAT1 was barely detectable. Several potential acceptors of cycle-generated methyl groups, the DNA methyltransferases (DNMT1, DNMT3A, DNMT3B and DNMT3L), glycine methyltransferase and the polyamine biosynthetic enzymes, SAM decarboxylase and ornithine decarboxylase, were also expressed. Expression of folate receptor alpha suggests a propensity for folate metabolism. Methotrexate-induced depletion of folate resulted in elevated intracellular homocysteine concentration after 7 days in culture and a concomitant increase in cysteine and glutathione, indicating clearance of homocysteine through the transulphuration pathway. These studies indicate that altered methyl group metabolism provides a potential mechanism for inducing epigenetic changes in the preimplantation embryo.     

Endometriosis and assisted reproduction: the role for reproductive surgery?

PURPOSE OF REVIEW: The aim of this review paper is to discuss the relationship between endometriosis and assisted reproductive technology. More specifically, the following clinically relevant issues will be discussed. (1) Does the presence of endometriosis affect the outcome of assisted reproductive technology? (2) Does surgical treatment for endometriosis prior to or after assisted reproductive technology treatment affect the outcome of assisted reproductive technology? (3) Is assisted reproductive technology a risk factor for the recurrence of endometriosis after medical or surgical therapy? RECENT FINDINGS: The review is based on recently published review papers/meta-analyses or international guidelines as published by the European Society of Human Reproduction or the American Society of Reproductive Medicine, updated with a selective review of recent papers searching PubMed with the key words 'Endometriosis', 'Assisted Reproduction', 'IVF', 'IUI' and 'Reproductive Surgery'. SUMMARY: At the end of this review, a practical proposal for the clinical management of women with endometriosis-associated subfertility is proposed, based on our own experience.     

What is the role of assisted reproduction technology in the management of age-related infertility?

Although in the UK the upper age limit for National Health Service (NHS) provision of in?vitro fertilisation (IVF) is 39 years of age there has been an increase in number of women having fertility treatment in their 40s. However, the success rates of IVF and intra-uterine insemination (IUI) in this group remain low. Human Fertilisation and Embryology Authority (HFEA) data from 2006 showed that the live-birth rate from IVF in the UK was 11% in the age group 40-42, 4.6% in the age group 43-44 and less than 4% in women over 44. We performed a literature search for studies using terms and combinations of terms in online databases and published meta-analyses reporting the outcome of interventions in older women. This review showed that assisted reproduction technologies (ARTs) continue to have low live-birth rates in women over 40. Trials showed that assisted hatching may increase the chance of pregnancy in women with poor history. Blastocyst transfer is associated with better outcome, whereas application of pre-implantation genetic screening (PGS) in older women has not increased the success rates. It appears that, with the exception of egg-donation, ART has no answer yet to age-related decline of female fertility.     

Is there a place for immunomodulation in assisted reproduction techniques?

We briefly review the history of the concepts of the materno foetal relationship, and the (various) rationales which have been used to justify lymphocyte alloimmunisation (LA) as a treatment for recurrent spontaneous abortion of putative immune origins. The effectiveness of the treatment is at best dubious and limited to a small number of women for which there is no real positive selection rationale, at worst it is not efficient. The rationales themselves are rather "evolutive". The present one is to use the Th1:Th2 paradigm and, thus, to propose to "dampen NK activity" in abortion prone women and this concept has been extended by some to implantation failure. We briefly review why the Th1:Th2 paradigms is no longer fully valid, describe briefly why it is inappropriate for implantation, and conclude that alloimmunisation should no longer be proposed for RSA, hence, more for implantation failure. We, however, do not reject immunotherapy, but we believe that molecular and cellular defects specific approaches should be used, tailored for the specific pathway whose disruption cause the clinical symptom.     

Ethics or legislation for the regulation of assisted reproduction technology?

Many new procedures for assisted reproduction treatments (such as in-vitro fertilization, embryo selection, cloning, egg-, spermatozoa- and embryo-storage, and stem cells transplant) have recently become available. Some form of regulation or legislation for their use is essential. This is made difficult because of the rapid pace of genetic discoveries and derived technologies, the diversity of opinions on the legitimate application of these new techniques, and the pluralistic and evolving social norms of society regarding the use of the new reproductive methods. This paper examines some of the problems that can arise when regulation is attempted in each of the above fields. A variety of solutions such as referendums, moratoriums, ethical codes of professional bodies or the drafting of scientifically accurate and appropriate legislation depending on particular circumstances are considered as a means of achieving a flexible and responsive approach to the challenges posed by the use of the new techniques for assisted reproduction technologies.     

Endometriosis and assisted reproductive technologies: are outcomes affected?

The preponderance of recent data suggests that endometriosis does not adversely affect in-vitro fertilization pregnancy rates. However, many studies demonstrate impaired oocyte quality, decreased fertilization, and compromised implantation rates. Such findings give insight into the mechanisms by which endometriosis may impact on fertility, and provide clues as how to focus assisted reproductive technologies in order to overcome these deficiencies. Specifically, extended downregulation protocols, ample use of gonadotropins for ovarian stimulation, and conservative management of endometriomas have all been suggested as means to optimize in-vitro fertilization outcomes for women with endometriosis.     

Is there a benefit of low-dose aspirin in assisted reproduction?

PURPOSE OF REVIEW: Assisted reproduction is an effective treatment for infertile women but, despite advances in ovarian stimulation and laboratory techniques, overall pregnancy rates are still relatively low suggesting that methods to improve implantation are required. One strategy is to increase the blood flow to the uterus with low-dose aspirin. The objective of this review is to determine if low-dose aspirin improves clinical pregnancy rates when administered to infertile women undergoing treatment with assisted reproduction. RECENT FINDINGS: A retrospective review was unable to demonstrate improved pregnancy rates when low-dose aspirin was compared with no treatment. Such studies, however, have limited value in clinical decision-making because of poor methodological quality. A recent high-quality randomized, placebo-controlled trial of low-dose aspirin was also unable to demonstrate any benefit, a finding supported by a meta-analysis of 10 trials that collectively had sufficient power to detect a clinically relevant improvement in clinical pregnancy rate. Evidence also exists that low-dose aspirin is potentially harmful, because of increased bleeding problems, miscarriage and congenital anomalies. SUMMARY: Given the lack of efficacy and the potential for harmful effects to both the patient and her offspring, low-dose aspirin should not be administered to infertile women undergoing treatment with assisted reproduction.     

Is assisted hatching beneficial in patients with recurrent implantation failures?

PURPOSE: To assess the possible role of assisted hatching in patients with recurrent implantation failure during IVF cycles. DESIGN: Prospective randomized study. SETTING: IVF unit of an academic medical center. PATIENTS: Women who underwent IVF after at least three failed IVF-ET attempts. INTERVENTIONS: Patients were prospectively randomized to undergo assisted hatching of their embryos prior to their replacement by mechanical partial zona dissection. RESULTS: The study (assisted hatching) and control groups included 104 and 103 patients, respectively. There were no significant between-group differences in patient age, cause of infertility, mean number of previous IVF trials, number of oocytes retrieved, fertilization rate, or number of embryos transferred. No difference in pregnancy rate was noted on comparison of the whole study group, to the whole control group (21% and 27%, respectively). However, when the results were re-analyzed by age groups, assisted hatching was found to be harmful in the youngest group (< 34 years), significantly decreasing pregnancy rates (15% vs 35%, p < 0.05). CONCLUSION: Repeated implantation failure alone is not an indication for assisted hatching. Although assisted hatching appears to be effective in a selected group of older patients, in younger patients it may further hamper implantation and should be avoided.     

Human chorionic gonadotropin for in vitro oocyte maturation: does it improve the endometrium or implantation?

OBJECTIVE: To determine the effect of human chorionic gonadotropin (hCG) priming on endometrial receptivity in women with polycystic ovary syndrome undergoing in vitro maturation. STUDY DESIGN: The study was a randomized, controlled trial. After a withdrawal bleed, on day 8-10 of the cycle, women were randomized to receive 10,000 IU hCG or none 36 hours before immature oocyte retrieval. Oocytes were matured and fertilized, and up to 3 embryos were transferred. Prior to transfer, endometrial thickness, uterine artery pulsatility index and subendometrial bloodflow were determined. RESULTS: There was no difference in endometrial thickness (10.1 vs. 10.4 mm), uterine artery pulsatility index (2.45 vs. 2.65) or absent subendometrial bloodflow (23% vs. 18%) between the treatment and control groups. Higher numbers of embryos were produced in the treatment group (7.0 vs. 3.6), resulting in more pregnancies, although the implantation rates (16.7 vs. 16.0%) were similar. CONCLUSION: Preretrieval hCG priming does not improve the ultrasound parameters of endometrial receptivity or the implantation rate, although more embryos are generated.     

Gay male couples and assisted reproduction: should we assist?

Gay male couples seeking fatherhood through assisted reproduction deserve the same attention to care that other couples, lesbian and heterosexual, receive at fertility centers throughout the country.     

Evidence-based medicine and the role of the private sector in assisted reproduction: a response to Dr Fishel’s commentary ‘Evidenced-based medicine and the role of the National Health Service in assisted reproduction’

We respond to Dr Fishel’s commentary on evidenced-based medicine in assisted reproduction and the role of the UK’s National Health Service. We agree that proper randomised clinical trials are not easy to set up or execute. Recruitment is also challenging but requires that all personnel involved in the study, clinicians, embryologists and nurses, agree with its aims and buy in to the need for an answer. Those who believe fervently in the method under scrutiny prior to the availability of robust evidence are likely to undermine the success of any trial. New technologies are not necessarily better technologies. Neither is the supposed ‘logic’ of a treatment nor anecdotal clinical experience a substitute for evidence properly gained and fairly demonstrated. Dr Fishel would agree that the first obligation of healthcare professionals, whether they are in the public or private sector, is not to do harm to their patients. Adopting new interventions without rigorous assessment of the potential for harm flies in the face of this basic principle.     

Does the empty follicle syndrome occur in cases of low number of maturing follicles in assisted reproduction?

The pathophysiology of the genuine empty follicle syndrome (EFS) is still debated. Ovarian aging has been contested as a cause of this condition. Our aim was to investigate the occurrence of the genuine EFS in cases of a low number of mature follicles in a prospective manner. Ninety-five infertile women were recruited and evaluated following conventional controlled ovarian stimulation (COS) with?≤?six follicles of ≥14?mm diameter on the day of hCG administration. Enrolled women were 37.5?±?5.2?years of age with basal FSH level of 9.1?±?3.7 mIU/L, antral follicle count (AFC) of 6.9?±?4.6, and number of ≥14?mm follicles (on the day of hCG) of 3.4?±?1.5. Among the 95 women, four were complicated by the genuine EFS (4.2%) with features of the depleted ovarian reserve. Comparison between these four cases and the 91 controls revealed significant differences between age, AFC, number of ≥14?mm follicles, and serum E₂ level corresponding to 41.8?±?1.7 versus 37.4?±?5.2 years, 1.7?±?0.6 versus 7.1?±?4.5, 2.0?±?0.8 versus 3.4?±?1.5 follicles, and 356?±?200 versus 975?±?557?pg/mL, respectively. Post hoc analysis revealed that 56 among the 95 women fulfilled the Bologna criteria for poor ovarian response and all four cases matched the definition of the genuine EFS raising its incidence to 7.1% in this group. A logistic regression analysis showed that AFC was a significant factor in the development of the genuine EFS. We conclude that the genuine EFS complicates infertile women characterized by a low number of mature follicles. Our findings suggest that the mechanism behind this occurrence is associated with a more exhausted ovarian reserve.     

Do assisted reproductive technologies have effects on the demography of monozygotic twinning?

This study examined the incidence of monozygotic twinning of one embryo with the use of cycles in which only one embryo, treated by various assisted reproductive technologies (ART), was transferred. It also examined the possibility of demographic alterations in the overall incidence of monozygotic twinning in Japan induced by ART. A total of 134 clinics or institutes participated in this study. Overall, it is noted that the incidence of monozygotic twinning in Japan has been almost constant (0.402%). In ART treatments, the monozygotic twinning rate was significantly higher than that of natural pregnancies (P = 0.0204). For in vitro fertilization (IVF) treatment cycles, the monozygotic twinning rate was also higher than that of natural pregnancies (P = 0.6285). However, this difference was not statistically significant because of the small number of IVF pregnancies. Moreover, in the context of microinsemination cycles, the monozygotic twinning rate was significantly higher than that of natural pregnancies (P = 0.0285) or IVF (P = 0.0006). In terms of the possible impact of ART on the demography of monozygotic twinning, adoption of mechanically assisted hatching for all embryos in Japan may alter the demography of monozygotic twinning.     

Do ovarian reserve tests predict miscarriage in women undergoing assisted reproduction treatment?

Objective

The objective of the study was to compare the peri-operative outcomes of single port access (SPA) laparoscopic adnexal surgery and conventional laparoscopic adnexal surgery.

Study design

This is a retrospective case-control study matched by body mass index (BMI; kg/m²). A single surgeon (T-JK) performed 17 SPA laparoscopic adnexal surgeries (cases) consecutively between December 2008 and March 2009; 34 conventional laparoscopic adnexal surgeries (controls) were performed by another surgeon who had similar surgical skill at our hospital during the same time period. Data on the SPA laparoscopic adnexal surgery cases were collected prospectively into our data registry after Institutional Review Board (IRB) approval and we reviewed the data on the controls from the electronic medical records with IRB approval.

Results

In both groups all procedures were performed without failure. Among preoperative baseline characteristics there was no difference between the two groups including preoperative size of ovarian tumor and bilaterality. The pathology findings were similar; a mature cystic teratoma was the most common pathological feature in both groups. The two groups were comparable with regard to operative outcomes according the surgery type. There were no differences between SPA and conventional groups in median operation time (64 min vs. 57.5 min, p = 0.252), the number of patients that requested additional parenteral non-steroidal anti-inflammatory drugs (7 patients vs. 19 patients, p = 0.597), and the absolute decrease (1.3 mg/dl vs. 1.1 mg/dl, p = 0.640) from preoperative hemoglobin to postoperative day 1 measurements. No patient from either cohort required a blood transfusion. There were no complications in either group including umbilical incision complications in the SPA group.

Conclusion

Our study demonstrated that SPA laparoscopic adnexal surgery had comparable operative outcomes to conventional laparoscopic adnexal surgery. A prospective comparison is needed for confirmation and to define the role of SPA in gynecological adnexal surgery.