Transrectal electroejaculation combined with in-vitro fertilization: effective treatment of anejaculatory infertility due to spinal cord injury

Infertility due to spinal cord injury (SCI) in young men is a frequent complication of their injury. When the simpler methods of management of the erectile and ejaculatory dysfunction that invariably follow the more severe types of SCI are not effective, then semen production by transrectal electroejaculation (TREE) combined with in-vitro fertilization (IVF) and embryo transfer is effective. A retrospective analysis is presented of data on the treatment and outcome of 35 couples who wished to have a family but in whom the male partner had suffered SCI. These 35 couples had 71 attempts at IVF with spermatozoa obtained following TREE. Normal fertilization and cleavage of the embryos occurred in 48.2% of the oocytes. Fresh embryos were transferred in 54 cycles and frozen-thawed embryos in 14 cycles. In all, 18 clinical pregnancies were achieved in 54 fresh and 14 frozen embryo transfer cycles, with a live birth rate of 16.5% (14/85) per treatment cycle started, 20.6% (14/68) per transfer cycle and 40.0% (14/35) per couple who started treatment, in a mean of 1.9 transfer cycles. We conclude that TREE combined with IVF and embryo transfer is an effective treatment for the infertility problems associated with SCI.      

The value of menotrophin treatment for unexplained infertility prior to an in-vitro fertilization attempt

This work was undertaken in order to evaluate retrospectively the relative efficacy of ovulation induction by menotrophins and that of in-vitro fertilization and embryo transfer (IVF-ET) in the treatment of unexplained infertility. These two treatments were compared between two groups of patients: 87 couples undergoing 446 cycles of ovulation induction by menotrophins (group A) and 72 couples undergoing 108 cycles of IVF-ET (group B). A total of 30 and 20 pregnancies were achieved in groups A and B for a rate of 34 and 28% per patient, respectively. A similar cumulative pregnancy rate (CPR) was achieved for three cycles of ovulation induction (23%) and one cycle of IVF-ET (22%). The cumulative live birth rate (CLBR) in group A was 22% after three cycles and exceeded that of one IVF-ET cycle (17%). It is concluded that menotrophin treatment in unexplained infertility is highly beneficial and should precede an IVF attempt.     

The probability of a successful treatment of infertility by in-vitro fertilization

The objective of this study was to define several estimatesof the success rate of in-vitro fertilization and embryo transfertreatment in relation to treatment outcome. The data were collectedin a retrospective study of 591 patients treated during 3 yearsin one Belgian university hospital. Several models used forevaluating the treatment of infertility were fitted to the data(logistic model, binomial model, double binomial model, exponentialmodel, the Speirs model. The number of oocytes retrieved andthe proportion of fertilized oocytes at the first attempt canbe used as prognostic factors. According to these factors, thesuccess rate after five attempts varies from 28 to 88%     

Andrology: The ability of the hemizona assay to predict human fertilization in different and consecutive in-vitro fertilization cycles

The objective of this prospective study was to examine the abilityof the hemizona assay (HZA) to predict fertilization outcomeof mature, pre-ovulatory oocytes under in-vitro fertilization(IVF) conditions. Since a large number of patients were evaluatedover a long period, the power of the HZA to prognosticate fertilizationresults in the same and subsequent (consecutive) IVF cyclesof those same patients was assessed. For IVF, only metaphaseII oocytes were used. For the HZA, both fresh oocytes donatedby patients at the time of IVF and oocytes recovered from surgicallyremoved ovarian tissue (and salt-stored) were used, and bisectedby micromanipulation techniques. Matching hemizonae were co-incubatedeither with spermatozoa from the patient (test) or from a fertileman (control) for 4 h. The number of spermatozoa tightly boundto the zona was counted. Patients (n = 112) were divided intotwo groups based on HZA results (expressed as HZA index or HZI):HZI 30% (n = 72) and <30% (n = 40). The patients with HZI<30% had significantly lower fertilization rates in boththe HZA—IVF cycle and in subsequent cycles compared topatients with HZI 30% (P < 0.03). Linear discriminant analysisindicated the HZA to have a sensitivity of 84%, and positiveand negative predictive values of 85 and 70% respectively, forprediction of fertilization outcome in a total of 233 cycles.It was concluded that the HZA is a good predictor of fertilizationrate in vitro, and can be used in the IVF setting to supplyadditional clinical information in malefactor patients.     

Successful combination of transrectal electroejaculation and intracytoplasmic sperm injection in the treatment of anejaculation

We describe the case of a couple whose infertility was causedby the absence of seminal emission following retroperitonealsurgery for testicular cancer. Ejaculate could be retrievedfrom the husband by rectal probe electroejaculation (RPE) butsperm quality was so poor that conventional in-vitro fertilizationwas impossible. With intracytoplasmic sperm injection of spermatozoaretrieved by RPE — a combination not reported previously— we were able to induce a pregnancy with successful outcome.     

Andrology: Subzonal sperm insertion with aged human oocytes from failed in-vitro fertilization attempts: fertilization results and some applications

This study was undertaken to assess the potential of aged humanoocytes from failed in-vitro fertilization attempts as a modelfor the study of fertilization events after subzonal sperm insertion(SUZI). Criteria of aged oocyte suitability for this purposewere (i) the absence of nuclei, (ii) the presence of a polarbody, (iii) the absence of cell division or fragmentation, (iv)marked ooplasmic contraction in hyperosmotic medium, and (v)rapid ooplasmic relaxation after returning into normo-osmoticmedium following the micromanipulation. Micro-injection techniqueswere essentially the same as for SUZI with fresh oocytes. Oocytesthat fused with the micro-injected spermatozoa developed pronucleiof typical internal structure. However, the number of pronucleiwas often higher than that theoretically expected if each spermnucleus incorporated into the oocyte gave rise to a single pronucleus.Thus, the use of aged oocytes implies the need for a specificmethod to assess the frequency of fusion in sperm samples examined.The results suggest that the method described here can be appliedin a preliminary diagnostic test before a therapeutic SUZI attemptand in studies aimed at the optimization of sperm treatmentprotocols to increase the fusion capacity of subzonally insertedspermatozoa.     

Andrology: Sperm aspiration from vas deferens and in-vitro fertilization in cases of non-treatable anejaculation

Spermatozoa were aspirated from the proximal vas deferens offive men with persistent anejaculation which could not be overcomeby using a vibrator or electro-ejaculation. Three men had spinalcord injury, one man had undergone a pelvic lymphadenectomy,and in one of them the aetiology was unknown. Fairly good numbersof spermatozoa (from 7.5 to 170 million) with progressive motilityfrom 24 to 75% were obtained from all the eight microsurgicallyperformed aspiration attempts. In vitro fertilization (IVF)was successful in seven attempts. Eight embryo transfers (sixwith fresh and two with frozen embryos) resulted in three pregnancies.The pregnancy rates, 37% per aspiration and 37% per embryo transfer,show that in this small group of patients, aspiration of spermatozoafrom the vas deferens followed by IVF—embryo transferis a promising method in the management of infertility causedby persistent anejaculation.     

Two pregnancies after in-vitro fertilization with spermatozoa from alloplastic spermatocoeles

Two case reports describe successful in-vitro fertilization(IVF) of oocytes of two 28-year-old women with epididymal spermatozoaaspirated from alloplastic spermatocoeles of the husbands. Bothmen suffered from complete ejaculatory failure, which was causedby paraplegia in the first and by radical surgery of an embryoniccarcinoma of the testis in the second. Motile spermatozoa wereaspirated in the first case 4 months after implantation of thespermatocoele, and in the second at 1 month. For the first couple,IVF treatment led to a singleton pregnancy; the child has sincebeen born. In the second couple, IVF treatment resulted in atwin pregnancy, with intra-uterine abortion of one gestationalsac. The resulting singleton pregnancy is still ongoing.     

Pregnancy: Apparent lack of seasonal variation in implantation rates after in-vitro fertilization

It has been suggested that seasonal variation in endometrialreceptivity may occur in women, which could affect the likelysuccess of in-vitro fertilization (IVF) treatment. We thereforestudied implantation rates (fetal sacs as a proportion of embryostransferred) as an indirect index of receptivity in a narrowlydefined population of women under 40 years old with normal ovulatorycycles and normal uterus and men with normal sperm function.A total of 577 cycles of IVF treatment were undertaken usinga standard protocol of pituitary desensitization and ovarianstimulation during the 3 years 1990–1992. Results werecompared between calendar months and 3-month seasons. The overallimplantation rate was 14.9% of embryos, and the clinical pregnancyrate was 30.3% of cycles reaching egg collection. There wereno significant differences in the monthly rates of eggs collected,fertilization and cleavage, or embryos transferred. Implantationrates varied to a greater extent but analysis of variance showedno seasonal variation. These findings do not support a seasonalvariation in ovarian responsiveness or endometrial receptivitywhen stimulated for IVF treatment, but larger studies are neededfor firm conclusions to be drawn.     

Ovarian autoimmunity and corticotherapy in an in-vitro fertilization attempt

This case report describes a successful pregnancy and deliveryin a woman presenting with ovarian autoimmunity who had previouslybeen involved in two unsuccessful in-vitro fertilization (IVF)attempts. Ten days before a third attempt, she began a regimenof 25 mg per day of prednisolone which was continued throughoutthe whole IVF protocol. Ovulation was induced by human menopausalgonadotrophin. After administration of 5000 IU of human chorionicgonadotrophin, 18 oocytes were collected. At 48 h after inseminationwith the patient's husband's spermatozoa, four 4-cell pre-embryoswere transferred. A singleton pregnancy developed and led tothe birth of a girl who is doing well 10 months later.     

Infertility: Seasonality in the results of in-vitro fertilization

Seasonal variation has been found in various reproductive outcomes.As known causes for reducing the rate of success of in-vitrofertilization (IVF) cannot explain all the variation in IVFresults, we studied whether the season had any additional explanatorypower. The study population consisted of 1126 women who weretreated for the first time with IVF at the University Hospitalin Nijmegen, The Netherlands, between 1987 and 1993. Only firstIVF cycles were analysed. After adjusting for confounding bythe age of the woman, type of infertility, indication for IVFand year of aspiration, some seasonal variation was observedin the fertilization rate, embryo quality, pregnancy rate andbirth rate.     

Pregnancy: Endometrial ultrasonography as a predictor of pregnancy in an in-vitro fertilization programme

The endometrial pattern and thickness were analysed by ultrasonographyin 139 cycles stimulated for in-vitro fertilization (IVF) onthe day of administration of human chorionic gonadotrophin (HCG).A semi-programmed schedule based on the pill + clomiphene citrate+ human menopausal gonadotrophin (HMG) was used in all cycles.On the day of HCG administration, endometrial pattern and thicknesswere assessed with an Ultramark 4 (ATL) ultrasound equippedwith a 5 MHz vaginal probe. Endometrial pattern I (a ‘tripleline’multilayer) was observed in a total of 105 cycles (76%), andpattern II (fully homogeneous and hyperechogenic in relationto myometrial tissue) in 34 (24%). The incidence of clinicalpregnancy did not differ (P = 0.52) between the groups withendometrial patterns I (23.8%) and II (29.4%). Endometrial thicknesson the day of HCG administration in the group with pattern I(8.4 ± 1.9 mm) was similar (P = 0.96) to that observedin the group with pattern II (8.4 ± 2.0 mm). In addition,the endometrial thickness of the patients who became pregnant(8.0 ± 1.7 mm) did not differ (P = 0.15) from that ofwomen who did not achieve pregnancy (8.6 ± 2.0 mm). Theconclusion from the present data is that ultrasonographic analysisof endometrial thickness and refringency on the day of HCG administrationhad no predictive value for conception in IVF cycles.     

Andrology: A new predictive test for in-vitro fertilization based on the induction of sperm acrosome reaction by N-acetylglucosamine-neoglycoprotein

Neoglycoproteins with N-acetylglucosamine residues (BSA-GIcNAc)induced specifically the acrosome reaction (AR) in human spermatozoa.Our objective was to investigate the relationship between thisphenomenon and the in-vitro fertilization (IVF) rate. Spermsuspensions from IVF protocols were incubated with BSA-GlcNAc(t), using calcium ionophore (i) or medium alone (c) as positiveor negative controls. When the normalized AR percentage ratio(STIM) (%ARt-%ARc): (%ARi-%ARc) was compared with fertilizationrate in 31 couples from our IVF programme, a positive correlationwas found (r = 0.46, P < 0.01). The fertilization rate inpatients with STIM 0.2 was higher than in non-responders (STIM< 0.2); 72 ± 7% compared with 5 ± 3%. The overallpredictive value of this test for adequate fertilization rate(>30%) was 87%, sensitivity 91% and specificity 78%. Falsepositives were 9% and false negatives 22%. For successful fertilizationrates (>60%), the results were: overall predictive value,84%; sensitivity 100%; specificity 64%. False positives were23% and no false negatives were found. The results indicatedthat the induction of AR in human spermatozoa by GlcNAc-neoglycoproteinscould be used to predict their fertilizing ability in vitro.     

Low-dose prednisolone does not improve the outcome of in-vitro fertilization in male immunological infertility

Early reports of male immunological infertility suggested adecline in antisperm antibody concentrations in some patientsafter even short-term (10 day) therapy with lowdose prednisolone.In the present study, 53 men with positive results in spermatozoalmixed antiglobulin reaction (MAR) and serum tray agglutinationtests (TAT), were randomized to receive either 20 mg of prednisoloneor placebo daily for 2 weeks prior to in-vitro fertilization(IVF) treatment. The antibody levels were also monitored byflow cytometry (FCM). There were no significant differencesbetween these groups as regards fertilization rates (35% withprednisolone; 39% with placebo) and pregnancy rates (29%; 32%).No significant changes occurred in either MAR or FCM resultsin relation to therapy. Patients with fertilization rates of<10% had significantly higher immunoglobulin G (IgG) MARvalues compared with those with better fertilization, whereasthere was no relationship between IgA levels and fertilizationresults. As regards FCM, the results were similar, but withoutstatistical significance. In conclusion, IVF is a good courseof action in severe male immune infertility, but low-dose prednisolonetherapy does not lower the sperm-bound antibody numbers anddoes not improve the IVF outcome.     

Andrology: Percoll semen preparation enhances human oocyte fertilization in male-factor infertility as shown by a randomized cross-over study

The aim of this study was to compare two methods of semen preparation:multiple tube swim-up and Percoll separation, using a randomizedcross-over clinical study, in which sperm parameters, oocytefertilization rates, embryo quality and cell stage were analysed.Overall, there was no difference between the two preparationmethods in the normozoospermic cycles. In the male-factor cycles,Percoll extracted a higher total number of spermatozoa (P =0.02), increased the concentration of motile spermatozoa (P= 0.02), increased the total number of motile spermatozoa persample (P = 0.02), and enhanced the recovery rate of motilespermatozoa (P = 0.04) compared to swim-up. There was a significantimprovement in fertilization rates (P = 0.0006), in the percentageof embryos over 2-cell stage on day of transfer (P = 0.004),and in the number of replaced embryos per transfer (P = 0.01)in the Percoll as compared to swim-up cycles. There was no significantdifference in embryo quality. We conclude, therefore, that inadvanced reproductive procedures where sperm dysfunction exists,semen preparation with Percoll should replace the swim-up technique.     

Counselling: An evaluation of counselling for couples undergoing treatment for in-vitro fertilization

Fertility difficulties, along with their investigation and treatment,are widely believed to cause significant psychological problems.This study was designed to investigate the efficacy of a non-directivecounselling intervention with couples undertaking their firstcycle of in-vitro fertilization treatment. Couples were randomlyassigned to either a control group, given information aboutthe treatment programme, or to an experimental group, giventhe same information plus three sessions of counselling before,during and on conclusion of the first treatment cycle. Psychologicalassessments were made at three points in the treatment process.Ratings were also obtained from the couples on the stress engenderedby different parts of the treatment, the effects on their relationshipand satisfaction with counselling. The results showed the patientsto be generally well adjusted and anxiety levels dropped overthe course of treatment. Counselling compared to informationalone did not lead to any enhanced reduction in levels of anxietyor depression. The implications of the findings for serviceprovision are discussed.     

Risk of thromboembolism in relation to an in-vitro fertilization programme: three case reports

Severe thrombotic events following ovarian stimulation for in-vitrofertilization (IVF) procedures in three women are reported.None of these patients presented any concomitant clinical signof ovarian hyperstimulation syndrome. Coagulation inhibitorswere in the normal range but cardiovascular risk factors werepresent. It is postulated that early thrombosis could be favouredby high endogenous plasma oestrogen concentrations subsequentto ovarian stimulation when associated with another risk factor.Our data are discussed in relation to previous publications.It is suggested that risk factors must be considered individuallybefore each IVF attempt. In patients at high risk, clinicalmanagement of the post-transfer period is recommended.     

Human chorionic gonadotrophin concentrations in early pregnancy after in-vitro fertilization.

There is increased risk of early pregnancy loss after assisted reproduction. In this study the use of serum human chorionic gonadotrophin (HCG) concentrations on day 12 after in-vitro fertilization (IVF) and embryo transfer was evaluated to predict pregnancy outcome. A total of 417 IVF pregnancies were included. Early pregnancy loss was defined as biochemical pregnancies, ectopic pregnancies and first trimester abortions. Vital pregnancies were defined as delivered singletons, multiple pregnancies and second trimester abortions. On the post embryo transfer day 12, the mean HCG concentration of the vital pregnancy group was significantly higher than in early pregnancy loss outcomes (P < 0.00001). Receiver operating characteristic (ROC) curve analysis was performed to evaluate the cut-off value of HCG giving maximal sensitivity and specificity in order to discriminate early pregnancy losses from vital pregnancies. A patient with a HCG value higher than the calculated cut-off value (55 IU/l) had a 90% chance of having a vital pregnancy after IVF and embryo transfer. It can be concluded that a discriminatory HCG value on day 12 after IVF and embryo transfer cycles may be useful in predicting pregnancy outcome and may guide clinicians in identifying those pregnancies at risk for adverse outcomes and instituting more intensive surveillance in this population.     

The incidence of chromosomal abnormalities in frozen-thawed mouse oocytes after in-vitro fertilization.

Cryopreservation of mouse oocytes induced a high rate of atresia. Frozen oocytes observed immediately after thawing did not exhibit any alteration in the frequency of chromosomal abnormalities, aneuploidy or polyploidy. After in-vitro fertilization attempts, the cleavage rate of frozen-thawed mouse oocytes was decreased. Cytogenetical observations of inseminated eggs also confirmed this decrease in fertilization rate. First and second cleavages were delayed compared to fresh controls but subsequent development to the 4-cell stage was not altered. Freeze-thawing increased the incidence of chromosomal abnormalities in inseminated oocytes but this only concerned the frequency of triploidy and not monosomic or trisomic aneuploidy. The increase in triploidy seemed to be largely due to the presence of digynic embryos. Second polar body retention seemed to be mainly responsible for this high rate of polyploidy.     

Infertility: Assessments of embryo transfer after in-vitro fertilization: effects of glyceryl trinitrate

The role of embryo transfer and its associated difficultieson the outcome of human in-vitro fertilization (IVF) were examinedusing a standardized procedure and a scoring system (embryotransfer scores 1–5). This system was used to assess anyeffects of the smooth muscle relaxant glyceryl trinitrate (GTN)on embryo transfer. Patients (n = 120) were randomized in adouble-blind manner at their first embryo transfer to receivesublingual GTN or placebo before the transfer. Retrospectiveanalysis showed that higher pregnancy rates were associatedwith uncomplicated transfers (score 1; P < 0.01). The outcomemeasures included pregnancy rate, total time of cervical manipulation(embryo transfer time) and embryo transfer score. All pregnancieshad a transfer score of 1 or 2, but no recorded parameter differentiatedbetween pregnant or non-pregnant cycles, and GTN had no significanteffect on any parameter.