A critical appraisal of assisted reproduction techniques

Several treatments for infertility have been promoted with onlylittle supporting objective data demonstrating their therapeuticvalue. The choice of an assisted reproductive technique dependson a balance between numerous factors. Seldom is the choiceabsolute as in patients with tubal block. There is conflictingevidence on the efficacy of simpler methods such as ovarianstimulation with or without artificial insemination and theavailable data suggest that the more invasive methods such asgamete intra-Fallopian transfer or in-vitro fertilization aremore effective in the treatment of couples with unexplainedinfertility. Equally, there is no conclusive evidence that pregnancyrates with any of the invasive techniques are superior to anyothers. However, a higher implantation rate following tubalembryo transfers is observed in many studies. This review presentsa critical asséssment of the effectiveness of assistedreproductive techniques.     

The 2004 Italian legislation regulating assisted reproduction technology: a multicentre survey on the results of IVF cycles

BACKGROUND: The new Italian law, passed in 2004, regulating assisted reproduction technology imposes that no more than three oocytes can be fertilized at one time and that all embryos obtained must be transferred simultaneously. Oocyte cryopreservation is allowed while embryo cryostorage is banned. The aim of this study was to evaluate the clinical impact of these limitations. METHODS: Seven Italian infertility centres were invited to collect data on IVF cycles performed over the first 4 months of application of the new legislation. As a control, all centres provided data on cycles performed in the same solar period, 1 year before. RESULTS: Data from 1861 cycles were obtained, 961 in the pre-law period and 900 in the post-law period. Pregnancy rate per oocyte retrieval and rate of multiple pregnancies in the pre- and post-law periods were 27.0 and 24.2% (P=0.18) and 25.8 and 20.9% (P=0.11) respectively. However, the prohibition to freeze embryos does appear to have markedly reduced the cumulative rate of success. CONCLUSIONS: The rate of success of IVF-ICSI cycles using fresh embryos is not significantly influenced by the new legislation while the prohibition to freeze embryos seems to result in a more relevant impact.     

Ethical and legal aspects of assisted reproduction practice in Asia

This report describes the ethical and legal aspects of assistedreproduction technology (ART) that have been instituted in Asiancountries. The data were collected by a questionnaire circulatedto ART units in Asia. These are Taiwan, Singapore, Korea, Indonesia,Thailand, Japan, Iran, India, Jordan, Malaysia, China, Israel,Hong Kong, Pakistan, Lebanon, Saudi Arabia, and Persian Gulfcountries. According to the survey, there are approximately260 ART centers in Asia (half of which are in Japan). On a globalbasis each ART centre in Asia serves an average population of13 million people. On the other hand, in those Asian countrieswhere the standards of living are relatively high, the availabilityof ART services, including the more sophisticated and costlyART procedures like micromanipulation, is similar to that inthe Western world. In most of the Asian countries practisingART, however, no state registry exists. Taiwan is the only countrythat has specific legislation, and in six other countries somekind of ministerial regulations are practised. We conclude thatART is now practised in 20 countries in Asia. The prevailingrules and cultural heritage in many of these Asian countrieshas a major influence on the implementation of ART in Asia.However, in view of the complicated and sensitive issues involved,and as no supervision on ART clinics exists in most of theseAsian countries, we advocate that some kind of quality controlshould be urgently instituted in all centres practising ART.In this way, it is hoped that the highest standards be attainedfor all parties concerned.     

Pregnancy rate fluctuations during routine work in an assisted reproduction technology unit

BACKGROUND: Fluctuations in spontaneous pregnancy rates have been observed in the general population. The purpose of this study was to evaluate whether pregnancy rates fluctuate over time in a homogeneous assisted reproduction treatment unit. METHODS: The study sample consisted of 3522 consecutive assisted reproduction cycles conducted from January 1996 to December 1999. Only fresh cycles in women <41 years old were included. All pertinent clinical data were prospectively collected on a computerized database and analysed at the end of the study. RESULTS: Throughout the 4 years of the study, monthly pregnancy rates fluctuated between 10.5 and 34.1% (mean 21.4%) per cycle, and between 13.6 and 41% (mean 27.26%) per transfer. These fluctuations did not follow any specific seasonal pattern. CONCLUSION: During routine work in an assisted reproduction treatment unit, there are random fluctuations in the pregnancy rate. This factor should be considered in studies performed in a specific time-period.     

GnRH antagonist in assisted reproduction: a Cochrane review

BACKGROUND: In the present systematic review, we wished to compare the efficacy of gonadotrophin-releasing hormone (GnRH) antagonist and GnRH agonist administration for controlled ovarian hyperstimulation in assisted conception. METHODS: Five randomized controlled trials fulfilled the inclusion criteria. In four studies, the multiple low-dose (0.25 mg) antagonist regimen was applied and, in one study, the single high-dose (3 mg) antagonist regimen was investigated. In all trials, reference treatment included a long protocol of GnRH agonist (buserelin, leuprorelin or triptorelin) starting in the mid-luteal phase of the preceding cycle. RESULTS: In comparison with the long protocol of GnRH agonist, the overall odds ratio for the prevention of premature LH surges was 1.76 [95% confidence interval (CI) 0.75-4.16], which was not statistically significant. There were significantly fewer clinical pregnancies in those treated with GnRH antagonists (OR 0.79; 95% CI 0.63-0.99). There was no statistically significant reduction in incidence of severe ovarian hyperstimulation syndrome between the two regimens (relative risk 0.51; OR 0.79; 95% CI 0.22-1.18). CONCLUSIONS: We concluded that the fixed GnRH antagonist protocol is a short and simple protocol with good clinical outcome, but the lower pregnancy rate compared with the GnRH agonist long protocol and the non-significant difference between both protocols regarding prevention of premature LH surge and prevention of severe ovarian hyperstimulation syndrome necessitates counselling subfertile couples before recommending change from GnRH agonist to antagonist. The clinical outcome may be further improved by developing more flexible antagonist regimens, taking into account individual patient characteristics.     

Pentoxifylline: actions and applications in assisted reproduction

Data are presented covering various studies on the use of thephosphodiesterase inhibitor pentoxifylline (PF) in the spermpreparation for procedures in assisted reproduction. Significantimprovements have been shown in the fertilization rate of oocytesalong with a reduced risk of failed fertilization cycles utilizingoligo/asthenozoospermic semen samples. Fertilization is alsoimproved for normozoospermic samples when the acrosome reactionis suboptimal. PF has proven effects on sperm motility, increasingthe proportion of hyperactivated spermatozoa. It can also enhancethe acrosome reaction and this may be the more relevant functionfor clinical prediction. There is a further action as a suppressoror scavenger of reactive oxygen species although higher concentrationsthan that in current clinical use may be required to optimizethis effect. PF should be washed out of the sample used forinsemination to avoid inhibiting the completion of oocyte maturation.     

High outcome predictability after IVF using a combined score for zygote and embryo morphology and growth rate

BACKGROUND: A scoring system has been developed to determine preimplantation embryo quality, and used to select embryos for transfer into the uterus of patients. METHODS AND RESULTS: The system was used to study early embryo development and to test whether these scores alone can accurately predict IVF outcome. Following zygote and embryo scores through early development, the data showed that a top quality zygote does not necessarily indicate that the resulting embryo will be top quality after in-vitro culture. The embryo quality score can change dramatically when embryos are cultured to day 2 or 3 post-fertilization. Pregnancy rates and implantation rates were compared with the cumulative and separated zygote and embryo scores. Analysis of the predictability of scoring systems suggested that morphological scores alone are relatively unpredictive of IVF outcome. When weighted for in-vitro growth rate, scores were highly predictive, more so than the rate of development alone. CONCLUSIONS: These data suggested that a combination of in-vitro growth rate and morphological analysis both of zygotes and embryos was highly indicative of outcome after IVF. The results can be adopted to the single embryo transfer approach to IVF.     

Attitudes towards human reproductive cloning, assisted reproduction and gene selection: a survey of 4600 British twins

BACKGROUND: Surveys have shown opposition to human reproductive cloning (HRC) in many countries. Views of identical (monozygotic, MZ) twins are of particular interest, as they naturally share 100% of their genes. We investigated attitudes of British twins towards HRC in the context of assisted reproduction technologies (ART) and gene selection. METHODS: About 4651 identical and non-identical (dizygotic, DZ) twins expressed their degree of agreement or disagreement to nine statements relating to ART, gene selection and HRC in a self-completion questionnaire. RESULTS: Most subjects (70% and 78% respectively) did not regard the use of medical technologies to treat infertility as interfering with either nature or God's will, despite believing that infertility is not a disease (54%). Attitudes to gene selection and HRC were context dependent, with more favourable views towards preventing serious diseases than towards enhancing traits. About 44% supported a permanent ban of HRC. MZ twins were significantly more likely to agree that HRC should be allowed for medical purposes, such as saving a sibling's life, than were DZ twins. Increasing religiosity generally correlated with more negative attitudes. CONCLUSIONS: Many attitudes are context dependent. More positive views of MZ twins towards HRC could be linked to their experience with being genetically identical.     

Life table (survival) analysis to generate cumulative pregnancy rates in assisted reproduction: an alternative method of calculating the cumulative pregnancy rate in assisted reproduction technology

The current method of calculating cumulative pregnancy rate can lead to an overestimation of treatment efficacy, especially over many cycles of assisted reproduction treatment. The choice of scale of passage of time should be dependent upon the types of treatment to be evaluated. The number of treatment cycles to which patients' effort and commitment is directly related may be appropriate where the chance of pregnancy is expected to be significantly higher than non-treatment for them. Limiting the calculation of cumulative pregnancy rate only to the second or third cycle within 1 or 2 years will ensure that most patients are included in the calculation. More research is needed to assess different methods and develop better variables for assessing the efficacy of infertility treatment that can be informative for patients over the course of their treatment.     

A prospective trial of blastocyst culture and transfer

BACKGROUND: The aim of this study was to evaluate the effectiveness of the blastocyst culture method compared with the conventional day 3 transfer method using a prospective trial. METHODS: A total of 235 patients with 273 cycles were evaluated for a period of almost 1 year. Depending upon the sequence in which the ovum retrieval was performed, patients were prospectively assigned (alternate allocation) to a culture period of 3 or 5 days duration. Embryos were transferred either on day 3 (after culture in human tubal fluid) or on day 5 (after culture in sequential media). RESULTS: The pregnancy rates after embryo transfer on days 3 and 5 were similar at 26.5 and 25.9% respectively. Among the day 5 embryo transfer group, patients were divided into three groups corresponding to three sequential media. The pregnancy rates were 32.0% using Irvine blastocyst medium, 6.9% using G1.2/G2.2 and 32.4% using Cook blastocyst medium. CONCLUSIONS: The results of our study were not as successful as previous studies had been. Additionally, there may have been problems in day 5 embryo transfer, such as choosing the sequential media, quality control, contamination and so on. From the results of this study, it appears that day 5 embryo transfer has no advantages for ordinary patients of assisted reproductive technology.     

Hyperactivated motility of human spermatozoa: a review of physiological function and application in assisted reproduction

Hyperactivated motility is a specific movement pattern which has been recognized in mammalian spermatozoa for over 25 years. During this time, it has been established that hyperactivation is part of the complex process of sperm capacitation, which is necessary before fertilization can occur. The recent introduction of computed sperm motility analysis has allowed detailed studies of sperm movement characteristics to be undertaken, and evidence is accumulating that hyperactivated motility may correlate with fertility. In this review, the physiological consequences of hyperactivated motility, methods of measurement and their application in assisted reproduction are discussed.     

Analysis of the bleeding pattern in assisted reproduction cycles with luteal phase supplementation using vaginal micronized progesterone

This study was designed to determine the effects of a vaginal micronized progesterone preparation on bleeding patterns and pregnancy outcomes after in-vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). The study population consisted of 149 consecutive women who had undergone IVF-ICSI using 'long-protocol' stimulation with buserelin-human menopausal gonadotrophin (HMG). A retrospective chart analysis of computerized medical records was undertaken. Vaginal progesterone (200 mg three times daily) was begun the day before oocyte retrieval and continued for a minimum of 16-19 days following human chorionic gonadotrophin (HCG) administration. Occurrence of bleeding following HCG injection, pregnancy rate and outcomes, and serum concentrations of oestradiol were measured. Women undergoing IVF and embryo transfer with ICSI and using vaginal progesterone for luteal support had normal luteal phase lengths (day of HCG minus day of onset of bleeding). In the absence of pregnancy, bleeding occurred after 19.2 +/- 3.9 days (mean +/- SD). Out of the pregnant group only three women bled within 19 days of HCG administration: two had biochemical pregnancies which spontaneously vanished and one evolved to term. The results reflect the normal bleeding pattern to be expected when vaginal progesterone is used for luteal support in IVF and embryo transfer, an approach whose efficacy has been amply proven. No shortened luteal phases were observed using vaginally administered progesterone.     

Doppler ultrasound examination of uterine arteries on the day of oocyte retrieval in patients with uterine fibroids undergoing IVF

BACKGROUND: There is no consensus as to whether uterine fibroids have any adverse effects on the outcomes of assisted reproduction treatment. This prospective study compared implantation/pregnancy rates of women with and without fibroids undergoing IVF-embryo transfer and measured uterine blood flow indices of the fibroid group. METHODS: Patients who had fibroids that, during transvaginal scanning, were found to be not distorting the endometrial lining were placed in the fibroid group, while patients with normal uteri were controls. Those with previous myomectomy or pedunculated subserosal fibroids only were excluded. All received a standard ovarian stimulation regimen. Doppler ultrasound examinations of uterine arteries were carried out in the fibroid group prior to oocyte retrieval. RESULTS: Similar implantation/pregnancy rates, multiple pregnancy rates and pregnancy outcomes were noted in both groups. In the fibroid group, significantly lower pulsatility index (PI) and resistance index (RI) of the right uterine artery and the average of right and left uterine arteries were found in those failing to conceive than in those patients who subsequently conceived (P < 0.001). CONCLUSION: The presence of fibroids not distorting the endometrial lining does not adversely affect implantation and pregnancy rates during IVF-embryo transfer. Significantly lower uterine artery PI and RI were found in non-pregnant women with fibroids than in their pregnant counterparts.     

The importance of fibroblasts in remodelling of the human uterine cervix during pregnancy and parturition

It is well established that fibroblasts play a crucial role in pathophysiological extracellular matrix remodelling. The aim of this project is to elucidate their role in normal physiological remodelling. Specifically, the remodelling of the human cervix during pregnancy, resulting in an enabled passage of the child, is used as the model system. Fibroblast cultures were established from cervices of non-pregnant women, women after 36 weeks of pregnancy and women directly after partus. The cells were immunostained and quantified by western blots for differentiation markers. The cultures were screened for cytokine and metalloproteinase production and characterized by global proteome analysis. The cell cultures established from partal donors differ significantly from those from non-pregnant donors, which is in accordance with in vivo findings. A decrease in alpha-smooth actin and prolyl-4-hydroxylase and an increase in interleukin (IL)-6, IL-8 and matrix metalloproteinases (MMP)-1 and MMP-3 were observed in cultures from partal donors. 2D-gel electrophoresis followed by mass spectrometry showed that the expression of 59 proteins was changed significantly in cultures of partal donors. The regulated proteins are involved in protein kinase C signalling, Ca2+ binding, cytoskeletal organization, angiogenesis and degradation. Our data suggest that remodelling of the human cervix is orchestrated by fibroblasts, which are activated or recruited by the inflammatory processes occurring during the ripening cascade.     

Babies born after ART treatment cost more than non-ART babies: a cost analysis of inpatient birth-admission costs of singleton and multiple gestation pregnancies

BACKGROUND: Currently, about one-third of infants born after assisted reproductive technology (ART) worldwide are twins or triplets. This study compared the inpatient birth-admission costs of singleton and multiple gestation ART deliveries to non-ART deliveries. METHODS: A cohort of 5005 mothers and 5886 infants conceived following ART treatment were compared to 245 249 mothers and 248 539 infants in the general population. Birth-admission costs were calculated using Australian Refined Diagnosis Related Groups and weighted national average costs (2003-2004 euro). RESULTS: ART infants were 4.4 times more likely to be low birthweight (LBW) compared with non-ART infants, translating into 89% higher birth-admission costs (euro2,832 and euro1,502, respectively). ART singletons were also more likely to be LBW compared with non-ART singletons, translating into 31% higher birth-admission costs (euro1,849 and euro1,415, respectively). After combining infant and maternal admission costs, the average cost of an ART singleton delivery was euro4,818 compared with euro13 890 for ART twins and euro54 294 for ART higher order multiples. Findings were not sensitive to changes in casemix. CONCLUSIONS: The poorer neonatal outcomes of ART singletons compared with non-ART singletons are significant enough to impact healthcare resource consumption. The high costs associated with ART multiple births add to the overwhelming clinical and economic evidence in support of single embryo transfer.     

The impact of successful assisted reproduction treatment on female and male mental health during transition to parenthood: a prospective controlled study

BACKGROUND: The dynamics of mental health during the transitionto parenthood have not been a focus of research. Our prospectivelongitudinal study was designed to reveal whether there aredifferences in mental health during the transition to parenthoodbetween parents undergoing treatment with assisted reproductiontechniques (ART) and those who conceive spontaneously. METHODS:Study group: 367 couples with a singleton ART pregnancy usingtheir own gametes. Control group: 379 couples with a spontaneoussingleton pregnancy. Men and women separately filled in questionnairesincluding the General Health Questionnaire: at the 18th–20thweek of pregnancy, 2 months postpartum and 1 year postpartum(T3). The effect of social and child-related factors on mentalhealth was examined. RESULTS: ART women had fewer depressivesymptoms during pregnancy than controls, but at T3 their depressivesymptoms were at the same level as seen in controls. Anxietysymptoms increased among control but not among ART women acrossthe transition. ART men reported generally fewer mental healthsymptoms than their controls. Social and child-related stressorshad negative impacts on mental health changes among controlcouples, whereas no impact was found among ART couples. CONCLUSIONS:Successful ART did not predict mental health problems duringthe transition to parenthood. Moreover, ART couples’ mentalhealth was remarkably resistant to social and child-relatedstress during the transition to parenthood.     

Medically assisted reproduction in the presence of chronic viral diseases

Teams practising medically assisted reproduction techniques try to avoid viruses as much as possible. Attitudes towards chronic carriers of viruses are rapidly changing, especially for human immunodeficiency virus (HIV) patients. We focus our attention on the legitimacy of systematic screening before assisted reproductive techniques and the need for specialized approaches including an adapted laboratory for viral hazards as well as the need for a multidisciplinary team. Specificities of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV) carriers and the hypothesis of a reduced fertility potential are discussed. Are male HIV carriers a new indication for assisted reproductive techniques in order to prevent virus transmission? It is largely proven that sperm gradient preparation techniques efficiently decrease viral loads and therefore have a protective effect on contamination risk during assisted reproductive techniques. Although a few thousand assisted reproductive technique cycles were performed in the world for this indication without contamination, it is still too early to demonstrate that this technology is fully safe. Two examples of contaminations during insemination are examined. Many questions remain unresolved, such as the lack of standardized techniques for semen preparation or virus detection or the relative merits of intrauterine insemination or ICSI to prevent HIV contamination during assisted reproductive techniques. The authors plead for well-structured, separate programmes of care linked to research objectives.     

Impact of elective single embryo transfer on the twin pregnancy rate

BACKGROUND: It is unclear how the implementation of elective single embryo transfer in clinical practice would affect clinical pregnancy and delivery rates and multiple birth rates. METHODS: This retrospective study analysed 1871 IVF/ICSI cycles carried out from 1997 to 2001 in the IVF programme of a single university infertility clinic. RESULTS: The number of elective single embryo transfers increased from 11 to 56%. At the same time the clinical pregnancy rate was relatively stable; mean 34.0% (range 28-42). The number of embryos per embryo transfer decreased from 1.8 to 1.3. The multiple pregnancy and delivery rates dropped markedly from 25 to 7.5% and from 25 to 5% respectively. CONCLUSIONS: An elective single embryo transfer programme can be adopted in daily practice that decreases the twinning rate to <10% and does not affect the overall pregnancy rate.     

Live-birth rates and multiple-birth risk of assisted reproductive technology pregnancies conceived using thawed embryos,USA 1999-2000

BACKGROUND: Increasing use of assisted reproductive technology treatments has been associated with the current rise in multiple births in the USA. Embryo cryopreservation and subsequent thawed embryo transfer may favourably impact the multiple-birth risk by relieving some pressure that patients and providers may feel to transfer several embryos in a single cycle. The study objective was to examine both live-birth rates and multiple-birth risk in thawed cycles. METHODS: The authors used a population-based sample of 21 555 assisted reproductive technology procedures performed in US clinics in 1999 and 2000 that used thawed embryos derived from the patient's oocytes. RESULTS: Both patient age and the number of embryos transferred were independent predictors of live birth. Even among women aged 20-29 years, the transfer of three embryos resulted in an increase in the live-birth rate compared with cycles in which one or two embryos were transferred. This increase in success was accompanied by an increased multiple-birth risk. In all age groups up to 40 years, the transfer of just two embryos resulted in a multiple-birth risk of 16-17%. The multiple-birth risk increased with the number of embryos transferred. CONCLUSIONS: Patient age and the number of embryos transferred significantly affect live-birth and multiple-birth rates among women who use thawed embryos.