Effect of microsurgical ampullary segmental reversal on fertilization in the rabbit

Microsurgical reversal of a 1-2cm segment of mid ampulla was performed in rabbits. The fertility rate and location of ova were determined at 24 and 48 hours post coitum (hr p.c.). Oviducts in which a similar segment of mid ampulla was double-transected without reversal served as surgical controls. Contralateral oviducts in all animals served as unoperated controls. All ova and embryos recovered from oviducts with a reversed segment of mid ampulla had not been transported beyond the reversed segment at 24 or 48hr p.c. In contrast, all ova recovered from unoperated oviducts at 24 and 48hr p.c. and from double-transected oviducts at 48hr p.c. had undergone normal transport. We conclude that the ampullary isthmic junction and proximal ampulla are not unique, obligate sites for fertilization, that tubal ciliary activity is a minor determinant of sperm transport through the ampulla and that reversal of a 1-2cm segment of mid ampulla in the rabbit is consistent with normal sperm transport and fertilization. In contrast, ciliary activity prevents passage of ova or embryos past the reversed segment into the proximal oviduct.     

In vitro fertilization in the Netherlands: Experiences and opinions of Dutch women

We sent written questionnaires to 93 Dutch women [73 current and potential clients of the Rotterdam in vitro fertilization (IVF) program and 20 fertile nonusers] to determine the motivation for participation in IVF, patients' reactions to treatment, and views of concerned laypersons on current ethical/social issues. Seventy-eight (84%) completed the questionnaires. A large majority was strongly positive toward the having of children and toward IVF, but fewer fertile than infertile women (P< 0.05) believed that a child of one's own was a right and that government insurance ought to cover IVF. Nearly all the patients (with or without successful pregnancies) were very satisfied with their clinical treatment and would recommend IVF. A large majority of all the women favored gamete donation and surrogate gestation, but fewer fertile than infertile women approved experiments with spare embryos or implanting donor embryos.     

Superior clinical pregnancy rates after microsurgical epididymal sperm aspiration

Purpose

To assess normal fertilization, clinical pregnancy, and live birth rates after the use of microscopic epididymal sperm aspiration (MESA).

Methods

One‐hundred‐and‐sixty azoospermic participants who underwent MESA were evaluated. The MESA was performed by using a micropuncture method with a micropipette. In cases in which motile sperm were not obtained after the MESA, conventional or micro‐testicular sperm extraction (TESE) was completed.

Results

Adequate motile sperm were retrieved in 71 participants by using MESA and in 59 out of 89 participants by using TESE. Of the total number of patients, 123 underwent intracytoplasmic sperm injection. After MESA, the normal fertilization rate was 73.5% and the clinical pregnancy rate per case was 95.7%. Healthy deliveries resulted after MESA in 65 (92.9%) cases and after TESE in 38 (71.7%) cases.

Conclusion

The MESA specimen collection does not have any special requirements, such as mincing tissue disposition. The MESA also can reduce the amount of laboratory work that is needed for cryopreservation. In the authors' experience, MESA is a beneficial procedure and should be given priority over TESE.     

Controversies in IVM

Purpose  

To explore four areas of controversy: the benefits of gonadotropin priming, benefits and timing of hCG trigger as well as the ideal protocols for endometrial preparation and luteal support.     

Intrauterine fertilization capsules—A clinical trial

Treatment of 26 women with tubal infertility was attempted using intrauterine capsules loaded with oocytes and spermatozoa. The stimulation protocol was as used for in vitro fertilization and embryo transfer and consisted of short-term use of Buserelin, human menopausal gonadotropin, and human chorionic gonadotropin. Oocytes were collected by ultrasonically guided transvaginal aspiration, and spermatozoa were prepared by swim-up technique. The gametes were placed in agar capsules 4 hr after oocyte collection, and the capsules were introduced to the uterine fundus using an insertion tube and piston from an intrauterine device. Six complete capsules and parts of two other capsules were expelled. None of the women became pregnant, compared with a pregnancy rate of 21% per aspiration following in vitro fertilization and embryo transfer during the same period.     

短时受精与长时受精对体外受精及临床妊娠结局的影响

目的:探讨短时受精与长时受精对体外受精及临床妊娠结局的影响。方法:2008年1月至2010年12月因女性输卵管因素或盆腔炎症在本中心接受短时IVF与长时IVF。短时IVF共1095周期,长时IVF共1008周期,比较短时受精与长时受精两组患者的基本情况、受精、胚胎及临床妊娠情况。结果:两组患者正常受精(2PN)率的差异无统计学意义(P>0.05)。长时受精的0PN率(18.1%vs 13.5%)、1PN率(3.8%vs1.6%)明显高于短时受精组,3PN率比较,结果相反(4.5%vs 7.8%)。短时受精的卵子利用率(58.4%vs 53.7%)、优质胚胎率(70.6%vs 65.5%)、胚胎利用率(85.2%vs80.1%)明显高于长时受精组,两组临床妊娠率无统计学差异(44.6%vs 41.5%,P>0.05)。结论:短时IVF的多PN率比长时IVF高,但是0PN、1PN率显著降低,卵子利用率提高。短时IVF的优质胚胎率、胚胎利用率明显高于长时IVF。短时受精在一定程度上能提高卵子利用率,改善胚胎质量从而提高胚胎利用率。     

Partial zona dissection or subzonal sperm insertion: microsurgical fertilization alternatives based on evaluation of sperm and embryo morphology

OBJECTIVE: To establish guidelines for application of partial zona dissection, subzonal sperm insertion, and regular in vitro fertilization (IVF) in severe male factor patients. DESIGN: Two studies were performed: partial zona dissection and IVF was applied in 57 couples during the first period, and subzonal sperm insertion was also applied in a second group of 47 couples. SETTING: Procedures were performed in an academic research environment. PATIENTS, PARTICIPANTS: Couples who failed fertilization previously, others not acceptable for IVF, and a third group in whom IVF was expected to fail. INTERVENTIONS: Oocytes were micromanipulated with either partial zona dissection or subzonal sperm insertion, or the zona pellucida was left intact. Embryos were replaced in patients prophylactically treated with methylprednisolone and antibiotics. MAIN OUTCOME MEASURES: Because several microsurgical fertilization techniques are now available, this study was performed to compare sperm parameters, embryo morphology, fertilization, and implantation rates after application of two successful micromanipulation procedures. RESULTS: Twenty-one pregnancies were established in 104 patients, 5 definitely from subzonal sperm insertion and 4 from partial zona dissection. Patients who failed IVF before had a similar chance of pregnancy after the use of micromanipulation, as first time patients (9/53 versus 12/51). In a subgroup of 15 patients who failed IVF with insufficient numbers of motile sperm, fertilization was significantly higher after subzonal sperm insertion. Partially zona-dissected embryos from couples with severe teratozoospermia (less than or equal to 5% normal forms; strict criteria) had significantly more morphological abnormalities than those from patients with moderate teratozoospermia (6% to 10% normal forms). In severely teratozoospermic patients, significantly fewer partially zona-dissected than subzonally inserted embryos implanted. CONCLUSIONS: The decision of which micromanipulation method to perform can possibly be based on careful analysis of sperm morphology.     

Results of microsurgical treatment of tubal infertility and early second-look laparoscopy in the post-pelvic inflammatory disease patient: implications for in vitro fertilization

Sixty-nine patients with tubal infertility secondary to pelvic inflammatory disease were surgically treated by one of three infertility surgeons, who used microsurgery for repair of the tubal pathologic condition and early second-look laparoscopy 6 to 30 days postoperatively for lysis of postoperative adhesions. No patient was included in this group whose disease was thought to have originated from endometriosis or prior abdominal surgery. The average follow-up time was 43.1 months (range 12 to 85.9). Nine patients were excluded from the analysis. Pregnancy outcome by procedure, expressed as the percentage of patients conceiving, was as follows: adhesiolysis, 69% (61% term, 8% ectopic); fimbrioplasty, 35% (25% term, 10% ectopic); salpingostomy, 30% (18% term, 12% ectopic); and cornual implantation, 60% (40% term, 20% ectopic). No added therapeutic value could be attributed to the use of early second-look laparoscopy. Given the relatively poor outcome of fimbrioplasty and salpingostomy, it may be prudent to advise patients with bilateral partial and/or total tubal occlusion against tuboplasty in favor of in vitro fertilization and embryo transfer.     

Controversies in gestational diabetes

Gestational diabetes mellitus (GDM) and controversy are old friends. However, several major studies in the field have clarified some of the main issues. There is now no doubt that hyperglycaemia, at levels less than those that occur in overt diabetes, is associated with adverse pregnancy outcomes, such as large-for-gestational age infants, neonatal hyperinsulinism, neonatal hypoglycaemia and pre-eclampsia. We also have evidence now that a standard approach to GDM with diagnosis at 24-28 weeks, dietary advice, self-monitoring of blood glucose and insulin therapy as needed reduces these adverse perinatal outcomes. Unknown, however, is if this same approach is effective at reducing long-term risks of metabolic syndrome, type 2 diabetes and cardiovascular disease in both the mothers and babies. For example, could our management strategies miss critical time points of fuel-mediated injury to the foetus important for the baby's long-term metabolic health? The implications of a recent international consensus statement on new diagnostic criteria for GDM are discussed, as well as issues relating to the timing of diagnosis. The potential place for a risk calculator for adverse outcomes in GDM pregnancy that takes into account glycaemic and non-glycaemic risk factors is considered. Such a tool could help stratify GDM women to different levels of care. Ongoing issues relating to maternal glycaemic and foetal growth targets, and the use of oral hypoglycaemic agents in GDM are discussed. To resolve some of the remaining controversies, further carefully designed randomised controlled trials in GDM with long-term follow-up of both mothers and babies are necessary.     

Controversies in Gestational Diabetes

Gestational diabetes (GD) occurs in women with a pre-existing abnormality of glucose metabolism. Although the O’Sullivan criteria were initially based on the development of Type II diabetes in the future, subsequent studies found adverse perinatal outcomes in women who had GD diagnosed by these criteria. Macrosomia in infants of mothers with GD is associated with more complications, both mechanical and metabolic, than in non-diabetics. A number of studies suggests that the O’Sullivan criteria are not strict enough and that typical diabetic complications can occur with lesser degrees of glucose intolerance. Study methods include showing a continuum of risk based on glucose tolerance test (GTT) values, retrospective evidence of increased glucose levels in mothers who delivered macrosomic infants, and abnormal outcomes in patients with untreated impaired glucose intolerance and patients with GTT normal by the O’Sullivan criteria but abnormal by the Coustan criteria. These studies indicate the need to screen universally for GD and to assess glucose metabolism in any patient showing evidence of macrosomia. With tight glucose control, normal outcomes can be achieved.     

Controversies in neonatal resuscitation

Abstract

Despite recent advances in perinatal medicine and in the art of neonatal resuscitation, resuscitation strategy and treatment methods in the delivery room should be individualized depending on the unique characteristics of the neonate. The constantly increasing evidence has resulted in significant treatment controversies, which need to be resolved with further clinical and experimental research.