Endometrial Staining of CD56 (Uterine Natural Killer), BCL-6, and CD138 (Plasma Cells) Improve Diagnosis and Clinical Pregnancy Outcomes in Unexplained Infertility and Recurrent IVF Failures: Standardization of Diagnosis with Digital Pathology.

In women with unexplained infertility (UI) and recurrent in vitro fertilization (IVF) failures, the etiology is often unclear. Endometrial immune perturbations and the use of immune markers associated with these dysregulations are of great interest in the diagnosis and treatment of UI. However, reliable biomarkers and standardized quantification methods are lacking. Here, to address endometrial immune dysregulation in UI patients with recurrent IVF failures, we performed endometrial tissue sampling and immunostaining of CD56 (uNK), CD138, and BCL-6. Of these cases, 57.9% had positive CD56 in the endometrial stroma, while 46.1% had positive BCL-6 in the glandular epithelium, and 14.5% of the cases were found to be positive for CD138. Combined staining rates were 60.5%, 68.4%, and 71.05% for (CD56 or BCL-6), (CD56 or CD138), and (CD56, BCL-6, or CD138), respectively. There was a significant correlation between CD56 and BCL-6 positivity, while CD138 positivity was an independent parameter. After the recommended targeted therapy, pregnancy rates were found to increase from 58.5% to 61.6% and 73.8% in CD56-positive, (CD56- or BCL-6-positive), and (CD56-, BCL-6-, or CD138-positive) cases, respectively. Notably, a retrospective evaluation of digital pathology and light microscopy results showed a significant correlation. This study suggests that the examination of CD56, BCL-6, and CD138 in the same endometrial sample may be an effective method in determining the etiology of UI and reaching an early diagnosis and treatment options. Moreover, digital pathology can be used in the evaluation of CD56 and BCL-6 to provide objective, rapid, and reliable results.

Frozen-thawed cleavage-stage embryo transfer cycles after previous GnRH agonist or antagonist stimulation.

This study presents the results of fresh and frozen-thawed embryo transfers in women undergoing IVF with gonadotrophin-releasing hormone (GnRH) agonists and GnRH antagonists. By evaluating cycle outcomes, the impact of two different protocols on the endometrium was indirectly evaluated. For 714 women, embryos were frozen following day-3 fresh embryo transfer and the outcome of those fresh cycles (329 agonist cycles and 290 antagonist cycles) and subsequent frozen-thawed embryo transfer (91 agonist cycles and 104 antagonist cycles) were evaluated. Peak oestradiol concentrations of both groups were similar; however, significantly more oocytes were retrieved and more embryos frozen in the agonist versus antagonist group (both P = 0.0001). In fresh embryo transfer cycles, implantation and pregnancy rates in the agonist versus antagonist group were 42.3% versus 32.0% (P = 0.0001) and 68.6% versus 58.2% (P = 0.009) respectively. However, neither implantation or pregnancy rate significantly differed among frozen-thawed embryo transfer cycles between the two groups (21.4% versus 23.5% and 52.2% versus 52.4% respectively). These results suggest that ovarian stimulation parameter outcomes of GnRH antagonist cycles were not inferior to GnRH agonist cycles, therefore reduced embryo implantation and pregnancy rates in GnRH antagonist cycles can be attributable to possible deleterious effects on the endometrium.

Use of a GnRH antagonist in controlled ovarian hyperstimulation for assisted conception in women with polycystic ovary disease: a randomized, prospective, pilot study.

OBJECTIVE: To compare the outcome of using gonadotropin-releasing hormone (GnRH) antagonists versus agonists in women with polycystic ovary disease (PCOD) who underwent controlled ovarian hyperstimulation (COH) for assisted reproductive techniques (ART). STUDY DESIGN: A total of 129 patients with PCOD were randomly allocated to undergo COH with a GnRH antagonist (59 patients) and GnRH agonist (leuprolide acetate) (70 patients) to prevent a premature luteinizing hormone (LH) surge. Assisted fertilization following oocyte retrieval and embryo transfer was performed. RESULTS: None of the cycles were cancelled due to a premature LH surge. There was no significant difference between the antagonist and agonist arms in the number of gonadotropin ampules consumed per cycle. However, in the antagonist arm a shorter duration of ovarian stimulation was recorded as compared to the agonist arm. Although similar numbers of oocytes was retrieved from both groups of patients, the quality of the oocytes, as measured by metaphase 2/total oocyte ratio, was lower in the antagonist arm as compared to the agonist arm. Pregnancy rates were 57.6% and 58.5% in the antagonist and agonist arms, respectively (p > 0.05). Implantation rates were not different (34.0% and 34.6%, respectively). The frequency of ovarian hyperstimulation syndrome also did not differ between the treatment groups (5% and 7.1%, respectively). CONCLUSION: The size of our study, on a specific subgroup of patients, does not allow a reliable conclusion regarding ART outcomefollowing the use of a GnRH antagonist versus agonist. Nevertheless, the protocol with the antagonist gave results that were as good as those of the protocol with the agonist in this PCOD patient population.

Prenatal karyotypes of fetuses conceived by intracytoplasmic sperm injection.

OBJECTIVE: To evaluate the rate of chromosomal abnormalities in babies conceived by intracytoplasmic sperm injection (ICSI). DESIGN: Retrospective case-control analysis. SETTING: Private IVF center. PATIENT(S): One thousand one hundred thirty-six karyotype results obtained from fetuses conceived by ICSI. INTERVENTION(S): Amniocentesis and prenatal karyotyping. MAIN OUTCOME MEASURE(S): Presence of normal and abnormal chromosomal configurations. RESULT(S): Abnormal karyotypes were detected in 17 (1.5%) of 1,136 fetuses. Eight (0.7%) of these were from singleton and nine (0.8%) from twin pregnancies. There was no difference in the autosomal chromosome structure or the number or structure of sex chromosomes in karyotyped fetuses of singleton and twin pregnancies. However, abnormal numbers of autosomal chromosomes were more frequent in singletons (2.3%) than in twins (1.1%). There was also no difference in the frequency of chromosomal aberrations between ICSI groups in which ejaculated spermatozoa (1.9%) and testicular spermatozoa (1.5%) were used. There was no difference in the frequency of chromosomal aberrations between fetuses for whom ICSI was used because of male factors (1.8%) compared with babies for whom ICSI was also the choice of assisted fertilization method for other types of infertility factors (0.9%). CONCLUSION(S): Sperm source does not influence the karyotype of babies conceived by ICSI. By comparing our results with previously reported data from natural pregnancies, we show that ICSI babies carry a significantly increased risk of an abnormal karyotype. However, the increased risk is similar among the different infertility groups.

Bilateral internal jugular venous thrombosis following successful assisted conception in the absence of ovarian hyperstimulation syndrome.

The majority of the venous thromboembolic events seen in patient following gonadotropin administration were associated with the development of ovarian hyperstimulation syndrome (OHSS). However, in this case report, a 29-year-old woman that conceived by controlled ovarian hyperstimulation, intracytoplasmic sperm injection and subsequent embryo transfer without conjunction of OHSS was described. Bilateral jugular venous thrombi were detected by duplex Doppler in the 8th week of pregnancy when she was admitted to the emergency room for difficulty in swallowing and bilateral neck pain. She had unremarkable history and negative results for thrombophilia screening. Full anticoagulation with intravenous heparin was initiated and continued subcutaneously throughout pregnancy. She delivered two healthy babies at 36 weeks of pregnancy. Venous thromboembolism should be taken in account in patients undergoing gonadotropin administration for assisted conception with the complaint of extremity pain regardless of having risk factors for thromboembolism.

Klinefelter syndrome: does it confer a bad prognosis in treatment of nonobstructive azoospermia?

OBJECTIVE: To determine the effectiveness of microsurgical testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI) for men with Klinefelter syndrome (KS). DESIGN: Retrospective clinical study. SETTING: Private IVF center. PATIENT(S): Men with nonmosaic KS (n = 106), and men with nonobstructive azoospermia (NOA) and normal karyotypes (n = 379). INTERVENTION(S): Micro-TESE on the day of oocyte retrieval. MAIN OUTCOME MEASURE(S): Sperm recovery, fertilization, pregnancy, and spontaneous abortion rates. RESULT(S): Sperm was successfully recovered in 50 of 106 (47%) men in the KS group and 188 of 379 (50%) in the NOA group. The fertilization rate was higher in the NOA group than the KS group (65% vs. 57%, respectively); however, pregnancy (55% vs. 53%) and abortion rates (12% vs. 11.5%) did not differ statistically significantly between groups. In the KS group, 23 pregnancies resulted in 29 live births; the 21 children who underwent genetic evaluation had normal karyotypes. CONCLUSION(S): Sperm recovery rates in men with KS were similar to those of men with NOA and normal karyotypes. The fertilization rate was statistically significantly lower for men with KS than men with NOA, but pregnancy and abortion rates were similar. We observed good sperm recovery and ICSI outcomes for patients with KS.

Gonadotrophin therapy in combination with ICSI in men with hypogonadotrophic hypogonadism.

The aim of this study was to evaluate the impact of gonadotrophin therapy in combination with intracytoplasmic sperm injection (ICSI) in men with hypogonadotrophic hypogonadism (HH). Twenty-five azoospermic men were diagnosed with HH due to low FSH, LH and total testosterone concentrations. These patients were treated with human chorionic gonadotrophin for 1 month plus recombinant FSH the following month. Total testosterone concentrations were measured in the first and third months. Semen analyses were performed monthly after the third month of treatment. ICSI was performed when sperm production commenced. Total testosterone concentration and testicular volume were significantly increased after gonadotrophin therapy (P < 0.001). On average, spermatozoa were detected in the ejaculate after 10 months. Spontaneous pregnancies were achieved in four couples. Twenty-two ICSI cycles were performed in 18 couples using ejaculated or testicular spermatozoa, and 12 pregnancies (54.5% per cycle) were achieved. These results showed that HH could be treated successfully with hormonal therapy combined with ICSI using ejaculated spermatozoa. The use of ICSI made it possible to achieve pregnancy when spermatozoa appeared in the ejaculate, and shortened the duration of gonadotrophin therapy.

Comparison of preovulatory follicular concentrations of epidermal growth factor, insulin-like growth factor-I, and inhibins A and B in women undergoing assisted conception treatment with gonadotropin-releasing hormone (GnRH) agonists and GnRH antagonists.

Follicular fluid contents of 69 age-matched women undergoing ovarian stimulation with a GnRH agonist and a GnRH antagonist were collected during oocyte retrieval. The groups did not differ in baseline characteristics and in terms of assisted conception treatment outcome. Similarly, follicular fluid levels of epidermal growth factor, insulin-like growth factor, and inhibins A and B were found not to be different. Our results suggest that follicular development in regard to ovarian growth factor dynamics is not different in women undergoing ovarian stimulation with GnRH antagonists than in women using GnRH agonists.

Impact of coasting in patients undergoing controlled ovarian stimulation with the gonadotropin-releasing hormone antagonist cetrorelix.

Coasting is the most popular modality for the prevention of ovarian hyperstimulation syndrome, but this procedure has not been evaluated in patients undergoing controlled ovarian hyperstimulation (COH) with GnRH antagonists. The impact of coasting in a cycle in which GnRH antagonist is used was evaluated in 29 women, and it was found that coasting did not deleteriously affect the outcome in high-responder patients undergoing COH with GnRH antagonists.

Outcome of 1114 ICSI and embryo transfer cycles of women 40 years of age and over.

The purpose of this study was to contribute to the development of strategies to obtain acceptable outcomes in assisted reproduction treatments in women over 40 years of age. A retrospective study was carried out on the database of the German Hospital in Istanbul using data from the years 1997 to 2004. A total of 1114 embryo transfer cycles were assessed. The pregnancy, implantation and delivery rates of the assessed population were 18.2, 8.3 and 10.9% respectively. The results showed that the demographics and outcome of cycles of women at 40 years differed significantly from those over 40. Cycles in which six or more oocytes were retrieved displayed better characteristics and outcome than those with five or fewer. The clinical pregnancy and delivery rates after transfer of three embryos were similar to four or more. Therefore, women over 40 years with a good ovarian response and at least three embryos available for transfer have an acceptable pregnancy and delivery rate with a low multiple pregnancy risk.

Aging may adversely affect testicular sperm recovery in patients with Klinefelter syndrome.

OBJECTIVES: To investigate the clinical parameters or laboratory analyses that may have a predictive value for successful sperm retrieval in Klinefelter syndrome (KS). METHODS: A total of 74 patients with nonmosaic KS were included in this study. All patients were azoospermic and underwent microdissection testicular sperm extraction for sperm recovery. The predictive values of patient age, testicular volume, serum follicle-stimulating hormone, luteinizing hormone, and testosterone levels were assessed for successful sperm recovery. RESULTS: Testicular sperm recovery was successful in 42 (56.7%) of 74 men. The serum follicle-stimulating hormone, luteinizing hormone, and total testosterone levels did not show any difference between the patients with successful and those with unsuccessful sperm recovery. However, the patients with successful sperm recovery were significantly younger (31.6 +/- 4.3 years) than those with failed attempts (35 +/- 5.1 years, P = 0.002). In the receiver operating characteristics curve analysis, a cutoff of 30.5 years of age had a sensitivity of 78% and a specificity of 48% for successful sperm retrieval. Logistic regression analysis showed that sperm recovery was inversely related to patient age (odds ratio 0.854, 95% confidence interval 0.76 to 0.95). CONCLUSIONS: Microdissection testicular sperm extraction is an effective sperm recovery technique in patients with KS. Our data have demonstrated that aging might adversely affect the sperm recovery rate in men with KS. These results suggest that earlier infertility assessment and testicular sperm extraction in men with KS might play a critical role in their treatment.

Efficiency of changing the embryo transfer time from day 3 to day 2 among women with poor ovarian response: a prospective randomized trial.

OBJECTIVE: To compare the outcome of day 2 and day 3 embryo transfers in women demonstrating poor ovarian response. DESIGN: Prospective randomized clinical trial. SETTING: Private assisted reproductive technology center. PATIENT(S): Two hundred eighty-one women demonstrating poor ovarian response to controlled ovarian hyperstimulation. INTERVENTION(S): Women who were poor responders were randomly allocated to day 2 or day 3 embryo transfer following oocyte retrieval. MAIN OUTCOME MEASURE(S): Implantation rates and pregnancy rates per oocyte retrieval and embryo transfer. RESULT(S): The clinical pregnancy rates per oocyte retrieval (37.2% vs. 21.4%, respectively; P<.05) and per embryo transfer (38.9% vs. 24.1%, respectively; P<.05) were significantly higher in the day 2 embryo transfer group compared with day 3. On the other hand, implantation rates were not different between groups (23.9% vs. 17.2%, respectively; P=.08). CONCLUSION(S): Our results demonstrated that transfering embryos on day 2 could provide an alternative to the management of poor responder patients.

Elevated oestradiol concentrations are not associated with increased first trimester miscarriage rates of singleton gestations conceived by assisted conception treatment.

The study evaluated the impact of elevated oestradiol concentrations on pregnancy loss during the first trimester in singleton gestations conceived via ovarian stimulation and intracytoplasmic sperm injection (ICSI). Following determination of oestradiol concentrations during 6478 ICSI cycles, patients were assorted by oestradiol percentile. Hyper-responders were defined as patients having peak oestradiol concentrations over the 90th percentile (>4200 pg/ml, 685 cycles), moderate responders were defined as patients having peak oestradiol concentrations between the 75th and 90th percentiles (3250-4200 pg/ml, 958 cycles) and normal responders were defined as patients having peak oestradiol concentrations between the 25th and 75th percentiles (1350-3250 pg/ml, 3325 cycles). The relationship between first trimester miscarriage rates and oestradiol percentiles was analysed in 1184 singleton gestations. Pregnancy rate was significantly lower in normal responders (54.4%) than in moderate (58.8%, P = 0.02) and hyper-responders (60.9%, P = 0.003), but there were no intergroup differences in miscarriage rate (19.6%, 17.1%, and 16.8%, respectively). Although women with severe ovarian hyperstimulation syndrome had a miscarriage rate of 40%, this rate did not differ significantly from the miscarriage rates of the other groups. The findings suggest that high oestradiol concentrations during ovarian stimulation do not expose singleton pregnancies to an increased risk of miscarriage during the first trimester.

Endometrial fluid visualized through ultrasonography during ovarian stimulation in IVF cycles impairs the outcome in tubal factor, but not PCOS, patients.

BACKGROUND: The aim of the present study was to examine the impact of the presence of endometrial fluid (seen through ultrasound) on the outcome of IVF cycles and its association with the aetiology of infertility, in tubal and polycystic ovary syndrome (PCOS) cases specifically. METHODS: We retrospectively evaluated the charts of all PCOS and tubal factor infertility patients that underwent IVF between June 1, 2001 and May 31, 2002. Twenty-four PCOS and 14 tubal factor infertility patients in whom endometrial fluid was detected were compared with 94 PCOS and 160 tubal factor patients whose stimulation cycles did not show any fluid collection. The main outcome measures were implantation and pregnancy rates. RESULTS: Implantation rates were lower in the tubal factor patients in the presence of endometrial fluid (6.12% and 21.4%, respectively) in comparison with all other tubal factor infertile patients in whom no fluid accumulation inside the cavity was detected. In PCOS cycles there was no significance in patients with presence of endometrial fluid in comparison with the all other PCOS cycles without any fluid accumulation. CONCLUSIONS: When fluid collection inside the endometrial cavity is first seen during ovarian stimulation of PCOS patients undergoing IVF, embryo transfer can be performed safely if the fluid has disappeared and not returned by the day of embryo transfer. However, in tubal factor cycles one should think of either cancellation of the cycle or cryopreservation of all embryos.

The reproductive performance of women with hypogonadotropic hypogonadism in an in vitro fertilization and embryo transfer program.

PURPOSE: To evaluate the outcome of women with hypogonadotropic hypogonadism undergoing in-vitro fertilization (IVF). METHODS: We retrospectively assessed outcomes in 58 women with hypogonadotropic hypogonadism (HH) and, as matched controls, in 116 women with tubal factor (TF) infertility who underwent assisted reproduction treatment (ART). For ovulation induction, human menopausal gonadotropin (hMG) was used in HH patients and a combination of hMG and gonadotropin releasing hormone (GnRH) agonist was used in TF patients. Conception and implantation rates, as well as duration of stimulation and number of oocytes retrieved, were the main outcome measures. RESULTS: Of the 58 HH patients, 53 (91.3%) responded adequately to ovulation induction and underwent ET. A larger amount of gonadotropins and a longer duration of ovarian stimulation were needed in HH patients than in TF patients. The mean number of retrieved oocytes and implantation rates did not differ between the groups. In addition, there were no differences between the HH and TF groups in pregnancy (53.8 vs. 48.6%) and multiple pregnancy (63.4 vs. 48.4%) rates. In the HH group, the miscarriage rate was 3.4%, and none of these patients developed severe OHSS. CONCLUSION: IVF in HH patients, in which there was a background of previous failed ovulation induction, was as successful as in women with TF infertility.

The significance of coasting duration during ovarian stimulation for conception in assisted fertilization cycles.

BACKGROUND: Withholding gonadotrophin administration and postponing HCG injection, termed coasting, has been suggested as a treatment modality in cases of impending ovarian hyperstimulation syndrome (OHSS). It presents an opportunity to reduce the risk of OHSS and salvage the treatment, without apparent compromise to outcome. However, the duration of the coasting period, which would maintain the advantage without reducing conception rate, has not been fully established. In this retrospective study, we attempted to define the optimal interval of coasting in patients at risk of developing OHSS. METHODS: Patients were grouped according to the number of days elapsed between cessation of gonadotrophins and administration of HCG. Overall, out of 207 patients (mean age 30.76 +/- 0.33 years) coasting lasted 1 day in 39 cycles (18.8%), 2 days in 61 cycles (29.4%), 3 days in 49 cycles (23.6%) and > or = 4 days in the remaining 58 cycles (28.5%). RESULTS: There was no difference between the groups in patients' age, serum estradiol concentrations at the time of HCG administration, oocyte maturity, fertilization and embryo cleavage rates. However, patients in whom coasting lasted > or = 4 days had significantly reduced implantation (10.5%) and pregnancy (26.7%) rates compared with patients with a shorter coasting interval (ranges 18.4-27.9 and 41-55.7% respectively; P < 0.05). CONCLUSION: Coasting for >3 days appears to reduce implantation and pregnancy rates while in-vitro oocyte and embryo quality do not appear to be affected. We suggest that in patients who need coasting for >3 days, cryopreservation of embryos should be considered.

Conception rates following assisted reproduction in poor responder patients: a retrospective study in 300 consecutive cycles.

Poor response to ovarian stimulation for assisted reproduction treatment is a therapeutic challenge. Oocyte donation may be unacceptable to some patients, and many couples opt to continue with treatment despite low follicle numbers. Minimal data are available regarding conception rates in poor responders who elect to undergo oocyte retrieval. This study summarizes the outcome of assisted reproduction treatment in poor responders who produced four or fewer oocytes during ovarian stimulation, in order to provide better counselling to such patients in the future. Embryo transfers were performed in 208 of 300 cycles demonstrating poor ovarian response. Pregnancy rate (PR) (15.9%) was significantly higher in patients in whom four oocytes were retrieved, compared with patients in whom one or two oocytes were retrieved (2.3 and 4.3% respectively). Younger patients (< or =34 years) had significantly higher PR (19.5%) compared with older patients (> or =35 and < or =39 years, PR 7.2% and > or =40 years, PR 1.5% respectively). One hundred and twenty-six age-matched normal responders in whom three embryos were transferred had higher implantation rates (15.3%) and PR (37.3%) compared with poor responders in whom three embryos were transferred (6.6 and 16.6% respectively; P < 0.05). In this regard, patient age, number of oocytes retrieved and number of embryos available for transfer determine prognosis for the success of IVF in patients who respond to ovarian stimulation with four or fewer follicles for assisted reproduction treatment.