Gonadal agenesis with hypoplastic paramesonephric ducts (PMNDs) derivatives in dizygotic twins.

The co-occurrence of gonadal agenesis alongside hypoplastic derivatives of the paramesonephric ducts has rarely been observed. PATIENT(S): 16-year-old dizygotic twin sisters were referred to our department because of primary amenorrhea. X-ray, bone densitometry, ultrasonography, pelvic MRI and measurement of pituitary, ovary, and thyroid hormones were performed. Both twins showed hypergonadotropic hypogonadism, bilateral gonadal agenesis, fallopian tube, uterus, and vaginal hypoplasia but normal kidney and urinary tract structures and skeletal system. Analysis of Q-banded chromosomes in peripheral blood for the search for centromeric X-chromosome DNA and SRY gene was normal as well as the molecular analysis of FMR1, GDF9, and BMP15 genes. Estradiol gel was administered for one year followed by estroprogestin treatment. Both twins growth increased; breast development was stimulated and first menses occurred. Deregulation in the expression of the various HOX genes along the axis of the developing reproductive tract in a determinate time of development may be one of the mechanisms involved in the origin of this complex and rare association.

Can we prevent premature luteinization in IVF cycles?

From 1991 there is a long-lasting discussion on a possible detrimental effect of premature increase of progesterone levels during ovarian stimulation in IVF. A recent meta-analysis of more than 60,000 cycles states that premature progesterone increase reduces pregnancy rates starting from P4 values of 0.8 ng/ml. The detrimental effect seems to be related to endometrial receptivity impairment according to lack of detrimental effect on oocytes competence in ovodonation. Embryo freezing and deferred embryo transfer on artificial endometrium permits to avoid this detrimental effect but the cycle has to be segmented in two phases. Moreover embryo freezing is an extra burden for IVF lab and could induce embryo damage. So the implementation of an effective pharmacological treatment to prevent premature luteinization could be very interesting for our daily ART practice. On the basis of so far available literature data and our preliminary proof of concept experience we suggest that metformin (1000-1500 mg daily) from first monitoring until ovulation triggering could be suitable for this purpose irrespective of ovarian reserve of the patient.

Anti-Mullerian hormone: determination of ovarian reserve in early breast cancer patients.

Breast cancer is the most common invasive cancer in women of reproductive age. In young women, chemotherapy may induce amenorrhea: it is still uncertain how to assess menopausal status in these patients despite the importance of its definition for choosing appropriate endocrine treatment. In the development of sensitive biomarkers for fertility and ovarian reserve, anti-Müllerian hormone (AMH) is considered a promising marker of ovarian reserve. The clearest data regarding a clinical use of AMH are related to the measurement of the ovarian pool in women who undergo IVF: the available data, also in breast cancer patients, seem to suggest that AMH measurement, before gonadotropin administration, can be a useful marker for the prediction of women at risk for poor-response or no response to ovarian stimulation. The utility of AMH as a potential marker of chemotherapy-induced ovarian follicular depletion and an early plasma marker of chemotherapy-induced gonadal damage has been evaluated both in young women after treatment for cancer in childhood and in young survivors of hematological malignancies and solid tumors. Several studies have demonstrated a potential utility of AMH, inhibin, or follicle-stimulating factor as biomarkers predicting infertility risk in breast cancer patients, but the studies conducted so far are not conclusive. Further studies are needed in order to define the regimen-specific action of chemotherapy on AMH levels, the percentage of post-treatment recovery of plasma levels of the hormone, and the relationship between menopausal status and AMH.

Pre-treatment and post-treatment fertility in young male patients affected by Hodgkin and non-Hodgkin lymphoma.

OBJECTIVES: The aim of this study is to evaluate the fertility in young patients affected by Hodgkin and non-Hodgkin lymphoma, before and after chemotherapy and/or radiotherapy. We conducted a retrospective study to analyse how treatment affects male fertility and a perspective study to assess pre-treatment sperm quality. MATERIALS AND METHODS: 28 patients, treated in our center or referred to our Medically Assisted Procreation Center, from 2002 to 2011, were selected for the retrospective study and asked if interested in their fertility assessment. Semen samples were taken from 11 patients (mean age 31.55: range 20-45); other possible causes of impaired fertility were excluded. We analyzed pretreatment semen samples of 61 patients (mean age 29.08 +/- 9.5) affected by leukaemia or lymphoma that were selected for the perspective study and referred to the Sperm Bank of Pordenone. All semen samples were analysed accordingly to 1999 World Health Organization guidelines. RESULTS: In the retrospective study all semen samples of the 11 patients selected were altered. Six patients treated with high dose alkylating agents and abdominal/pelvic radiotherapy were found azoospermic, 3 with severe oligoasthenozoospermic, 1 oligoteratozoospermic and 1 asthenozoospermic. In the perspective study pretreatment semen quality was poor in most of the samples of the 61 patients selected. Normozoospermia was observed in 14% of patients affected by Hodgkin lymphoma and in 25% affected by non-Hodgkin lymphoma. CONCLUSION: Chemotherapy, radiotherapy or their combination are followed by a temporary but sometimes irreversible reduction of fertility potential. Pre-treatment semen quality is acceptable to proceed with cyopreservation techniques. Sperm cryopreservation should be offered to all post puberal male patients who have not yet conceived before treatment with gonado-toxic agents.

Different ART outcomes at increasing peak estradiol levels with long and antagonist protocols: retrospective insights from ten years experience.

PURPOSE: To evaluate the impact of high estradiol (E2) levels on assisted reproductive technologies outcomes in high responders (≥12 oocytes retrieved) according to the controlled ovarian stimulation protocol (COS) used. METHODS: Clinical retrospective evaluation of total, clinical pregnancy and implantation rates in ART cycles performed in high responders according to the COS protocol used (long or antagonist) at Pathophysiology Unit of Human Reproduction and Sperm Bank of Pordenone from June 2000 to December 2010. RESULTS: In high responders total, clinical and implantation rates were significantly higher in long if compared with antagonist protocol with peak estradiol level ≤3,000 pg/ml; on the contrary there was a significantly higher implantation rate with antagonist than long protocol with peak estradiol >3,000 pg/ml. However in this subgroup of patients total and clinical pregnancy rates showed only a trend favouring antagonist possibly due to a statistical ß error. CONCLUSIONS: In high responders long protocol seems to work better than antagonist when peak E2 is lower than 3,000 pg/ml but the opposite may be true for cycles with higher E2 levels.

Ultrastructural evaluation of human metaphase II oocytes after vitrification: closed versus open devices.

OBJECTIVE: To compare the ultrastructural appearance of oocytes after vitrification and warming with two different devices. DESIGN: Oocytes were examined by ultrastructural analysis after vitrification and warming with use of closed (CryoTip; Irvine Scientific, Santa Ana, CA) or open (Cryotop; Kitazato BioPharma Co., Ltd., Shizuoka, Japan) devices. SETTING: Pordenone Hospital IVF Unit and Medical Morphological Research Department, University of Udine. PATIENT(S): Surplus oocytes from 10 patients (aged 31-39 years) undergoing assisted reproductive technologies at the Pathophysiology Unit of Human Reproduction and Sperm Bank between 2006 and 2008. INTERVENTION(S): Oocytes with normal invertoscopic appearance underwent vitrification and warming with closed (CryoTip) or open (Cryotop) devices and were processed for transmission electron microscopy. MAIN OUTCOME MEASURE(S): Cryodamage extent and cell alterations in oocytes after open or closed vitrification and warming procedures and their rehydration rate. RESULT(S): A higher rate of complete oocyte rehydration and less-severe ultrastructural alterations were observed after vitrification and warming with the open Cryotop device. CONCLUSION(S): These preliminary data suggest that oocyte ultrastructure is better preserved with an open rather than closed vitrification and warming protocol.

Heterozygous variant at nucleotide position 875+11A>T in exon 6A cystic fibrosis transmembrane conductance regulator gene induces 852del22 mutation false-positivity by line probe assay.

OBJECTIVE: To explain the lack of genotype-phenotype correlation observed in a patient double heterozygous for the 852del22 and F508del mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. DESIGN: Case report. SETTING: Medical laboratory department. PATIENT(S): A 42-year-old asymptomatic patient underwent genetic screening for in vitro fertilization (IVF). INTERVENTION(S): CFTR genetic screening (commercial kit aimed at detecting 57 mutations), segregation analysis, evaluation of the polymerase chain reaction (PCR) products using a denaturing high performance liquid chromatography (DHPLC), and sequence analysis. MAIN OUTCOME MEASURE(S): To avoid diagnostic errors and improve genetic counseling. RESULT(S): Segregation analysis allowed us to establish that the mutations were in trans. Analysis of the PCR products using a DHPLC apparatus showed a heteroduplex formation indicative of a heterozygous variant in exon 6A. Direct sequencing characterized the heterozygous variant as an A to T transversion at nucleotide position 875+11. Therefore, the change of one single nucleotide in a portion surrounding the 852del22 mutation facilitated the aspecific interaction between the commercial oligonucleotide probe and the amplified genomic DNA, which explains the 852del22 mutation false molecular positivity that was detected by the line probe assay. CONCLUSION(S): The individualization of 852del22 mutation by a standard genetic panel should be confirmed by more extensive analyses.

Homologous in vitro fertilization in Turner syndrome: insights from a case report.

OBJECTIVE: To describe a bigeminal pregnancy obtained with a homologous intracytoplasmic sperm injection cycle in a patient with high-grade mosaic Turner syndrome (45,XO/47,XXX 97.5%/2.5%) with bicuspid aortic valve. DESIGN: Case report. SETTING: Unit of Pathophysiology of Human Reproduction in a general hospital. PATIENT(S): Patient with mosaic Turner syndrome with bicuspid aortic valve. INTERVENTION(S): Homologous intracytoplasmic sperm injection cycle after controlled ovarian hyperstimulation with a GnRH agonist flare-up depot protocol and menotropins. MAIN OUTCOME MEASURE(S): Pregnancy development, echocardiographic monitoring of aortic root, karyotypes of progeny. RESULT(S): Ongoing bigeminal pregnancy with the delivery of two healthy infants (46,XX and 46,XY, respectively) by cesarean section without any cardiovascular complication or aortic root echocardiographic modification in the mother. CONCLUSION(S): Even in patients with Turner syndrome with high-grade 45,XO mosaicism and reduced ovarian reserve, a trial of homologous reproduction should be offered after a thorough cardiologic evaluation to avoid pregnancy-related cardiovascular complications.

Comparison of protocols efficacy in poor responders: differences in oocytes/embryos competence with different protocols, a retrospective study.

At present, there is no agreement on poor ovarian response definition, and no definitive evidence that this prognosis can be changed by a specific protocol. Our data suggest that a flare-up protocol with a depot gonadotropin-releasing hormone (GnRH) agonist formulation gives higher total pregnancy and implantation rates than a GnRH antagonist, possibly by improving oocyte/embryo competence.

Polycystic kidney disease and infertility: case report and literature review.

Adult polycystic kidney disease (APKD) is a frequent disease (1/1000) responsible for about 10% of chronic renal failure. It is an autosomic dominant disease due to mutation of one out of three genes: PKD1 (on the 16th chromosome), PKD2 (on the 4th chromosome) and PKD3 (still unmapped). In the past APKD diagnosis was normally done in fourteen-fifteen years old subjects who have completed their reproductive program. However frequently today, after renal ultrasound introduction, the APKD diagnosis is made during reproductive life. There are several reports of APKD-related infertility in male subjects. The frequency of this association appeared significantly higher than expected by chance alone in a recent observation. So a possible causal relation between APKD and male infertility may exists. Several pathogenetic mechanisms may be responsible of such an association. We recently observed an infertile couple with long standing infertility due to criptozoospermia (<1 x 10(6) spermatozoa/ml) and necrospermia (100% of died spermatozoa at eosin test) in an APKD affected patient. Endocrine tests showed normal testosterone and FSH levels. A TESA-ICSI was done with two embryos development after fertilization of two oocytes (fertilization rate: 25%). At the 14th day after pick up beta-HCG determination showed 72 mUI/ml. A male baby was born at 40th week of pregnancy. Prenatal morphological ultrasound excluded polycystic kidney.

Greater implantation and pregnancy rates with vaginal progesterone in intracytoplasmic sperm injection but not in in vitro fertilization cycles: a retrospective study.

OBJECTIVE: To compare the effectiveness of vaginal progesterone supplementation with intramuscular supplementation in assisted reproduction cycles. DESIGN: Retrospective study. SETTING: Physiopathology of Human Reproduction Unit, Pordenone, Italy, from July 2000 to June 2004. PATIENT(S): Three hundred and eight-five intracytoplasmic sperm injection (ICSI) procedures (188 with vaginal gel and 197 with intramuscular progesterone) and 373 in vitro fertilization (IVF) cycles (227 with vaginal and 146 with intramuscular progesterone). INTERVENTION(S): Progesterone luteal supplementation: vaginal gel (Crinone 8% 90 mg/day) or intramuscular (Prontogest 50 mg/day). MAIN OUTCOME MEASURE(S): Implantation rates, and total and clinical pregnancy rates. RESULT(S): Higher rates of implantation and total and clinical pregnancies were observed in the vaginal supplemented ICSI subgroup than in the intramuscular one. This difference was observed for all transfers (13.3% vs. 8.8%, 39.8% vs. 23.3%, and 28.7% vs. 18.6%) and for ultrasound-guided transfers (17.2% vs. 9.3%, 49% vs. 27%, and 36.9% vs. 21.1%, respectively). CONCLUSION(S): The vaginal route of luteal supplementation may be better than the intramuscular one, yielding higher implantation rates as well as total and clinical pregnancy rates in ICSI cycles but not in classic IVF treatments.

A case report of CUAVD with azoospermia: a proposal of a rational diagnostic approach.

Since its introduction in 1992, intracytoplasmic sperm injection (ICSI) has made the treatment of severe male infertility possible, particularly that of azoospermia, both secretory and secretory. Some azoospermic subjects have a pathological development of the seminal pathways, and in particular of the vas deferens and/or ejaculatory ducts. A large part of these subjects show, like patients affected by cystic fibrosis, mutations in the cystic fibrosis transmembrane regulator (CFTR) gene. Some of these azoospermic subjects are indeed paucisymptomatic fibrosis cystic patients who bear the risk of transmitting cystic fibrosis, seminal pathways alterations and, possibly, renal malformations to their offspring. We describe a case of an infertile patient with right CUAVD and azoospermia previously treated by crossed epididimovasostomy in the absence of any genetic and an adequate anatomic evaluation. He was then found to be CFTR mutation positive and without demonstrable spermatozoa in the vesicular fluid despite ultrasound evidence of left ejaculatory duct obstruction. During the second TESA-ICSI cycle an ongoing pregnancy was obtained. An extensive genetic examination for CFTR mutations and a through anatomical study is, therefore, mandatory in these patients to select the most appropriate treatment in CFTR mutation positive and negative CUAVD patients.