Prevalence and risk factors of zygotic splitting after 937 848 single embryo transfer cycles.

STUDY QUESTION: What is the prevalence of multiple pregnancy with zygotic splitting after single embryo transfer (SET)? SUMMARY ANSWER: The prevalence of multiple pregnancy with zygotic splitting after SET was 1.36%. WHAT IS KNOWN ALREADY: In 2008, the Japan Society of Obstetrics and Gynaecology (JSOG) recommended the adoption of SET to reduce multiple births. Since then, to improve the clinical pregnancy rate, elective SET using blastocyst transfer and frozen-warmed ET has increased. Blastocyst culture and zona pellucida manipulation, including ICSI and AH, have been widely reported as risk factors for monozygotic twinning. However, all these studies may have included cases with dizygotic pregnancies produced by a transferred embryo and a spontaneous conception. STUDY DESIGN, SIZE, DURATION: A retrospective observational study was performed, based on 937 848 SET cycles in registered ART data from the JSOG between 2007 and 2014. The study was approved by the Registration and Research Subcommittee of the JSOG and Juntendo University Ethics Committee. PARTICIPANTS/MATERIALS, SETTING, METHODS: To identify possible factors affecting the prevalence of zygotic splitting, we identified pregnancies, in which the number of foetuses exceeded the number of gestational sacs (GSs), to restrict our analysis to 'true' zygotic splitting. Multiple logistic regression analysis was performed using singleton pregnancy after SET, as control. P < 0.05 was considered statistically significant. MAIN RESULTS AND THE ROLE OF CHANCE: Fresh and frozen-warmed SET produced 276 934 clinical pregnancies (29.5%/SET), including 4310 twins (1.56% of pregnancies) and 109 triplets (0.04% of pregnancies). Based on sex analysis of dichorionic twins after SET, the prevalence of multiple pregnancy with zygotic splitting was 1.36%. Statistical analysis revealed that compared to singleton pregnancies zygotic splitting pregnancies were associated with frozen-warmed ET cycles (odds ratio [OR] = 1.34; 95% CI: 1.16-1.55), blastocyst culture (OR = 1.79; 95% CI: 1.54-2.09) or AH (OR = 1.21; 95% CI: 1.08-1.35). In fresh ET cycles, the prevalence rate of zygotic splitting pregnancy after single blastocyst transfer was significantly higher than that after SET cycles with cleavage embryos (OR = 2.20; 95% CI: 1.83-2.66). However, no significant difference in ovarian stimulation and fertilization methods was recognized. LIMITATIONS, REASONS FOR CAUTION: In the current Japanese ART registry system, data regarding frozen-warmed ET do not include information about ovarian stimulation and fertilization methods. Registration for AH only began in 2010. There is no way of validating if data submitted by clinics is correct. WIDER IMPLICATIONS OF THE FINDINGS: Clinicians should consider whether to counsel couples about the small increase in the risk of zygotic splitting associated with some embryo manipulations. STUDY FUNDING/COMPETING INTEREST(S): No external funds were used for the study. The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER: None.

An algorithm for the management of coagulopathy from postpartum hemorrhage, using fibrinogen concentrate as first-line therapy.

BACKGROUND: We constructed an algorithm for the management of coagulopathy from massive postpartum hemorrhage. Fibrinogen concentrate was administered preferentially, and the dose of both fibrinogen concentrate and fresh frozen plasma given was determined by the plasma fibrinogen concentration and prothrombin time. The efficacy of the algorithm and the amount of fibrinogen concentrate and fresh frozen plasma transfused were determined. METHODS: The study was conducted in a single teaching perinatal center. Nineteen patients were included between April 2011 and March 2014 (patient group). For a historical comparison group, we retrospectively analyzed the records of 19 patients who had been treated for coagulopathy from massive postpartum hemorrhage between April 2006 and March 2011 (control group). RESULTS: Blood loss was significantly lower in the patient group. No adverse events were associated with this management in either group. The dose of fibrinogen concentrate administered was significantly higher and that of fresh frozen plasma administered was significantly lower in the patient group. CONCLUSION: This algorithm appeared to help reduce blood loss and the total amount of fresh frozen plasma transfused when treating coagulopathy from postpartum hemorrhage, and may represent another strategy for achieving hemostasis in this setting.

Should sexual intercourse be avoided during the embryo transfer cycle? Life-threatening ruptured heterotopic pregnancy after single thawed embryo transfer: case report and review of the literature.

BACKGROUND: To report the life-threatening complication of a raptured heterotopic pregnancy occurring from thawed single embryo transfer. CASE REPORT: A 33-year-old woman underwent in vitro fertilization (IVF) under a step-up regimen. After oocyte collection, blastocysts were frozen, and a single frozen-thawed blastocyst was then transferred according to the natural cycle. On day 17 after embryo transfer, an intrauterine pregnancy was confirmed. On day 28, she complained of sudden abdominal pain and ultrasonography revealed marked fluid retention in the peritoneal cavity. Emergency laparoscopy was performed, revealing hemoperitoneum and a ruptured interstitial heterotopic pregnancy (HP), which was then resected laparoscopically. Because sexual intercourse had occurred shortly before the transfer, a HP comprising a spontaneous pregnancy and a pregnancy achieved by assisted reproductive technology was assumed. The fetus in the uterus survived and was delivered. CONCLUSION: In this case, however, despite the single embryo transfer during the natural-cycle frozen-thawed embryo transfer process, the risk of life-threatening complication as a HP as a consequence of spontaneous pregnancy after sexual intercourse remained.

PP111. The preceding features before onset of gestational hypertension and preeclampsia in home blood pressure monitoring: The existence of the inflection point and the rapid increased speed of blood pressure.

INTRODUCTION: It has not been clarified whether home blood pressure monitoring (HBPM) during pregnancy is useful to detect high risk pregnant women with later onset of gestational hypertension (GH) and preeclampsia (PE). OBJECTIVES: We thought to determine the preceding features of blood pressure (BP) in HBPM before the onset of GH and PE. We especially focused on the existence of the inflection point, its level, when it occurs, and the increased speed of BP after the inflection point. We compared these features in normal pregnant women (NP), women with GH, and women with PE. METHODS: In this prospective cohort study, 361 singleton pregnant women, among them 100 women recruited due to high risk for GH/PH in the second trimester, participated in a couple of tertiary perinatal centers between 2008 and 2010. HBPM were measured with the validated OMRON HEM-5001(R) automated digital oscillometric sphygmomanometer (OMRON Healthcare Japan). The device was programmed to take three consecutive readings at 15-second interval. HBPM was measured twice a day, at the time of awakening and sleep, through the first to third trimester, and the average systolic blood pressure (SBP) and diastolic blood pressure (DBP) of each gestational week (almost 42 times a week) were calculated. We defined the data of HBPM which started before 28 gestational weeks and continued until 2 weeks before the onset of GH/PE or delivery are eligible. The increased speed of systolic or diastolic BP after the inflection point was defined as ("BP at the onset in GH/PE or at delivery in NP" - "BP at the inflection point") / ("Gestational weeks at the onset in GH/PE or at delivery in NP" - "Gestational weeks at the inflection point"). If there was no inflection point in HBPM, the increased speed of BP was defined as zero. The comparisons were performed using one-way analysis of variance (ANOVA) followed by multiple comparison. Data were shown as mean±SE. RESULTS: A total of 17 (4.7%) women developed PE, and 12 (3.3%) GH.The systolic blood pressure (SBP) levels at the inflection point in NP, GH and PE was 102.4±1.3, 118.7±2.9 and 117.4±2.2mmHg, respectively (Significant pairs: NP < GH, PE); the diastolic blood pressure (DBP) levels at the inflection point was 59.2±1.0, 74.5±2.0 and 73.1±2.0mmHg, respectively (NP < GH, PE). The inflection point in NP, GH and PE occurred at 31.3±0.9, 28.4±1.5 and 22.3±1.4weeks, respectively (PE < GH, NP). The increased speed of SBP in NP, GH and PE was 1.2±0.1, 3.0±0.4 and 4.7±0.7mmHg/wk, respectively (NP < GH, PE); the increased speed of DBP was1.1±0.1, 2.1±0.3 and 2.8±0.4mmHg/wk, respectively (NP < GH, PE). CONCLUSION: In women with later onset of GH/PE, the BP level at the inflection points was higher than in NP. The average inflection point in PE was earlier gestational weeks than in GH and NP. The average increased speed of blood pressure after the inflection point in GH/PE was faster than in NP. The preceding features of BP in HBPM may be clinically useful to detect high risk women with later onset of GH/PE.

Differential effects of urinary and recombinant chorionic gonadotropin on oxidative stress responses in decidualizing human endometrial stromal cells.

Human chorionic gonadotropin (hCG) is one of the earliest signals secreted by the implanting embryo. In addition to its well-known luteotropic function in early pregnancy, hCG also acts directly on decidualizing endometrium. Recently, we demonstrated that recombinant hCG (rhCG) prevented apoptosis in decidualizing human endometrial stromal cells (HESCs) exposed to oxidative stress. Two hCG preparations are widely used clinically: rhCG, produced by recombinant DNA technology, and urinay hCG (uhCG), extracted from urine of post-menopausal women. However, an analysis of the direct effects of rhCG and uhCG on the decidual phenotype of HESCs has not yet been done. In this study, we investigated the effects of uhCG and rhCG on the morphological and functional profiles of decidualizing HESCs. We demonstrate that neither rhCG nor uhCG alter the morphological appearance of the decidual HESC cultures, although rhCG but not uhCG attenuated prolactin expression, a major decidual marker protein. Moreover, rhCG, but not uhCG, protected decidualizing HESCs from oxidative cell death, mediated at least in part by two major mechanisms. First, rhCG, but not uhCG, enhances the expression of manganese superoxide dismutase, a cardinal enzyme in the cellular defense against oxidative damage. Second, rhCG signaling selectively limits activation of the apoptotic machinery in decidualizing HESCs by enhancing Bcl-2 expression whereas uhCG induces the expression of Fas ligand. Our results suggest that rhCG might be a preferable agent to protect the maternal decidua against oxidative damage in pregnancy, especially at the time of implantation and beyond.

Radial density profile measurement by using the multichannel microwave interferometer in GAMMA 10.

Plasma density radial profile measurements are an important study for fusion plasma researches. We reconstructed a multichannel microwave interferometer for radial plasma electron density and density fluctuation measurements with both changing the transmission horn position and using the Teflon lens by only using this system in a single plasma shot. By using this system, we can successfully measure the radial density and density fluctuation spectra in a single plasma shot.

[Pseudomesotheliomatous carcinoma of the lung].

Pseudomesotheliomatous carcinoma is the lung cancer with marked pleural extension resembling malignant pleural mesothelioma on diagnostic imaging. We report a rare case of pseudomesotheliomatous carcinoma of the lung in a 72-year-old man. The patient had complained of dyspnea and a chest roentgenogram showed right pleural effusion. Computed tomography (CT) of the chest revealed diffuse irregular pleural thickening, which mimicked pleural malignant mesothelioma. Pleural tissue sampling was performed to obtain definitive diagnosis by video-assisted thoracoscopic surgery. At the operation. the tumor was found to have a spread along the pleural surface and primary lesion was not detected in the right lung parenchyma. Immunohistochemically, the tumor was positive for carcinoembryonic antigen (CEA), but negative for calretinin, thrombomodulin, and pulmonary surfactant apoprotein. Final diagnosis was adenocarcinoma of the lung.

Observation and control of transverse energy-transport barrier due to the formation of an energetic-electron layer with sheared ExB flow.

Off-axis electron-cyclotron heating in an axisymmetric barrier mirror produces a cylindrical layer with energetic electrons, which flow through the central cell and into the end region. The layer, producing a localized bumped ambipolar potential Phi(C), forms a strong shear of radial electric fields E(r) and peaked vorticity with the direction reversal of E(r)xB sheared flow near the Phi(C) peak. Intermittent vortexlike turbulent structures near the layer are suppressed in the central cell by this actively produced transverse energy-transport barrier; this results in T(e) and T(i) rises surrounded by the layer.

Angiotensin II augmented migration and invasion of choriocarcinoma cells involves PI3K activation through the AT1 receptor.

While angiotensin II (Ang II) has been shown to inhibit migration of extravillous trophoblasts via plasminogen activator inhibitor-1 (PAI-1) activation, it has remained unclear whether it stimulates or inhibits malignant behavior of choriocarcinoma cells. Since we previously found an involvement of the renin-angiotensin system (RAS) in the proliferative potential in choriocarcinoma cells (BeWo), mediated via the Ang II type 1 receptor (AT1R), in the present study we investigated the effects of Ang II on choriocarcinoma cell migration/invasion in vitro using Transwell cell culture chambers. Ang II (10(-8)M) promoted migration and invasion by a choriocarcinoma cell line and augmented random cell mobility on checkerboard analysis. Immunoblotting showed Ang II to activate the phosphorylation of FAK and Akt in BeWo cells. Furthermore Ang II effects on cell migration were abolished by a selective AT1R antagonist and a phosphatidylinositol 3-kinase (PI3K) inhibitor. The present results suggest that Ang II-induced migration and invasion of choriocarcinoma cells probably involves PI3K following binding to the AT1R.

Ikaros is expressed in human extravillous trophoblasts and involved in their migration and invasion.

The transcriptional factor Ikaros was originally found to function as a key regulator of lymphocyte differentiation. In addition, we have reported that Ikaros regulates the human placental leucine aminopeptidase (P-LAP)/insulin-regulated aminopeptidase (IRAP) gene in choriocarcinoma trophoblastic cells, suggesting that Ikaros might be involved in placental development, while even its presence in human placenta remains undetermined. We therefore sought to clarify the location and roles of Ikaros in human placenta. Immunohistochemical analysis showed modest Ikaris expression in syncytium, and intense expression in extravillous trophoblasts (EVTs) in first trimester placenta. Western blot analysis showed that villous trophoblasts principally expressed Ikaros-2/3, while Ikaros-x (Ikx) was predominantly expressed in cultured EVTs. Furthermore, to investigate the functional role of Ikx in EVTs, the EVT cell line HTR-8/SVneo was infected with a retrovirus vector expressing the hemagglutinin (HA)-tagged dominant negative isoform Ikaros-6 (Ik6), which prevents the DNA-binding activity of Ikx. Antibody against HA showed successful transduction of Ik6 in HTR-8/SVneo cells on immunocytochemistry and Western blotting. Transduction of Ik6 significantly reduced the migratory and invasive abilities of HTR-8/SVneo cells. These results suggest that Ikx is involved in migration and invasion of EVTs in early placentation.

Changes in placental dipeptidyl peptidase IV in preeclampsia with intrauterine growth restriction.

The purpose of this study was to examine alterations in placental expression of dipeptidyl peptidase IV (DPPIV). The localization of DPPIV was compared in control and preeclamptic placentas. Enzyme activity, mRNA, and protein expression were also measured. In term placentas, DPPIV was expressed preferentially in the fetal vascular endothelial cells within stem villi and only weakly in the villous stromal cells. DPPIV activity in control placentas showed no remarkable changes throughout gestation. Levels of activity in samples from normotensive control cases and women having preeclampsia with or without intrauterine growth restriction were 11.8 +/- 2.1, 13.4 +/- 1.1, and 15.3 +/- 0.62 pmol pNA/min/mg protein, respectively. The preeclamptic placentas with intrauterine growth restriction thus showed significantly higher levels of activity than the controls (p < 0.05). We propose that placental DPPIV influences fetal metabolism via the degradation of fetoplacental circulating bioactive peptides, including incretins, resulting in the regulation of fetal growth.

Observation of the effects of radially sheared electric fields on the suppression of turbulent vortex structures and the associated transverse loss in GAMMA 10.

Vortexlike turbulent structures in hot-ion mode plasmas with several keV are observed in the case with a radially produced weak shear of electric fields E(r). However, a strong E(r) shear formation due to a high ion-confining potential phi(c) production clears up these vortices together with plasma-confinement improvement and disappearance of both drift-wave and turbulencelike Fourier spectral signals. These findings are based on three-time progress in phi(c) in comparison to phi(c) attained 1992-2002. The significant advance of phi(c) is well extended in line with proposed potential-formation physics scalings.

Umbilical plasma kininase I activity in fetal hypoxia.

To shed light on the role of bradykinin in preeclampsia in addition to acute hypoxia, we measured the activity of kininase I, the enzyme responsible for its degradation, in umbilical plasma. Kininase I activity in umbilical arteries was compared with that in the umbilical veins. The relationship between kininase I and pH values was also evaluated in women with and without preeclampsia. Also, enzyme activity in supernatants of fetal hepatic cells (NFL/T) cultured under hypoxic or normoxic conditions were determined. Kininase I activity levels in fetal umbilical arteries and veins (n = 33) were similar (r = 0.77). Hypoxia caused suppression of kininase I activity in the supernatant cultures of NFL/T after one hour. However, after 8 and 24 hours, kininase I activity was significantly greater than under normoxic conditions (p < 0.05). Kininase I activity of fetal umbilical vein significantly decreased in the presence of acidemia in the uncomplicated group (n = 75, r = 0.42), whereas the activity negatively correlated with umbilical arterial pH in the preeclamptic group (n = 10, r = - 0.65). Kininase I activity levels in cases complicated with preeclampsia were significantly higher than without preeclampsia (49.2 +/- 9.1 vs. 66.2 +/- 11.3 nmol/ml/min). The present study indicates that kininase I acts as a regulatory factor in bradykinin degradation.

Bestatin results in pathophysiological changes similar to preeclampsia in rats via induction of placental apoptosis.

OBJECTIVE: To establish a rat preeclampsia model with fetoplacental growth restriction caused by bestatin via induction of placental apoptosis. STUDY DESIGN: 200 mg/kg/day of bestatin or saline as a control were infused intraperitoneally into pregnant Wistar rats from 15 days' gestation. In the first experiment, maternal blood pressure and proteinuria were examined during the pre- and postpartum periods. In the second experiment, cesarean sections were performed at 20 days' gestation and the weights of pups and placentas, and levels of proteinuria and placental apoptosis were examined. RESULTS: Physiological decrease of blood pressure in late pregnancy was not detected in the bestatin group but proteinuria level at 20 days' gestation was elevated. The weights of pups and placentas in the bestatin group were significantly lower than those in the controls, bestatin strongly inducing apoptosis in the placenta. CONCLUSION: Bestatin may cause a preeclampsia-like condition through induction of placental apoptosis.

Conservative treatment of a second trimester cervicoisthmic pregnancy diagnosed by magnetic resonance imaging.

BACKGROUND: A cervicoisthmic pregnancy, which may be carried to term, is potentially dangerous for the pregnant woman. With ultrasonographic evaluation alone the diagnosis of a cervical pregnancy in the second trimester is difficult. CASE: A nulliparous 33-year-old woman at 21 weeks' gestation was diagnosed by ultrafast T2-weighted magnetic resonance imaging (MRI) to have a cervicoisthmic pregnancy. After the infant was delivered live by cesarean with a vertical fundal incision, methotrexate was infused into the placenta via the umbilical vein. The next day she received uterine artery methotrexate infusion and embolization with platinum coils. Eight months later there was no trace of the placenta on ultrasonography or MRI. She subsequently resumed normal menstrual cycles, conceived, and delivered a healthy infant at term by cesarean after 2 years. CONCLUSION: This report describes MRI and successful preservation of fertility with such an advanced cervicoisthmic pregnancy.

Differential distribution of placental leucine aminopeptidase/oxytocinase and aminopeptidase A in human trophoblasts of normal placenta and complete hydatidiform mole.

Placental leucine aminopeptidase (P-LAP)/oxytocinase (OTase) degrades several small peptides such as oxytocin (OT), arginine vasopressin (AVP) and angiotensin III (ANGIII), and aminopeptidase A (AP-A) converts angiotensin II (ANGII) to ANGIII. These proteases play an important role in foetal growth and the maintenance of human homeostasis during pregnancy. In this study, we confirmed the distribution of P-LAP and AP-A proteins and messenger RNAs in human trophoblasts in normal placenta and complete hydatidiform mole by immunohistochemical and in-situ hybridization techniques. Immunoreactivity of P-LAP was mainly noted in the apical membrane of syncytiotrophoblasts, and the expression of messenger RNA (mRNA) for P-LAP was predominantly noted in the cytoplasm of syncytiotrophoblastic cells. However, immunoreactivity of AP-A was mainly noted in the apical membrane of cytotrophoblasts and in the basal zone of the syncytiotrophoblasts, and the expression of mRNA for AP-A was predominantly noted in cytoplasm of cytotrophoblastic cells and a little in cytoplasm of syncytiotrophoblastic cells. Thereby, the two proteases were differentially distributed both in normal placenta and hydatidiform mole throughout the gestational age. These results are useful for the further understanding of not only the pathophysiology of pregnancy, but also the pathogenesis of trophoblastic diseases.

Possible involvement of placental peptidases that degrade gonadotropin-releasing hormone (GnRH) in the dynamic pattern of placental hCG secretion via GnRH degradation.

The presence of an extrahypothalamic gonadotropin releasing hormone (GnRH) in human placenta is well known and this decapeptide is presumed to play an important role in the regulation of the function and growth of human placenta. Immunohistochemistry showed that neutral endopeptidase 24.11 (NEP), a candidate of the responsible enzyme of GnRH degradation, is highly expressed on the cell surface of trophoblasts. Hydrolysis of GnRH by human villi was studied by measuring liberated amino acids using high performance liquid chromatography. The GnRH degrading activity was 1.53 times higher after incubation with the membrane fraction of first trimester villi than that after incubation with the membrane fraction of term villi. Phosphoramidon, a potent inhibitor of NEP, reduced the liberated amino acids to about a half, suggesting that NEP is a responsible enzyme for GnRH degradation. Ubenimex, which can inhibit several aminopeptidases, also reduced the liberated amino acids to about 50 per cent. O-phenanthroline, EDTA, and thiorphan could inhibit GnRH degradation but inhibitors of post proline endopeptidase could not. Furthermore, GnRH degrading activity of the membrane fraction was reduced remarkably after the membrane fraction was immunotitrated by anti NEP and anti placental leucine aminopeptidase (P-LAP) IgG. In conclusion, NEP and P-LAP are responsible enzymes for GnRH degradation in human villi.

Hepatocyte growth factor in human breast milk acts as a trophic factor.

To evaluate the significance of hepatocyte growth factor (HGF) in milk in the perinatal period, we examined immunoreactive HGF levels and bioactivity in human milk. Human milk samples were obtained from women at various postpartum ages, and the levels of HGF were measured by ELISA. In the cross sectional study, the concentration of milk HGF from term deliveries showed a significant inverse correlation with progress of lactation, whereas in cases of preterm delivery concentrations, levels remained high after a long period of lactation. In the longitudinal analysis, the contents of HGF in colostrum, transitional, and mature milk from preterm deliveries were significantly be higher than those from term deliveries. Although mature milk from term and preterm deliveries contained significantly lower levels of HGF than colostrum, high levels of HGF persisted in mature milk from preterm deliveries. After partial purification, immunoblotting analysis showed the presence of both alpha- and beta-chains of HGF. HGF in milk stimulated proliferation of rat hepatocytes in primary culture, which was inhibited by supplementation with anti-HGF antibody. Thus, a high concentration of bioactive HGF is present in human milk in the postpartum period. Our results suggest that HGF in milk acts as a trophic factor for the gastrointestinal tract in neonates.

Inability of IL-12 to down-regulate IgE synthesis due to defective production of IFN-gamma in atopic NC/Nga mice.

NC/Nga mice raised in nonsterile circumstances spontaneously suffer from atopic dermatitis-like skin lesions with IgE hyperproduction. We investigated effects of rIL-12 on the IgE production in NC/Nga mice. rIL-12 administration was successful to suppress the increase of IgE levels in BALB/c mice immunized with OVA and aluminum hydroxide, but failed to abrogate that in NC/Nga mice. Both in vivo and in vitro IFN-gamma production induced by rIL-12 was less in NC/Nga mice than in BALB/c mice. Addition of rIFN-gamma to rIL-4 and LPS completely abrogated IgE production by B cells of BALB/c mice, but was insufficient to suppress it by B cells of NC/Nga mice. In splenic cells pretreated with Con A, STAT4 was phosphorylated at the tyrosine residue by addition of rIL-12, which was more weakly inducible in NC/Nga mice than in BALB/c mice. Finally, we examined the preventive ability of rIL-12 on the clinical aspects of atopic dermatitis in NC/Nga mice. rIL-12 administration resulted in exacerbation of development of the skin lesions and IgE production in NC/Nga mice raised in nonsterile circumstances. These results suggest that defective production of IFN-gamma by T cells less sensitive to IL-12 and low responsiveness of B cells to IFN-gamma may contribute to IgE hyperproduction in NC/Nga mice, and that IL-12 may have no ability to improve the clinical aspects of NC/Nga mice.