Stimulating fertility awareness: the importance of getting the language right.

While education about fertility is not intrinsically controversial, finding the right language to communicate the topic can be challenging, as there are several risks of unintended negative effects such as dissonance, anxiety, culpability, and stigma due to social norming. In this article, we share some of our learnings from promoting fertility awareness in the hope that they will inspire further debate and research on this topic. Starting from the ethical principles of respect for reproductive autonomy, avoiding harm (in terms of stigma or anxiety) and inclusivity, we have formulated five recommendations: (i) frame fertility awareness messages with (reproductive) autonomy in mind and aim to be inclusive of those who do not represent the traditional nuclear family; (ii) be empathetic and steer clear of blame; (iii) avoid scaremongering and offer a positive angle; (iv) give due consideration to both women and men in fertility health messaging; and (v) tailor the messages to particular contexts and audiences and develop resources in close collaboration with the target groups.

Discarding IVF embryos: reporting on global practices.

PURPOSE: To provide a global scale report on a representative sample of the clinical embryology community depicting the practice of discarding supernumerary IVF embryos. METHODS: A web-based questionnaire titled "Anonymous questionnaire on embryo disposal practices" was designed in order to ensure anonymous participation of practicing clinical embryologists around the world. RESULTS: During a data collection period of 8 months, 703 filled-in questionnaires from 65 countries were acquired. According to the data acquired, the majority of practitioners, dispose of embryos by placing them directly in a trash can strictly dedicated for embryo disposal for both fresh and frozen cycles (39% and 36.7% respectively). Moreover, 66.4% of practitioners discard the embryos separately-case by case-at different time points during the day. Over half of embryologists (54%) wait until day 6 to discard the surplus embryos, while 65.5% do not implement a specially allocated incubator space as a designated waiting area prior to disposal. The majority of 63.1% reported that this is a witnessed procedure. The vast majority of embryologists (93%) do not employ different protocols for different groups of patients. Nonetheless, 17.8% reported the request to perform a ceremony for these embryos. Assessing the embryologists' perspective, 59.5% of participants stated that the embryology practice would benefit from a universally accepted and practiced protocol. CONCLUSION(S): This study uniquely provides insight into global embryo disposal practices and trends. Results highlight the divergence between reported practices, while indicating the significance on standardization of practice, with embryologists acknowledging the need for a universally accepted protocol implementation.

Should the flexibility enabled by performing a day-4 embryo transfer remain as a valid option in the IVF laboratory? A systematic review and network meta-analysis.

PURPOSE: The present systematic review and network meta-analysis aims to uniquely bring to literature data supporting the true place of the alternative practice of day-4 embryo transfer (D4 ET) in an IVF laboratory, beyond the one-dimensional option of facilitating a highly demanding program. METHODS: A systematic search was conducted in the databases of PubMed/Medline, Embase, and Cochrane Central Library, resulting to six prospective along with nine retrospective cohort studies meeting eligibility criteria for inclusion. A comparison of D4 ET with day-2 (D2), day-3 (D3), and day-5 (D5) ET, respectively, was performed employing R statistics. RESULTS: The sourced results indicate no statistically significant difference regarding clinical pregnancy rates, and ongoing pregnancy/live birth rates stemming from the comparison of D4 with D2, D4 with D3, and D4 with D5 ET, respectively. Additionally, no statistically significant difference could be established in respect to cancelation, and miscarriage rates, following the comparison of D4 with D3 and D4 with D5 ET. Interestingly, we report statistically significant lower preterm birth rates associated with D4 ET, in contrast with D5 ET (RR, 0.19; 95% CI, 0.05-0.67; p value = 0.01). CONCLUSIONS: The aforementioned results may serve as advocates buttressing the option of D4 ET as a valid candidate in the ET decision-making process. Possible limitations of the current study are the publication bias stemming from the retrospective nature of certain included studies, along with various deviations among studies' design, referring to number and quality of transferred embryos, or different culture conditions referring to studies of previous decades.

Risks in Surrogacy Considering the Embryo: From the Preimplantation to the Gestational and Neonatal Period.

Surrogacy is an assisted reproduction-based approach in which the intended parents assign the gestation and birth to another woman called the surrogate mother. The drivers of surrogacy refer largely to infertility, medical conditions, same-sex couples' parenting, and cases of diversity regarding sexual identity and orientation. Surrogacy consists of a valid option for a variety of conditions or circumstances ranging from medical to social reasons. However, surrogacy may be associated with risks during the preimplantation, prenatal, and neonatal period. It became obvious during the exhaustive literature research that data on surrogacy and its association with factors specific to the IVF practice and the options available were not fully represented. Could it be that surrogacy management adds another level of complexity to the process from the ovarian stimulation, the subsequent IVF cycle, and the techniques employed within the IVF and the Genetic Laboratory to the fetal, perinatal, and neonatal period? This work emphasizes the risks associated with surrogacy with respect to the preimplantation embryo, the fetus, and the infant. Moreover, it further calls for larger studies reporting on surrogacy and comparing the surrogate management to that of the routine IVF patient in order to avoid suboptimal management of a surrogate cycle. This is of particular importance in light of the fact that the surrogate cycle may include not only the surrogate but also the egg donor, sperm donor, and the commissioning couple or single person.

The cytogenetic action of ifosfamide, mesna, and their combination on peripheral rabbit lymphocytes: an in vivo/in vitro cytogenetic study.

Ifosfamide (IFO) is an alkylating nitrogen mustard, administrated as an antineoplasmic agent. It is characterized by its intense urotoxic action, leading to hemorrhagic cystitis. This side effect of IFO raises the requirement for the co-administration with sodium 2-sulfanylethanesulfonate (Mesna) aiming to avoid or minimize this effect. IFO and Mesna were administrated separately on rabbit's lymphocytes in vivo, which were later developed in vitro. Cytogenetic markers for sister chromatid exchanges (SCEs), proliferation rate index (PRI) and Mitotic Index were recorded. Mesna's action, in conjunction with IFO reduces the frequency of SCEs, in comparison with the SCEs recordings obtained when IFO is administered alone. In addition to this, when high concentrations of Mesna were administered alone significant reductions of the PRI were noted, than with IFO acting at the same concentration on the lymphocytes. Mesna significantly reduces IFO's genotoxicity, while when administered in high concentrations it acts in an inhibitory fashion on the cytostatic action of the drug.

Molecular diagnosis of CMV infection in fetal aborted tissues in the region of Thrace.

PURPOSE: To detect the incidence of CMV infection in spontaneous abortion in Thrace. METHODS: Genetic material from 143 fetuses aged from 11 to 39 weeks was examined. The material originated from various regions of Thrace. All fetuses and the respective placentas underwent routine histopathology. DNA was isolated from sections of paraffinized tissues. Detection of CMV in the DNA genomic samples was performed using a commercial PCR-based detection kit. RESULTS: From the 143 fetuses that were examined, two were found to be CMV positive. Pathological findings related to inflammatory corruptions were observed in the placentas of 97 embryos, including the CMV infected ones. CONCLUSIONS: This study indicates CMV-DNA infection in 1.4% of aborted fetuses. CMV infection incidence in aborted fetuses is similar to this reported in other European regions. The molecular technique of PCR applied on paraffin-embedded biopsy material is proven to be an accurate, valid and fast method for investigating the CMV infection in aborted fetuses.

Serum pattern of circulating soluble receptor of leptin throughout the menstrual cycle.

AIM: The aim of the study was to investigate the pattern of circulating soluble receptor of leptin (sLeptinR) during the menstrual cycle and the association of sLeptinR to leptin, sex hormones and gonadotropins. METHODS: Fasting blood samples were collected on alternate days throughout a full cycle from fifteen healthy volunteers. Immunoenzymatic assays were employed to record the relevant levels. RESULTS: sLeptinR concentrations throughout the cycle were found to vary negligibly. No significant correlations between sLeptinR and leptin, gonadotropins or progesterone, were established. During the follicular phase, subjects presenting with higher estradiol levels tended to have higher sLeptinR concentrations. CONCLUSION: The little variation of sLeptinR concentrations during the menstrual cycle indicates that the rise of leptin during the luteal phase implies an increase of its bioactivity.

Distribution of ABO and Rh blood groups in Greece: an update.

The aim of this study was to investigate and evaluate the frequency of the antigens classifying the ABO and Rh blood groups in the Greek population. In this study the 3.5% were first generation immigrants with both their parents immigrants from countries of the USSR, while 1.2% had only one immigrant parent, while the other one was Greek. We compared the frequency of distribution of blood groups ABO and Rh to previous studies conducted at a time before Greece became destination for refugees and immigrants from East and Northeast countries. Blood samples were collected from first year medical students. The frequency of distribution of the ABO and Rh blood groups was slightly differentiated in comparison to previous relevant studies. Significant increase was recorded with respect to the emergence of blood group B in the population investigated, and a considerable reduction was noted in blood group O. In reference to the remaining blood groups, no statistically significant difference was documented. The genetic pool and the genetic inventory of the population residing in Greece have been modified during the last years potentially due to the first generation immigrants. The results of this study could contribute significantly to the National Health System in aiding the prediction of percussions of certain diseases related to blood groups, as well as the requirement for certain blood groups within the blood donation program.

Leiomyomas of spermatic cord and testis presenting as hernia--chromosomal analysis.

We report a rare case of three leiomyomas of the permatic cord and testis in a 73-year-old man. Indirect, large, painful, non-reducible inguinal hernia was diagnosed at admission. During surgery, the hernia was revealed. Furthermore, two tumors were found, both attached on the spermatic cord, and a third tumor close to the testis. All the tumors were carefully removed and no orchidectomy was performed. Hernia repair was performed and the removed tumors were sent to the Pathology Department. All tumors were benign. At the first follow up, chromosomal analysis was also performed. Chromosomal lymphocyte analysis revealed increased fragility at site 4q31. Two years after surgery, the patient was admitted again with a new similar tumor, and underwent a new surgical treatment. In the case of large non-reducible inguinal hernias, surgeons have to consider tumors in the inguinal area in their differential diagnosis.

Differential expression of tenascin-C in the developing human lung: an immunohistochemical study.

Much of the specification for the basic embryonic body plan is the result of a hierarchy of developmental decisions at different developmental times. The extracellular matrix (ECM) appears to be a very dynamic structure during embryogenesis. One of the mesenchymal ECM proteins, tenascin, is reported to be transiently expressed during embryonic tissue development, and is absent or much reduced in most fully developed organs. The respiratory system is an outgrowth of the ventral wall of the foregut, and the epithelium of the larynx, trachea, bronchi and alveoli is of endodermal origin. The cartilaginous and muscular components are of mesodermal origin. The aim of this study was to investigate the role of tenascin-C (TNC) in the developing human lung, during the pseudoglandular, canalicular and saccular stage of lung maturation. Formalin-fixed, paraffin-embedded tissue from the lungs of 30 embryos (10 corresponding to the 10th to the 16th gestational week (pseudoglandular stage), 10 to the 17th to the 23rd gestational week (canalicular stage), and 10 to the 24th to the 27th gestational week (saccular stage), were investigated by conventional histology and immunohistology for the expression levels of TNC. The changes observed in the distribution patterns suggest that during embryogenesis, the rate of tenascin synthesis changes significantly. During the pseudoglandular stage, the density of cells expressing TNC was higher in the condensing mesenchyme surrounding the epithelial glands than in the epithelial cells, whereas the inverse result was observed during the canalicular stage. During the saccular stage the pattern of immunoreactivity with TNC was lower than those of the pseudoglandular and canalicular stage, either in epithelial or mesenchymal cells, but it was highly expressed in the basement membranes. This restricted spatiotemporal distribution suggests that tenascin has a key role (1) in mesenchymal tissue remodeling during the pseudoglandular stage, a period that describes the development of the complete bronchial tree and (2) on the epithelial cell shape and function during the canalicular stage, a period that describes the formation of pneumocytes type I and pneumocytes type II. The later, will produce the surfactant, a phospholipid-rich fluid capable of lowering surface tension at the air-alveolar interface. During the saccular stage, tenascin was present mainly in the basement membranes surrounding the acinar and vascular structures, indicating a supporting and mechanical role.

Induction of hepatic haematopoiesis with fibronectin expression by EMT stromal cells during the second trimester of development.

In an initial period of vertebrate phylogeny (bone marrow-less vertebrates), lymphohaematopoiesis takes place in numerous organs containing a suitable microenvironment. Among other organs (i.e., gonads, kidney and spleen), the liver is apparently the most appropriate site for homing and differentiation of haematopoietic cell precursors. Interaction between haematopoietic cells and stromal cells is important for regulation of haematopoiesis. Numerous soluble and membrane-bound factors directly regulating haematopoiesis have been documented, but little is known about the effect of the foetal hepatic epithelial-to-mesenchymal transition (EMT) stromal cells' activity and their product-fibronectin, on foetal hepatic haematopoiesis. The binding of late-stage erythroid cells to FN has been well characterised and is believed to be critical for the terminal stages of erythroid differentiation. The intention of this article is to provide a quantitative overview of FN, produced by hepatic EMT stromal cells, in foetal hepatic haematopoiesis during the first and second trimester of development. Paraffin-embedded specimens from the liver of 30 human embryos in the first and second trimesters of gestation were investigated by conventional histology and immunohistology for the presence of FN and specific haematopoietic cell types. The staining intensity, and localisation of FN and haematopoietic markers in sequential sections were examined. Furthermore, double immunohistochemical staining was performed to assess simultaneous detection of FN and haematopoietic markers. FN was expressed in the EMT stromal cells of the hepatic portal triads more strongly during the second trimester than the first. Furthermore, an intense immunostaining for haematopoietic lineages, and especially for erythropoiesis, was observed in the second trimester compared to the first. The results of the double immunostaining disclosed an intimate co-expression of the FN and CD haematopoietic markers. Foetal hepatic EMT stromal cells provide a unique microenvironment that supports the emergence, expansion and maintenance of human foetal haematopoietic development during the mid-gestational stage. FN produced by the EMT stromal cells follows a time course parallel to that of haematopoiesis. We suggest that in foetal liver, phenotypic modifications of EMT stromal cells expressing FN concerning the cell adhesion capacity of the protein are associated with proliferation and differentiation of specific haematopoietic cell lineages during the second trimester of gestation, probably reflecting the increasing demand of the growing foetus for mature erythroid and myeloid cells.

Follicular fluid levels of vascular endothelial growth factor and leptin are associated with pregnancy outcome of normal women participating in intracytoplasmic sperm injection cycles.

Cytokines play a critical and multifarious role in follicular maturation. Consequently, they may influence the pregnancy outcome in cycles of assisted reproduction. The aim of this study was to measure the levels of tumor necrosis factor-alpha (TNFalpha), vascular endothelial growth factor (VEGF) and leptin in serum and follicular fluids (FFs) from women undergoing controlled ovarian hyperstimulation (COH) for intracytoplasmic sperm injection cycles (ICSI). We tried to investigate their interrelationships and to evaluate them as predictive markers for the cycle's outcome. Seventeen women participated in this study. Male factor infertility was the only indication for ICSI cycles. For COH, the long agonist protocol with triptorelin and recombinant FSH was employed. Cytokines levels were evaluated by ELISA. Serum cytokine levels did not differ between pregnant and non-pregnant women. FF-VEGF levels were significantly elevated in non-pregnant women (722.2+/-1093.2 pg/ml) as compared to pregnant women (290.3+/-259.8 pg/ml). Leptin concentrations were also significantly higher in FFs of non-pregnant women (682.6+/-625.1 ng/ml) than those of pregnant women (231.6+/-286.5 ng/ml). There were significant positive correlations between FF-leptin and age, as well as between FF-leptin and FF-VEGF concentrations. It was concluded that elevated FF-leptin and VEGF levels are associated with failure of conception in IVF cycles and may serve as markers in clinical practice.

A borderline form of empty follicle syndrome. Case report.

BACKGROUND: Empty follicle syndrome is known as the failure of oocyte retrieval despite the adequate response to ovarian stimulation. It is a rare phenomenon in in-vitro fertilization and borderline forms of this syndrome have also been described. MATERIALS AND METHODS: Two cycles in the same patient were stimulated with GnRH agonist/hMG and recFSH; the first followed the long and the second followed the short protocol. RESULTS: There was a sudden drop in estradiol levels while the ovaries contained a large number of small and medium sized follicles. hCG was administered and oocyte retrieval was performed 36 hours later. There was no indication of low hCG levels. For the first cycle two oocytes were collected: one degenerated and one of poor quality. The second cycle resulted in total failure of oocyte retrieval. CONCLUSION: The two cycles were classified as borderline forms of empty follicle syndrome. The possible aetiology is discussed.

Gonadotropin releasing hormone antagonists and cryopreservation outcome: a review.

REVIEW: The outcome of freeze-thaw cycles with pronuclear stage oocytes or embryos, derived from collecting cycles stimulated with gonadotropin-releasing hormone (GnRH)-antagonists' protocols, was reviewed. CONCLUSION: The viability of cryopreserved pronuclear stage oocytes and embryos, the quality of transferred embryos and the pregnancy rates of the freeze-thaw cycles seem to be satisfactory regardless of the type and dose of GnRH-antagonist.

Preimplantation genetic diagnosis of chromosome abnormalities: implications from the outcome for couples with chromosomal rearrangements.

OBJECTIVES: Chromosomal rearrangements can lead to infertility or repeated spontaneous or induced abortions. The use of preimplantation genetic diagnosis (PGD) allows the selected transfer of chromosomally balanced embryos. The aim of this study was to carry out detailed analysis of the outcome of 11 PGD cycles for 8 patients carrying various chromosomal rearrangements. METHODS: Patients underwent routine in vitro fertilisation with biopsy of embryos on day 3. Specific fluorescent in situ hybridisation protocols were developed for each couple. Embryo transfer was possible in all 11 cycles. RESULTS: The outcome was four pregnancies, leading to three live births and one biochemical pregnancy. Post-zygotic mosaicism was detected in 75% of untransferred embryos, the majority of which were chaotic. Detailed follow-up and analysis provided evidence for the co-existence of chromosomally balanced and abnormal cells in six embryos. The mechanisms involved included chromosome breakage and loss of material. CONCLUSIONS: Biopsy and analysis of two blastomeres, where possible, reduced the risk of misdiagnosis in cases of balanced/aneuploid mosaics. The three live births achieved for the eight couples treated in this series, despite the poor history in almost all cases, is further proof that a policy of biopsying two cells from embryos consisting of six or more cells and a single cell from four- or five-cell embryos is compatible with a positive outcome.

Endometrial fluid accumulation during controlled ovarian stimulation for ICSI treatment. A report of three cases.

The occurrence of endometrial fluid accumulation was examined in patients undergoing ovarian stimulation in a program of intracytoplasmic sperm injection (ICSI), by vaginal ultrasound. Endometrial fluid accumulation was recorded in three cycles out of 124. In one case, the fluid was absorbed before embryo transfer (ET), but in the other cases it was present in ET. In these three cases, the endometrium had been evaluated as normal before ovarian stimulation. Fluid accumulation in the endometrial cavity possibly affects the implantation process negatively. Therefore, alternative options should be considered as cancellation of the embryo transfer and cryopreservation of embryos to be available in a subsequent mild stimulated cycle.

FISH analysis on day 5 post-insemination of human arrested and blastocyst stage embryos.

Preimplantation genetic diagnosis (PGD) is usually performed on cleavage stage embryos on day 3 post-insemination. Fluorescent in situ hybridization (FISH) has revealed four groups of chromosome patterns in embryos at this stage: uniformly normal, uniformly abnormal, mosaic and chaotic. Recently, some in vitro fertilization (IVF) clinics have started to perform blastocyst stage transfer. In blastocysts, conventional karyotyping has shown that all four groups of chromosome patterns are observed. In the present study, embryos were cultured to day 5 and were subject to a two-round multicolour FISH procedure for chromosome analysis to ensure almost every nucleus was examined. Probes for chromosomes X, Y and 18 were used in the first round and those for chromosomes 13 and 21 in the second round. Twenty arrested embryos (274 cells) and 19 blastocyst stage embryos (1272 cells) were analysed. Four arrested embryos and two blastocysts were uniformly diploid. The remaining 33 embryos were mosaic, including 17 blastocysts. Most of the blastocysts had a high proportion of diploid cells while in the arrested embryos, this proportion varied widely. For PGD, this high prevalence of mosaicism persisting to the blastocyst stage may pose problems similar to mosaicism in cleavage stage embryos.