Can you ever collect too many oocytes?

STUDY QUESTION: Does the chance of pregnancy keep improving with increasing number of oocytes, or can you collect too many? SUMMARY ANSWER: Clinical pregnancy (CP) and live birth (LB) rates per embryo transfer varied from 10.2 and 9.2% following one oocyte collected to 37.7 and 31.3% when >16 oocytes were collected. Regression modelling indicated success rates increased or at least stayed the same with number of oocytes collected. WHAT IS KNOWN ALREADY: It has been suggested that if >15 oocytes are collected, the success rate for fresh embryo transfers decreases. As this is counterintuitive, as more oocytes should result in more embryos, with a better choice of quality embryos, we decided to analyse the recent experience in a busy IVF unit. STUDY DESIGN, SIZE DURATION: A retrospective analysis of clinical pregnancy and live birth outcome, with respect to number of oocytes collected at Monash IVF for the 2-year period between August 2010 and July 2012, where patients under the age of 45 years underwent a fresh embryo transfer. This included 7697 stimulated cycles for IVF and ICSI. PARTICIPANT/MATERIALS, SETTING, METHODS: Statistical analysis involved data tables and graphs comparing oocyte number with outcome. Results of women who had their first oocyte collection with an embryo transfer within the reference period were analysed by logistic regression analysis including other covariates that might influence pregnancy outcome. Analysis was also carried out of all the 7679 oocyte collections undertaken, resulting in fresh embryo transfers by generalized estimating equations to allow for the within subject correlation in outcomes for repeated treatments. MAIN RESULTS AND THE ROLE OF CHANCE: The number of oocytes collected varied from 1 to 48. Clinical pregnancy and live birth rates per embryo transfer varied from 10.2 and 9.2% when only one oocyte was collected to 37.7 and 31.3% when >16 oocytes were collected. Regression modelling indicated success rates increased or at least stayed the same or with the number of oocytes collected. The percentage of women with embryos cryopreserved increased from under 20% with <4 oocytes collected to over 70% with >16 oocytes collected. There was a slight increase (from 18 to 22%) in oocyte immaturity and a more marked increase (from 0 to 3%) in cancelling fresh transfers to prevent Ovarian Hyperstimulation Syndrome (OHSS) with increase in number of oocytes collected above 16. The results of this study suggest that you cannot collect too many oocytes as both clinical pregnancy and live birth rates do not decrease with high numbers of oocytes collected. However, once >15 oocytes are collected, everything gets quite uncertain. LIMITATIONS, REASONS FOR CAUTION: As the data become sparse above 15 oocytes, we could not demonstrate a significant increase in pregnancy rates above this number. Larger studies would be required to answer the question whether there is a plateau, or rates continue to increase. The negative of aggressive stimulation to produce many oocytes is that the risk of OHSS increases, and this is the most serious complication of ovarian stimulation. STUDY FUNDING/COMPLETING OF INTERESTS: No funding was required. There is no conflict of interest, except that G.K., V.M. and C.M. are shareholders in Monash IVF Pty Ltd.

Quinn's advantage fertilization medium enhances zona pellucida-induced acrosome reaction compared with human tubal fluid medium.

The aim of this study was to compare sperm velocity, hyperactivation, zona pellucida (ZP) binding and ZP-induced acrosome reaction (AR) between Quinn's advantage fertilization (QAF), human tubal fluid (HTF) and Ham's F10 media. Semen samples were obtained from normozoospermic men and motile spermatozoa were prepared by gradient centrifugation (PureSperm). Unfertilized oocytes from clinical IVF were used for spermatozoa-oocyte interaction tests. Sperm velocity and hyperactivation were assessed using a Hamilton-Thorn motility analyser. When media were supplemented with human albumin, sperm motility and velocity and sperm binding were not significantly different between QAF and HTF. However, ZP-induced AR was significantly higher with QAF than HTF (42±22 versus 21±18, P<0.th001). Sperm velocity, hyperactivation and sperm binding were also significantly higher in QAF than Ham's F10 media. Supplementation of media with either human serum or human albumin showed no difference in effect on all sperm test results. In conclusion, QAF medium significantly enhances ZP-induced AR which is essential for sperm penetration. Thus QAF appears to be a better medium than HTF for sperm fertilizing ability in conventional IVF.

New assisted reproductive technology laws in Victoria: a genuine overhaul or just cut and paste?

A new Assisted Reproductive Treatment Act was passed in Victoria on December 2008 and came into effect on 1 January 2010. The new legislation changed who was eligible for assisted reproductive technology (ART) and the types of services that clinics could provide. This article reports on interviews with service providers in Victoria who experience first hand the impact of legislation on clinical practice and patients, as well as regulators who are able to provide insight into the values underpinning the regulatory framework. The new legislation was viewed by all participants as an improvement on the old Act because of the removal of discriminatory and ambiguous aspects. The authors argue that while some of the details of the legislation have changed, the underlying principles and the framework have not.

Men's experiences of infertility and infertility treatment 5 years after diagnosis of male factor infertility: a retrospective cohort study.

BACKGROUND: The aim of this study was to describe the perceptions of infertile men regarding the impact of infertility on their intimate relationships, their experience of treatment and their sources of information and support. METHODS: A cross-sectional survey of a consecutive cohort of men diagnosed 5 years earlier as infertile at Melbourne IVF and the Royal Women's Hospital Reproductive Services, Melbourne was conducted. Study-specific questions assessed the impact of male factor infertility on the intimate relationships, their perceived quality of infertility-related health care and their preferred sources of infertility-related information and personal support and the effectiveness of these. RESULTS: The response rate was 41% (112/276). Male factor infertility was reported to have had a negative impact on the intimate partner relationship by 25% of men, and 32% reported a negative effect on their sexual satisfaction. Satisfaction with medical care and clinic information was high and not influenced by the outcome of the treatment. Clinic-provided information and discussion with clinic staff were the most strongly preferred sources of information, and the partner and clinic staff were the most valued sources of personal support. Very few men found support groups useful and less than half confided in friends. CONCLUSIONS: The findings suggest that for a significant subgroup of men, male factor infertility affects their intimate relationship negatively. Wider sources of social support are not used by infertile men as they rely predominantly on clinic-provided information and support. This indicates that psychologically informed supportive clinical care is particularly important for men diagnosed as infertile.

Prevalence and risk factors for obstetric haemorrhage in 6730 singleton births after assisted reproductive technology in Victoria Australia.

BACKGROUND: Obstetric haemorrhages have been reported to be increased after assisted reproduction technologies (ART) but the mechanisms involved are unclear. METHODS: This retrospective cohort study compared the prevalence of antepartum haemorrhage (APH), placenta praevia (PP), placental abruption (PA) and primary post-partum haemorrhage (PPH) in women with singleton births between 1991 and 2004 in Victoria Australia: 6730 after IVF/ICSI, 24 619 from the general population, 779 after gamete intrafallopian transfer (GIFT) and 2167 non-ART conceptions in infertile patients. Risk factors for haemorrhages in the IVF/ICSI group were examined by logistic regression. RESULTS: The IVF/ICSI group had more APH: 6.7 versus 3.6% (adjusted OR 2.0; 95% CI 1.8-2.3), PP: 2.6 versus 1.1% (2.3; 1.9-2.9), PA: 0.9 versus 0.4% (2.1; 1.4-3.0) and PPH: 11.1 versus 7.9% (1.3; 1.2-1.4) than the general population. APH, PP and PA were as frequent in the GIFT group as in the IVF/ICSI group, but were less frequent in the non-ART group. Within the IVF/ICSI group, fresh compared with frozen thawed embryo transfers (FET) was associated with more frequent APH (1.5; 1.2-1.8) and PA (2.1; 1.2-3.7) and the odds ratio increased with number of oocytes collected (1.02; 1.00-1.04). Endometriosis patients had more PP (1.7; 1.2-2.4) and PPH (1.3; 1.1-1.6) than those without endometriosis. FET in artificial cycles was associated with increased PPH (1.8; 1.3-2.6) compared with FET in natural cycles. CONCLUSIONS: Obstetric haemorrhages are more frequent with singleton births after IVF, ICSI and GIFT. The exploratory analysis of factors in the IVF/ICSI group, showing associations with fresh embryo transfers in stimulated cycles, endometriosis and hormone treatments, suggests that events around the time of implantation may be responsible and that suboptimal endometrial function is the critical mechanism.

Increased risk of blastogenesis birth defects, arising in the first 4 weeks of pregnancy, after assisted reproductive technologies.

BACKGROUND: The reasons for increased birth defect prevalence following in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are largely unknown. Classification of birth defects by pathology rather than organ system, and examination of the role of embryo freezing and thawing may provide clues to the mechanisms involved. This study aimed to investigate these two factors. METHOD: Data on 6946 IVF or ICSI singleton pregnancies were linked to perinatal outcomes obtained from population-based data sets on births and birth defects occurring between 1991 and 2004 in Victoria, Australia. These were compared with 20,838 outcomes for singleton births in the same population, conceived without IVF or ICSI. Birth defects were classified according to pathogenesis. RESULTS: Overall, birth defects were increased after IVF or ICSI [adjusted odds ratio (OR) 1.36; 95% CI: 1.19-1.55] relative to controls. There was no strong evidence of risk differences between IVF and ICSI or between fresh and thawed embryo transfer. However, a specific group, blastogenesis birth defects, were markedly increased [adjusted OR 2.80, 95% CI: 1.63-4.81], with the increase relative to the controls being significant for fresh embryo transfer (adjusted OR 3.65; 95% CI: 2.02-6.59) but not for thawed embryo transfer (adjusted OR 1.60; 95% CI: 0.69-3.69). CONCLUSION: Our findings suggest that there is a specific risk of blastogenesis birth defects arising very early in pregnancy after IVF or ICSI and that this risk may be lower with use of frozen-thawed embryo transfer.

Enhancement of sperm-zona pellucida (ZP) binding capacity by activation of protein kinase A and C pathways in certain infertile men with defective sperm-ZP binding.

BACKGROUND: Defective sperm-zona pellucida (ZP) binding (DSZPB) is a common cause of failure of fertilization in vitro. This study was to determine if DSZPB is caused by defective pathways upstream of protein kinase A (PKA) and C (PKC), or reduced protein tyrosine phosphorylation (TP). METHODS: Infertile men with DSZPB and either normal sperm morphology (NSM) > or = 14% (n = 15) or < or =5% (n = 15) were studied. Sperm-ZP binding test was performed by incubation of motile sperm with oocytes for 2 h with or without dibutyryl cyclic AMP (dbcAMP, PKA activator) or phorbol myristate acetate (PMA, PKC activator). TP of capacitated sperm in medium was assessed by immunofluorescence with an anti-phosphotyrosine monoclonal antibody. RESULTS: For normal sperm with normal sperm-ZP binding, both PMA and dbcAMP significantly enhanced sperm-ZP binding in a dose-response manner. Only dbcAMP, but not PMA, significantly increased TP of capacitated sperm. In DSZPB men with severe teratozoospermia (NSM < or = 5%), neither PMA nor dbcAMP enhanced sperm-ZP binding, despite dbcAMP significantly increasing the TP of capacitated sperm for all samples. In contrast, for DSZPB with NSM > or = 14%, PMA caused significantly increased sperm binding up to normal levels (> or =40 sperm bound/ZP) in five men, and dbcAMP had a similar result in two men. Again TP was significantly enhanced only by dbcAMP, but not by PMA. CONCLUSIONS: There is defective signalling in pathways upstream of PKC and PKA in some men with DSZPB and normal semen analysis. Stimulation of TP by dbcAMP does not enhance sperm-ZP binding capacity in DSZPB men with low TP, regardless of sperm morphology.

Associations between andrological measures, hormones and semen quality in fertile Australian men: inverse relationship between obesity and sperm output.

BACKGROUND: The World Health Organization developed a time to pregnancy (TTP) study (number of menstrual cycles taken to conceive) to determine whether the average TTP is increasing and semen quality decreasing with time. The present study describes clinical, semen and hormone characteristics obtained from male partners of pregnant women in Melbourne, Australia, and examines the associations between these characteristics. METHODS: Male partners (n = 225) of pregnant women (16-32 weeks) who conceived naturally had physical examination, health and lifestyle questionnaires, semen and hormone (FSH, LH, sex hormone-binding globulin, testosterone and Inhibin B) analyses. RESULTS: Previously known associations between semen, hormone and clinical variables were confirmed as significant: sperm numbers (concentration and total sperm count) correlated positively with Inhibin B and inversely with FSH and left varicocele, while total testicular volume correlated positively with sperm numbers and Inhibin B and inversely with FSH. However, only abstinence, total testicular volume, varicocele grade and obesity (BMI > 30 kg/m2) were independently significantly related to total sperm count. Compared with those with BMI < 30 (n = 188), obese subjects (n = 35) had significantly lower total sperm count (mean 324 versus 231 million, P = 0.013) and Inhibin B (187 versus 140 pg/ml, P < 0.001) but not FSH (3.4 versus 4.0 IU/l, P = 0.6). CONCLUSIONS: Obese fertile men appear to have reduced testicular function. Whether this is cause or effect, i.e. adiposity impairing spermatogenesis or reduced testicular function promoting fat deposition, remains to be determined.

Recruitment bias in studies of semen and other factors affecting pregnancy rates in fertile men.

BACKGROUND: Recruitment bias is possible in population studies of semen quality because few men volunteer. We examine differences between Australian couples with natural conceptions who agreed or declined to participate in such a study. METHODS: Women pregnant between 16 and 32 weeks gestation participating in a retrospective time to pregnancy (TTP) study were each requested to recruit their eligible (on the basis of age, place of his birth and of his mother's birth) male partner to complete additional questionnaires, have a physical examination and provide blood and two semen samples. RESULTS: From 2061 women who completed the TTP questionnaire (response rate, 98%) there were 928 eligible male partners of whom 225 (24%) were responders. There were significant socio-demographic and self-reported exposure differences between responders and non-responders in particular, female professional occupation, knowledge of the fertile phase, pelvic inflammatory disease, non-smoker at time of conception and wine consumption per week were more frequent in the responders. There was no evidence of a bias for the subfertile being more likely to volunteer for the study. Mean TTP for planned pregnancies for responders and non-responders were 3.3 and 3.8 cycles (P = 0.319), respectively, and the cycle specific pregnancy rates were not significantly different after covariate adjustment by Cox regression. CONCLUSIONS: The present study confirms that participation rates are low in studies of semen quality. Although the expected higher participation of subfertile couples was not confirmed, there remains considerable potential for bias and other problems that could invalidate this type of study.

Pregnancies conceived using assisted reproductive technologies (ART) have low levels of pregnancy-associated plasma protein-A (PAPP-A) leading to a high rate of false-positive results in first trimester screening for Down syndrome.

BACKGROUND: First trimester screening (FTS) for Down syndrome combines measurement of nuchal translucency, free beta-human chorionic gonadotrophin and pregnancy-associated plasma protein-A (PAPP-A). The aim of this study was to undertake a detailed analysis of FTS results in singleton pregnancies conceived using assisted reproductive technologies (ART) and non-ART pregnancies. METHODS: A record linkage study compared outcomes in 1739 ART-conceived and 50 253 naturally conceived pregnancies. RESULTS: Overall, significantly lower PAPP-A levels were detected in ART pregnancies (0.83 multiples of median, MoM) than in controls (1.00 MoM) (t-test P < 0.001). This difference remained after excluding complicated pregnancies. Analysis of factors affecting PAPP-A levels suggested fresh compared with frozen embryo transfers and use of artificial cycles compared with natural cycles for frozen transfers were associated with lower values. The adjusted odds ratio (AdjOR) for receiving a false-positive result was 1.71 (95% CI 1.44-2.04; P < 0.001) for ART pregnancies compared with non-ART pregnancies, and this leads to a higher AdjOR (1.24, 95% CI 1.03-1.49; P = 0.02) for having a chorionic villous sampling (CVS) or amniocentesis. CONCLUSIONS: ART pregnancies have reduced FTS PAPP-A levels leading to an increased likelihood of receiving a false-positive result and having a CVS/amniocentesis. Lower PAPP-A may reflect impairment of early implantation with some forms of ART.

Factors affecting low birthweight after assisted reproduction technology: difference between transfer of fresh and cryopreserved embryos suggests an adverse effect of oocyte collection.

BACKGROUND: Data show that differences exist in the birthweight of singletons after frozen embryo transfer (FET) compared with fresh transfer or gamete intra-Fallopian transfer (GIFT). Factors associated with low birthweight (LBW) after assisted reproduction technology (ART) were studied. METHODS: Birthweight, distribution of birthweight, z-score, LBW (<2500 g), gestation and percentage preterm (<37 weeks) for singleton births >19 weeks gestation, conceived by ART or non-ART treatments (ovulation induction and artificial insemination) between 1978 and 2005 were analysed for one large Australian clinic. RESULTS: For first births, the mean birthweight was significantly (P < 0.005) lower, and LBW and preterm birth more frequent for GIFT (mean = 3133 g, SD = 549, n = 109, LBW = 10.9% and preterm = 10.0%), IVF (3166, 676, 1615, 11.7, 12.5) and ICSI (3206, 697, 1472, 11.5, 11.9) than for FET (3352, 615, 2383, 6.5, 9.2) and non-ART conceptions (3341, 634, 940, 7.1, 8.6). Regression modelling showed ART treatment before 1993 and fresh embryo transfer were negatively related to birthweight after including other covariates: gestation, male sex, parity, birth defects, Caesarean section, perinatal death and socio-economic status. CONCLUSIONS: Birthweights were lower and LBW rates higher after GIFT or fresh embryo transfer than after FET. Results for FET were similar to those for non-ART conceptions. This suggests IVF and ICSI laboratory procedures affecting the embryos are not causal but other factors operating in the woman, perhaps associated with oocyte collection itself, which affect endometrial receptivity, implantation or early pregnancy, may be responsible for LBW with ART.

Polymorphisms in the human cysteine-rich secretory protein 2 (CRISP2) gene in Australian men.

BACKGROUND: Cysteine-rich secretory protein 2 (CRISP2) is localized to the human sperm acrosome and tail. It can regulate ryanodine receptors Ca(2+) gating and binds to mitogen-activated protein kinase kinase kinase 11 in the acrosome and gametogenetin 1 (GGN1) in the tail. METHODS AND RESULTS: In order to test the hypothesis that CRISP2 variations contribute to male infertility, we screened coding and flanking intronic regions in 92 infertile men with asthenozoo- and/or teratozoospermia and 176 control men using denaturing HPLC and sequencing. There were 21 polymorphisms identified, including 13 unreported variations. Three SNPs resulted in amino acid substitutions: L59V, M176I and C196R. All were only present in a heterozygous state and found in fertile men. However, the C196R polymorphism was of particular interest as it resulted in the loss of a strictly conserved cysteine involved in intramolecular disulphide bonding. Screening of an additional 637 infertile men identified 23 heterozygous C196R men to give an overall frequency of 3.6%, compared with 3.4% in control men. The functional significance of the C196R polymorphism was defined using a yeast two-hybrid assay. The C196R substitution resulted in the loss of CRISP2-GGN1 binding. CONCLUSIONS: Although none of the many polymorphisms identified herein showed a significant association with male infertility, functional studies suggested that the C196R polymorphism may compromise CRISP2 function.

Assessing the health and development of ART-conceived young adults: A study of feasibility, parent recall, and acceptability.

BACKGROUND: Assisted reproductive technologies (ART) to treat infertility have been available for nearly three decades. There have been a number of systematic comparisons of the health and development of ART-conceived with spontaneously-conceived (SC) children. Data are equivocal, some finding no differences and others that there are more health and developmental problems in the ART group. It is agreed that perinatal mortality and morbidity are worse after assisted than spontaneous conception and the impact of the hormonally altered intrauterine environment on puberty and later fertility of offspring are unknown. To date however, there has been no investigation of the health and development of ART-conceived young adults, including from the world's few prospective cohorts of ART conceived children. Obtaining these data requires contact to be made with people at least twenty years after discharge from the treating service. Given the ethical difficulties of approaching families to participate in research up to two decades after cessation of treatment, the aim of this exploratory qualitative investigation was to assess the feasibility and acceptability of approaching mothers treated for infertility prior to 1988, and their recall of the health and development of their ART-conceived young adult children. METHODS: Mothers treated for infertility at the Royal Women's Hospital Reproductive Biology Unit in Melbourne, Australia prior to 1988 were approached by a senior clinician and invited to participate in individual semi-structured interviews which could include their partners and/or young adult children if they wished. Recruitment continued until theoretic saturation had been reached. RESULTS: Ten mothers, two of their husbands and five young adults participated in interviews, and the health and development of 15 ART-conceived young adults were described. The experience of conception, pregnancy, birth and the health and development of the children were recalled vividly and in detail. Families were pleased to have been approached and supported the need for systematic data collection. Mode of conception had been disclosed from childhood to all the offspring. CONCLUSION: With careful and sensitive recruitment strategies it is feasible and acceptable to contact women treated for infertility at least two decades ago and their families, to assess the health and development of ART-conceived young adults.

Human seminal clusterin (SP-40,40). Isolation and characterization.

Molecular cloning of the human complement inhibitor SP-40,40, has revealed strong homology to a major rat and ram Sertoli cell product, sulfated glycoprotein-2, known also as clusterin. This study reports the purification and characterization of human seminal clusterin. Two-dimensional gel electrophoresis revealed charge differences between clusterin purified from semen and the serum-derived material. Both preparations demonstrate comparable hemagglutination (clustering) activity and inhibition of C5b-6 initiated hemolysis. The average clusterin concentration in normal seminal plasma is considerably higher than that found in serum. Mean seminal plasma clusterin concentrations were significantly lower in azoospermia caused by obstruction or seminiferous tubule failure than with oligospermia or normospermia. Only men with vasal agenesis had undetectable seminal clusterin, suggesting that some of the seminal clusterin is produced by the seminal vesicles. Immunofluorescence of human spermatozoa revealed that clusterin was detected on 10% of spermatozoa, predominantly those that were immature or had abnormal morphology. A pilot study of 25 patients suggests that seminal clusterin concentration, together with sperm motility and morphology, is correlated with the fertilization rate in vitro. The function of seminal clusterin is unknown. Its extensive distribution in the male genital tract and its high concentration in seminal plasma suggests an important role in male fertility.

Relationships between timing of syngamy, female age and implantation potential in human in vitro-fertilised oocytes.

Although early developmental markers are frequently used to select embryos for transfer in human assisted reproduction, their value as independent predictors of outcome is often unclear. In this study, the value of using early syngamy and first cleavage as predictors of implantation potential of Day 2 embryos was investigated by examining their interrelationships with subsequent development, female age and implantation. Implantation rates were higher when syngamy occurred before 23-24 h post insemination even when all embryos analysed were transferred 42 h post insemination at the 4-cell stage (25.8 v. 11.9% for the later syngamy group; P < 0.01). Although there was a significant (r = 0.682; P < 0.001) relationship between earlier entry into syngamy and female age, earlier syngamy was still associated with a significantly higher implantation rate in Day 2 embryos with four blastomeres in women under 36 years of age (31.4 v. 15.4% for the later syngamy group; P < 0.05). The ability of timing of syngamy to predict implantation independent of other variables was confirmed by multiple logistic regression analysis. Although related to both subsequent embryo development and female age, early entry into syngamy is a predictor of implantation potential independent of both correlates in human Day 2 in vitro-fertilised embryos.

[Assessment of human sperm function and clinical management of male infertility].

In this article, we provide an update review on the implication of the assessment of human sperm function and the management of male infertility in clinical assisted reproductive technology (ART) known as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). In most ART clinics, the assessment of male fertility is still mainly based on routine semen analysis but it is inaccurate in predicting sperm fertilizing ability. Thus it is often difficult to determine if IVF or ICSI will be an optimal treatment for patients in the initial cycle. Before introduction of ICSI, frequency of low ( <30%) fertilization rate in IVF was very high (20-35% of patients). Evidence suggests that sperm defects are the major contributors to complete failure of fertilization in IVF. Most common sperm defects are oligozoospermia, asthenozoospermia and teratozoospermia though many of the patients are shown to be normal in routine semen analysis. In the literature, many new sperm function tests have been developed, including sperm DNA normalities assessed by Acridine Orange (AO), sperm-zona pellucida (ZP) binding, the ZP-induced acrosome reaction (AR) , sperm-ZP penetration and recently hyaluronan binding assay (HBA). For routine semen analysis, sperm morphology is one of the most useful values for the prediction of sperm function but is also the most difficult test to perform accurately and consistently. Oocytes that failed to fertilize in clinical IVF/ICSI are valuable biological materials for testing sperm function. The human ZP selectively binds sperm with normal morphology and an intact acrosome. The ZP-induced AR is highly correlated with sperm-ZP penetration and disordered ZP-induced AR causes infertility in about 25% men with unexplained infertility with normal semen analysis. Both oligozoospermic (sperm count < 20 x 10(6) /ml) and severe teratozoospermia (strict normal sperm morphology < or =5%) men have a very high ( >70%) frequency of defective sperm-ZP interaction. Thus patients with defects of sperm-ZP interaction should be identified and treated with ICSI since they have high risk of low or zero fertilization rate in IVF. HBA test highly correlates with sperm motility and normal morphology but provides no additional information about sperm fertility. Clinical value of sperm DNA normalities detected by AO for the prediction of ART outcomes is currently still inconclusive and requires further investigation. In conclusion, addition of some of these new sperm tests to routine semen analysis could significantly improve the management of male infertility in clinical ART.

Male fertility and sexual function after spinal cord injury.

Spinal cord injury has an enormous impact upon the sexual relationship of a man and his partner. Erection may be partial or absent, orgasm altered or impossible, and fertility severely impaired. New understanding of the physiology of sexual function and improved treatment can enable most cord-injured men to achieve erections suitable for sexual satisfaction. Modern methods of sperm collection and fertility treatment mean that many can also be fathers. The best results are obtained by a team approach involving rehabilitation and reproductive medicine clinicians, nurses, spinal cord injury specialists and counselors with the cord-injured man and his partner. Erections can be achieved by drugs, such as sildenafil, that block phosphodiesterase 5, prolonging the action of nitric oxide with resultant smooth muscle relaxation. Intracavernosal prostaglandin E1 and mechanical systems, such as vacuum pumps and constriction rings, are also effective. Sexual gratification can be promoted in the context of an understanding relationship in which the cord-injured person can gain pleasure from pleasing his partner and also from his partner's exploration of erotogenic areas not affected by the spinal cord injury. An emphasis on the broader view of sexuality in relationships allows for a continuance and strengthening of bonds between the couple. Vibration ejaculation or electroejaculation can be used to collect semen. For a limited period in the acute phase, usually for about 6-12 days after injury, normal semen can be obtained by electroejaculation from some cord-injured men. With chronic spinal cord injury the semen is of variable quality. Some patients have necrospermia, which may be improved by regular ejaculation. Others have poor quality semen or spermatogenic disorders and, in this situation, in vitro fertilization techniques must be used to achieve parenthood. Trials of assisted ejaculation help individualize cost-effective management of the infertility.

The relationship between immunosuppressive activity and immunoregulatory cytokines in seminal plasma: influence of sperm autoimmunity and seminal leukocytes.

While the contributions of prostasomes, polyamines and prostaglandins to the immunosuppressive activity (ISA) of human seminal plasma have been well-characterised, the contribution of immunoregulatory cytokines found in seminal plasma has received relatively little attention. Semen samples were collected from adult men displaying normospermic parameters, sperm antibodies or substantially elevated seminal leukocytes. Samples were processed through ultracentrifugation and dialysis (<3500Da) to remove prostasomes, polyamines and prostaglandins, and then assayed for ISA by an in vitro T lymphocyte inhibition assay, as well as by specific immunoassays for transforming growth factor beta(1) (TGFbeta(1)), interleukin-10 (IL-10), activin A and the activin-binding protein, follistatin. Seminal plasma from all groups retained substantial ISA following processing. Compared with normospermic men, this 'large' molecular weight ISA fraction was significantly increased in a subset of men with sperm antibodies, but was not altered in the group with elevated leukocytes. There was no relationship between ISA and any cytokine examined, and only TGFbeta(1) was present at levels sufficient to contribute to ISA. Inhibition with a TGFbeta-specific antibody reduced ISA in seminal plasma by approximately 50%. Across all patients, TGFbeta(1) levels were positively correlated with sperm numbers in the ejaculate and with activin A, but not with follistatin or IL-10. Activin A and IL-10 also displayed a positive relationship, and elevated leukocytes was associated with a significant elevation of IL-10 and activin A, but not TGFbeta(1). It is concluded that 'large' molecular weight molecules, the most important of which appears to be TGFbeta(1), make a significant contribution to immunosuppression by human seminal plasma.

Assisted reproductive technologies: professional and legal restrictions in Australian clinics.

The professional and legal regulation of assisted reproductive technologies (ART) in Australia is a vast maze of intersecting laws and guidelines which place restrictions on the provision of services such as infertility treatment, surrogacy, sex selection for social reasons, donor insemination, pre-implantation diagnosis and human embryo research. This study investigated the application of these restrictions on clinical practice in New South Wales, a relatively unregulated State, and Victoria, a relatively highly regulated State. The results of the survey indicate that the range of ART services in Victorian clinics was far more limited than in New South Wales clinics. The Victorian clinics uniformly restricted access of single and lesbian women and did not offer social sex selection procedures. The New South Wales clinics adopted different polices regarding these services. It was found that restrictive laws governing "social" issues have a significant impact on the availability of ART services and some respondents seemed unclear about the nature of restrictions and laws relevant to their work. It was also found that "reproductive tourism" is prevalent and restrictions were circumnavigated by patients with assistance from clinics. It was concluded that more evidence is required to evaluate regulation in this field of medicine.

Nuclear accumulation of androgens in perfused rat accessory sex organs and testes.

The uptake of androgens into the nuclei of caput epididymis, ventral prostate, seminal vesicle and testis was studied by recirculating physiological and pharmacological concentrations of [3H]testosterone in an artificial medium through the lower half (hemicorpus) of castrated or hypophysectomized rats. The accumulation of dihydrotestosterone in accessory sex organ nuclei was saturable, inhibited by perfusion of excess testosterone or cyproterone acetate, and associated with binding to 3S salt-extractable molecules. In castrated preparations the mean saturation levels (pmol/mg DNA) were different in the three organs: seminal vesicle, 2.8; ventral prostate, 1.8; caput epididymis, 0.9. The saturation level was significantly lower in ventral prostate of hypophysectomized rats (1.2) treated with testosterone to regenerate the accessory sex organs. Testosterone was the major nuclear androgen in the testes of mature hypophysectomized preparations perfused with testosterone. Although there was a large amount of nonspecific accumulation, testosterone binding to 3S molecules was shown by sucrose gradient centrifugation. Binding of dihydrotestosterone to 3S molecules in testicular nuclei was also demonstrated. The ratio of dihydrotestosterone to testosterone was different in immature and mature testicular nuclei and was altered by treatments known to affect testicular 5 alpha-reductase activity. The results suggest that in rat accessory sex organs and immature testis the major active androgen is dihydrotestosterone, whereas in mature testis it is testosterone. The shift in the predominant nuclear androgen in the testis from dihydrotestosterone to testosterone is most simply explained by the maturational change in 5 alpha-reductase activity.