The effect of an educational animation on knowledge of testicular health and fertility of adolescents.

STUDY QUESTION: Does the provision of an educational animation, developed with young people, about testicular health and fertility impact the knowledge of these topics among adolescents? SUMMARY ANSWER: The development and provision of education on testicular health and fertility were welcomed by adolescents and associated with a significant increase in knowledge. WHAT IS KNOWN ALREADY: Young people may know less than they should about testicular health and male fertility topics. Lack of knowledge can have implications for health including late medical help-seeking for signs and symptoms of scrotal disorders, such as torsion, for which late presentation frequently results in testicular damage. STUDY DESIGN, SIZE, DURATION: A mixed methods experimental pre- and post-design was used with embedded qualitative data collection. High school students completed a pre-animation questionnaire, watched four animations on testicular health and fertility, and completed a post-animation questionnaire. Data were collected during Personal Social and Health Education lessons across a 2-week period. PARTICIPANTS/MATERIALS, SETTING, METHODS: Four animations on testicular health and fertility, informed by andrologists, academics, designers, boys, and young men, were developed. Eligible participants were boys and girls in the UK school years 8 and 9 (age 13-14 years). Participants completed a Time 1 (T1) survey (fertility knowledge, demographics) prior to watching the animations and a Time 2 (T2) survey (fertility knowledge, perceptions of the animations) immediately after the animations. Perceptions were rated on 10-point response scales (higher scores better). Participants additionally expressed in their own words positive and negative aspects of the animations. ANOVA was used to examine the effects of the animations using a 2 (time: T1, T2)×2 (gender: male, female) design on topic knowledge, perceived importance, usefulness, and style of the animations according to gender. Regression analysis examined the associations between gender, disability, class year, and knowledge at T2 while controlling for knowledge at T1. Qualitative data on perceptions of the animations were analyzed using inductive thematic analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Results showed that the animations significantly increased testicular health and fertility-related knowledge from T1 (x̄=41.84 ± 24.72) to T2 (x̄=79.15, ±15.04). Boys had significantly higher levels of knowledge compared to girls at T1 (x̄=44.74, SD = 25.16 versus x̄=37.79 ± 23.49, respectively) and T2 (x̄=80.07, SD = 15.68 versus x̄=77.89 ± 14.30, respectively) but knowledge gain from T1 to T2 was not significantly different according to gender (P = 0.11) as shown by non-significant gender×time interaction. There were no significant gender differences in the perceived usefulness and importance of the animations or liking of the style of the animations, with both genders considering the animations as useful, important, and likable. Regression analysis showed only knowledge at T1 to be significantly associated with knowledge at T2. Qualitative data showed three main themes: accessibility of important and useful information; information engagement and help-seeking behaviour; and inclusivity of information. LIMITATIONS, REASONS FOR CAUTION: This was a pre- and post-study with a sample of young people from a selected educational institution without a control group. Only short-term effects of the animations were recorded. WIDER IMPLICATIONS OF THE FINDINGS: Adolescents are interested in and learn from the provision of engaging fertility-related information. Boys and men should be considered as being a relevant target population for fertility education, not just girls and women. STUDY FUNDING/COMPETING INTEREST(S): This research was carried out in partnership with the British Fertility Society, was financially supported by an Economic and Social Research Council Impact Acceleration Award (520792) and commercial sponsorship from iMediCare Ltd, Bayer AG, Merck Group, Cryos International given to the British Fertility Society, and a financial contribution from Orchid Cancer Appeal. The authors are fully responsible for the content of the animations and this manuscript, and the views and opinions described in the publication reflect solely those of the authors. J.B. reports a grant from Merck Serono Ltd outside the submitted work. C.H., G.G., A.D., E.B., U.G., M.L, B.W., and M.H. declare no conflict of interest. K.M. reports honoraria from Bayer and Merck. A.P. reports paid consultancy for Cryos International, Cytoswim Ltd, Exceed Health, and Merck Serono in the last 2 years, but all monies have been paid to the University of Sheffield. TRIAL REGISTRATION NUMBER: N/A.

Luteinizing hormone/chorionic gonadotrophin receptor overexpressed in granulosa cells from polycystic ovary syndrome ovaries is functionally active.

Polycystic ovarian syndrome (PCOS) is associated with anovulatory infertility. Luteinizing hormone/chorionic gonadotrophin receptor (LHCGR), which is critical for ovulation, has been suggested to be expressed prematurely in the ovarian follicles of women with PCOS. This study aimed to analyse the expression and activity of LHCGR in ovarian granulosa cells from PCOS patients and the involvement of ARF6 small GTPase in LHCGR internalization. Granulosa cells (GC) isolated from follicular fluid collected during oocyte retrieval from normal women (n = 19) and women with PCOS (n = 17) were used to study differences in LHCGR protein expression and activity between normal and PCOS patients. LHCGR expression is up-regulated in GC from PCOS women. LHCGR in PCOS GC is functionally active, as shown by increased cAMP production upon human gonadotrophin (HCG)-stimulation. Moreover, ARF6 is highly expressed in GC from PCOS patients and HCG-stimulation increases the concentrations of active ARF6. The inhibition of ARF6 activation attenuates HCG-induced LHCGR internalization in both normal and PCOS GC, indicating that there are no alterations in LHCGR internalisation in GC from PCOS. In conclusion, the expression and activation of LHCGR and ARF6 are up-regulated in GC from PCOS women but the mechanism of agonist-induced LHCGR internalization is unaltered.

Successful Pregnancy and Live Birth from Oocytes Retrieved After 50 Hours of Human Chorionic Gonadotropin Injection: A Case Report.

BACKGROUND: The timing of human chorionic goadotropin (hCG) injection and oocyte retrieval in women undergoing in vitro fertilization and intracytoplasmic sperm injection is crucial. If not properly timed, premature spontaneous luteinizing hormone surge or even premature ovulation may lead to cancellation of the treatment cycle. Commonly, oocyte retrieval is planned 32-36 hours after hCG injection. This time interval is of relevance because a number of essential processes, including the start of luteinization and resumption of the reduction division of the oocytes, should be well established before oocyte retrieval. CASE: We present a rare case in which, due to patient misunderstanding of timing of hCG injection, oocytes were retrieved 50 hours after hCG injection. On the morning of the oocyte retrieval at 08.00 hours it became apparent that, by mistake, the patient had taken the hCG injection at 09.15 hours rather than at 21.15 hours, 12 hours earlier than advised. It was therefore already 48 hours post-hCG injection. Nineteen good- quality, mature oocytes were retrieved, resulting in 11 good-quality embryos. A single expanded blastocyst was transferred, resulting in pregnancy and delivery of a healthy female infant. CONCLUSION: This is the first reported case of successful pregnancy after oocyte retrieval 5o hours after hCG injection. This case could be a stimulus for others to conduct further studies of prolonged exposure of hCG to oocyte retrieval to show the improved outcome of assisted reproduction treatment.

The relationship between serum Chlamydia antibody levels and severity of disease in infertile women with tubal damage.

BACKGROUND: The study explores the relationship between serum Chlamydia antibody titres (CAT) using the whole-cell inclusion immunofluorescence (WIF) test and severity of tubal damage in infertile women undergoing laparoscopy. METHODS: Comparisons between the extent of specific lesions, including their severity found at laparoscopy, and CAT levels were analysed in 408 infertile women with tubal damage. CAT levels were assayed using the WIF test. RESULTS: There were significant differences in the severity of individual lesions (tubal occlusion, tubal pathology, fimbrial state, extent and type of tubal and ovarian adhesions, type of tubal and ovarian adhesions) for both left and right adnexa in relation to CAT (P < 0.0001). The presence and severity of lesions found in one adnexum significantly correlated with the findings on the contra-lateral side (r > 0.5; P < 0.01). The American Fertility Society grades for tubal occlusion and adhesions in the right adnexum did not correlate with CAT. CONCLUSIONS: CAT levels are quantitatively related to the severity of tubal damage in infertile women. Wide variations in the severity of lesions observed in relation to CAT were suggestive of broad individual differences in response to chlamydial infection.

Significance of positive Chlamydia serology in women with normal-looking Fallopian tubes.

Chlamydia trachomatis poses a potential threat to the fertility of women by causing tubal damage. Many women with serological evidence of past Chlamydia infection have normal tubal appearances on laparoscopic assessment. The aim of this study was to assess if serological evidence of past chlamydial infection affects the likelihood of conception in women with normal tubes. Infertile couples in which the female partner was under the age of 40 years, with normal ovulatory function and a male partner with normal sperm function were studied. All women had normal tubes as assessed by laparoscopy. Serum Chlamydia antibody titres were assayed using the immunofluorescence test. Pregnancy rates were related to grouped Chlamydia antibody titres (<64, 64-256 and > or =512). A total of 174 women were studied. The cumulative pregnancy rates (SE) according to these titres were 45.1% (6.2), 42.6% (9.3), 59.1% (11.8) and the risk ratios (95% confidence interval) were 1, 1.59 (0.82-3.07) and 1.04 (0.52-2.08) respectively. The differences were not statistically significant. Therefore, in women with normal-looking tubes, serological evidence of past chlamydial infection does not appear to have an adverse effect on pregnancy rates. These findings suggest that laparoscopic findings and not Chlamydia serological titres are the key to prognosis.

The effect of early coasting on blastocyst development and outcome following blastocyst transfer in IVF/ICSI programme.

OBJECTIVE: Coasting is a well-known strategy to decrease severity of Ovarian Hyperstimulation Syndrome (OHSS). The purpose of this study is to assess the effect of Coasting on blastocyst development and subsequent clinical outcome following exclusive blastocyst transfer. METHODS: We conducted an observational cohort study of patients having blastocyst transfer following IVF/ICSI treatment. Patients undergoing IVF/ICSI cycles were included in the study. Patients at risk of OHSS were coasted. Outcome following exclusive blastocyst transfer was compared between coasted and non-coasted groups. The main outcome measures were the rate of blastocyst development and live birth rates in coasted and non-coasted cycles. Within coasted cycles, outcome was further analysed based on coasting duration and serum estradiol (E2) drop (difference between peak E2 and E2 on day of HCG). RESULTS: A total of 166 coasted cycles and 656 non-coasted cycles had blastocyst transfer. Blastocyst development (45.97% vs. 48.6%) and live birth rates (45.18% vs. 43.44%) were not significantly different between coasted and non-coasted cycles. The overall clinical pregnancy (54.21% vs. 49.08%) and implantation rates (43.95% vs. 39.54%) following blastocyst transfer in coasted cycles were not significantly different from those of non-coasted cycles. CONCLUSION: Coasting duration up to 6 days and drop in serum E2 levels did not compromise blastocyst development, implantation, clinical pregnancy or live birth rates. We conclude that coasting with subsequent blastocyst transfer can be used as an effective strategy in patients at risk of OHSS with no detrimental effects on blastocyst development or live birth outcome.

Cohort study of perinatal outcomes of children born following surgical sperm recovery.

There is a relative paucity of data on perinatal outcomes following Intracytoplasmic Sperm Injection using surgically retrieved sperm. In this retrospective cohort study, data were collected on couples who conceived following Intracytoplasmic Sperm Injection using surgically retrieved sperm from 1996 to 2014. Outcome measures included live birth, miscarriage, congenital abnormality, birthweight, gestation at delivery, stillbirth and neonatal death. Outcome measures were compared according to male diagnosis and sperm source. Live birth rates were similar between groups (obstructive azoospermia 90%, non-obstructive azoospermia 83%, p = 0.55). There was a trend towards higher miscarriage rates in the non-obstructive azoospermia group (17% versus 9%, p = 0.45). Other perinatal outcomes were similar between groups. In those with obstructive azoospermia, live birth rates were similar regardless of source of sperm (epididymal 89%, testicular 91%, p = 0.79). Median gestation at delivery was earlier in the epididymal sperm group (39 weeks versus 40 weeks, p = 0.02). Other perinatal outcomes were unaffected by sperm source. Overall these results are reassuring, suggesting high live birth rates regardless of diagnosis or sperm source, although there may be higher miscarriage rates in cases of non-obstructive azoospermia. Other perinatal outcomes were not affected by diagnosis or sperm source.

Assisted conception in the azoospermic male.

The advent of intracytoplasmic sperm injection (ICSI) has offered new solutions for the management of patients with azoospermia. Surgical sperm recovery combined with ICSI has allowed many men with azoospermia to father their own biological children. Azoospermia can be classified as obstructive and non-obstructive, with investigations, management and success rates varying markedly between the two forms. In certain cases of obstructive azoospermia surgical reconstruction remains a viable option, whereas cases with congenital obstruction need to be screened for mutations of the cystic fibrosis gene. In most cases of obstruction sperm can be retrieved from the epididymis using percutaneous epididymal sperm aspiration (PESA). If PESA is unsuccessful, testicular sperm extraction (TESE) is successful in all cases. With non-obstructive azoospermia, the genetic basis has been investigated intensely. Screening for karyotypic abnormalities as well as Y microdeletions is recommended. Irrespective of the histological diagnosis, focal spermatogenesis can be observed in 40-50% of cases using multiple testicular biopsies.

A systematic review of psychosocial factors associated with emotional adjustment in in vitro fertilization patients.

BACKGROUND: IVF treatment is usually stressful for patients, but individual differences in emotional response do exist. Differences in the stress response may be related to reproductive outcomes as well as to the development of psychiatric problems. This review collates research exploring which psychosocial factors (e.g. personality traits and coping strategies) are associated with the emotional adjustment of IVF patients. The aim is to reveal what is currently known about risk and protective factors for coping with the stress of IVF treatment and where further enquiry would be most beneficial. METHODS: The databases, MEDLINE/PUBMED (US National Library of Medicine), PsycINFO (American Psychological Association), Web of Science (Social Sciences Citation Index) and EMbase, were searched from 1978 to September 2012 using relevant key words. All published peer-reviewed studies exploring associations between psychosocial factors and emotional adjustment outcomes were considered for inclusion. RESULTS: There were 23 studies identified for review. One-third of the psychosocial factors explored were found to be significantly related to emotional adjustment outcome measures. Neuroticism and the use of escapist coping strategies were positively associated with distress by multiple studies. Social support was negatively associated with distress by several studies. A number of other psychosocial variables appear to be associated with distress, including self-criticism, dependency, situation appraisals and attachment style, but these have only been explored by one or two studies at most. There is a paucity of research using positive emotional outcome measures (e.g. well-being, positive affect, happiness or life satisfaction) to quantify emotional adjustment. CONCLUSIONS: Whilst some psychosocial variables appear to be consistently associated with distress for IVF patients, two-thirds of the variables tested to date do not appear to be associated with emotional adjustment. This review highlights key psychosocial factors to assist the identification of patients at high risk of psychological distress. These findings highlight at least two psychological factors that may be amenable to alteration with psychological or educational interventions. Future work should explore whether experimental manipulation of such psychosocial factors can provide effective stress reduction in this clinical context.

Discrepancies between Antimullerian Hormone and Follicle Stimulating Hormone in Assisted Reproduction.

Data from 107 women undergoing their first IVF/ICSI were analyzed. Relationships between antimullerian hormone (AMH) and follicle stimulating hormone (FSH) were analyzed after dividing patients into four groups according to AMH/FSH levels. Concordance was noted in 57% of women (both AMH/FSH either normal or abnormal) while 43%of women had discordant values (AMH/FSH one hormone normal and the other abnormal). Group 1 (AMH and FSH in normal range) and group 2 (normal AMH and high FSH) were younger compared to group 3 (low AMH and normal FSH) and group 4 (both AMH/FSH abnormal). Group 1 showing the best oocyte yield was compared to the remaining three groups. Groups 3 and 4 required higher dose of gonadotrophins for controlled ovarian hyperstimulation showing their low ovarian reserve. There was no difference in cycle cancellation, clinical pregnancy, and live birth/ongoing pregnancy rate in all groups. These tests are useful to predict ovarian response but whether AMH is a substantially better predictor is not yet established.

Prediction of ovarian hyperstimulation syndrome in coasted patients in an IVF/ICSI program.

AIM: To determine why a subgroup of coasted patients developed moderate/severe ovarian hyperstimulation syndrome (OHSS) in an assisted reproduction setting. MATERIALS AND METHODS: Retrospective study of 2948 in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment cycles with 327 patients requiring coasting. Long protocol gonadotrophin releasing hormone analogue (GnRH-a) regimen was used and serum estradiol (E(2)) checked when ≥20 follicles were noted on follicular tracking. Coasting was initiated when leading three follicles were ≥15mm with E(2) ≥1635pg/ml. RESULTS: The incidence of moderate/severe OHSS was 10.4% in coasted patients (equivalent 1.15% of the total IVF/ICSI cycles in the Center). Coasted patients who subsequently developed OHSS showed a significantly higher number of retrieved oocytes, higher serum E(2) level on the day of human chorionic gonadotrophin (hCG) administration, and multiple pregnancies. No significant differences were noted with female age, BMI, cause of infertility, gonadotrophin dosage, coasting duration, and % of E(2) drop. CONCLUSION: Moderate/severe OHSS might be predicted in coasted patients by a combination of total oocyte numbers and E(2) level on the day of hCG. Multiple pregnancies also significantly increased the risk.