Efficacy of MLPA for detection of Y-chromosome microdeletions in infertile Brazilian patients.

PURPOSE: Worldwide publications follow the gold standard method-the polymerase chain reaction (PCR)-for detecting Y-chromosome microdeletions; however, markers are frequently variable between the studies. Can we detect the deletions by another molecular method with more genomic coverage? The Y chromosome harbors several different genes responsible for testicular development and spermatogenesis, and its repetitive conformation predisposes it to complex rearrangements that have clinical impact. Our aim was to evaluate a molecular diagnostic method, the Multiplex Ligand Probe-dependent Amplification (MLPA), which is also a valuable ancillary method for the identification of deletions, duplications, and rearrangements in a single and faster reaction, leading to a better comprehension of patients' phenotypes, and should be considered a useful tool for detection of Y chromosome deletions. METHODS: This is a study of diagnostic accuracy (transversal prospective study) conducted to investigate Y-chromosome deletions in 84 individuals through PCR and MLPA methods. Forty-three infertile men (azoospermic and oligozoospermic) and 41 controls (40 fertile men and 1 normal karyotyped woman) were analyzed by PCR and MLPA techniques. RESULTS: We diagnosed seven (7) deletions (16.2%) by PCR and 9 with MLPA (21%). In addition, we found five (5) duplications and a suggestive mosaic. CONCLUSION: Our results demonstrate that MLPA technique is valuable in the investigation of microdeletions and microduplications. Besides deletions, duplications can cause instability of chromosome genes, possibly leading to infertility. Both studied techniques provide an advantageous diagnostic strategy, thus enabling a better genetic counseling.

Ovarian reserve in women with primary antiphospholipid syndrome.

OBJECTIVE: The objective of this paper is to evaluate ovarian reserve in primary antiphospholipid syndrome (PAPS) women and the association between ovarian reserve tests and clinical and laboratorial parameters, and anti-corpus luteum antibody (anti-CoL). METHODS: We screened 85 female patients between 18 to 40 years old with APS. Of these, 67 patients were excluded because of association with other autoimmune diseases (n = 42), contraindication or unwillingness to stop hormonal contraceptive (n = 21), current pregnancy or breastfeeding (n = 3) and previous ovarian surgery (n = 1). Therefore, a cross-sectional study was conducted in 18 PAPS patients and 24 healthy women. They were evaluated at early follicular phase with measurement of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and anti-Müllerian hormone (AMH) and sonographic antral follicle count (AFC). Serum measurement of anti-CoL was determined by immunoblot analysis. All analyses were performed after at least six months from the last intake of hormonal contraceptive and resumption of menstruation. RESULTS: The mean age was comparable in PAPS and controls (33.0 ± 5.0 vs. 30.4 ± 7.0 years; p = 0.19). Regarding ovarian reserve tests, the frequencies of low AFC (≤10) (56% vs. 22%, p = 0.04) and very low AFC (≤5) (37% vs. 9%, p = 0.04) were significantly higher in PAPS patients than controls. Trends of higher frequencies of reduced (<1.0 ng/ml), low (<0.5 ng/ml) and negligible (<0.2 ng/ml) AMH levels were found in PAPS patients (p = 0.08, p = 0.07 and p = 0.07, respectively). FSH, LH and estradiol were similar in patients and controls. There was no association between low ovarian reserve and specific types of antiphospholipid antibodies. Anti-CoL was solely observed in PAPS patients (11% vs. 0%; p = 0.177) and was not related to ovarian reserve tests. CONCLUSION: Women suffering from PAPS possessed reduced ovarian reserve, with prevalence greater than 50%.

Production of 3 alpha-androstanediol glucuronide in human genital skin.

3 alpha-Androstanediol glucuronide (3 alpha diol-G) is produced extrasplanchnically and is a good clinical marker of androgen action in peripheral tissues. However, the direct formation of androgen glucuronides in peripheral sites such as skin has not been determined in man. Genital skin from 21 premenopausal women and 8 men and foreskin from 6 neonates were incubated with either [14C]testosterone [14C]dihydrotestosterone (DHT) to determine the production of DHT glucuronide and 3 alpha diol-G in skin. After hydrolysis of incubation medium with glucuronidase, followed by extraction and sequential chromatography, constant 3H to 14C ratios of 3 alpha diol confirmed the production of DHT glucuronide and 3 alpha diol-g. The conversion of DHT to 3 alpha diol-G was higher than the conversion from testosterone (P less than 0.05), and conversion was higher in men than in women. These data provide evidence for the direct formation of C19 steroid glucuronides by human skin.

Methods used to improve gamete efficiency.

Male factor infertility accounts for a significant percentage of problems in infertile couples. With clinical utilization of the technologies for selection of good-quality spermatozoa from the ejaculate, our ability to successfully treat the severely affected male factor couple has improved. However, it must be remembered that even with current technologies, fertilization success is reduced in these patients but remains above a 50% level. Other factors that can be used in the future to improve on these statistics are being investigated in regard to the in vitro environment for gametes, that is, the type of culture medium, the methods of coincubation of the sperm and egg, and other methods of enhancement of sperm fertilizing potential. However, methods of sperm preparation will achieve improvement in a percentage of these males treated, and can be used to improve fertilization and pregnancy success. It is important to understand the limitations of the zona-free hamster test, but it is also important to use that test as a screening method for sperm handling. By utilizing the SPA to select out the optimal method of sperm preparation, the fertilization and pregnancy outcome can be improved. Overall, the live-birth rate in male factor infertile couples is lower than non-male-factor couples treated by IVF and GIFT. Until more is known about basic spermatozoal function, and the ability to improve that function in affected males, the live-birth rate should not be expected to change substantially.

Gonadotropin and estradiol levels during ovarian stimulation in women treated with leuprolide acetate.

Levels of FSH, LH, and estradiol (E2) were measured in the serum of 209 gonadotropin-releasing hormone analogue-treated women and in 202 control subjects during the final 5 days of ovarian stimulation in our in vitro fertilization program. Levels of FSH and E2 in serum of gonadotropin-releasing hormone analogue-treated subjects significantly exceeded control values during the sampling period, whereas LH levels were significantly lower. Concentrations of E2 in serum of gonadotropin-releasing hormone analogue-treated and control subjects were similar when corrected for differences in numbers of follicles aspirated at oocyte retrieval (mean of 8.9 and 7.2 follicles per subject, respectively). Pregnancy rates by diagnostic ultrasound were 18 and 11%, respectively, a statistically significant difference.

Cryopreservation of human spermatozoa: correlations of ultrastructural sperm head configuration with sperm motility and ability to penetrate zona-free hamster ova.

Freezing and storage of human male gametes is associated with a reduction in the overall semen quality and establishment of pregnancy. This study was done to evaluate the integrity of sperm head ultrastructure (SHU) with computerized and vapor freezing. Comparisons were made between the effect of cryopreservatives glycerol (G) and dimethylsulfoxide (DMSO) on SHU. Twelve ejaculates from five proven fertile donors were studied with the use of routine semen analysis, zona-free hamster ova, and SHU. Both cooling processes, regardless of the preservative used, significantly reduced sperm function and the number of SH with intact plasma membranes. The staged cooling technique was substantially superior to vapor freezing in all parameters analyzed (P less than 0.01). G was less detrimental to the postthaw SHU than 1 M DMSO. A significant positive correlation (r = 0.98; P less than 0.01) was noted between the total number of intact SH and motile sperm. Computerized freezing in a G-diluted semen rendered a sperm environment that allowed the highest number of forms with intact SH membranes and with the best chances to penetrate zona-free hamster ova.

Measurements of 3 alpha,17 beta-androstanediol glucuronide in serum and urine and the correlation with skin 5 alpha-reductase activity.

Serum and urinary measurements of 3 alpha,17 beta-androstanediol glucuronide (3 alpha-diol G) reflect peripheral androgen action and have been useful clinically. This study was designed to compare these levels in hirsute women, normal premenopausal and postmenopausal women, and in men and to correlate each measurement with skin 5 alpha-reductase activity (5 alpha-RA), an excellent correlate of androgenicity. Although serum 3 alpha-diol G values were similar in premenopausal and postmenopausal women, values were higher in hirsute women and in men. This pattern was similar for urinary 3 alpha-diol G but with greater overlap in values between hirsute and nonhirsute women and men. Serum 3 alpha-diol G showed a highly significant correlation with levels of genital 5 alpha-RA (r = 0.839, P less than 0.001), whereas urinary 3 alpha-diol G did not correlate. Serum and urinary 3 alpha-diol G also did not correlate with one another (r = 0.03). These data suggest that while both serum and urinary 3 alpha-diol G may be useful clinically, serum 3 alpha-diol G appears to correlate better with androgenicity and 5 alpha-RA. It is suggested further that the sources of serum and urinary 3 alpha-diol G may be somewhat different.

High implantation and pregnancy rates with transfer of human blastocysts developed in preimplantation stage one and blastocyst media.

OBJECTIVE: To evaluate the proficiency of preimplantation stage one (P1) and blastocyst media in supporting human blastocyst development and to document implantation and clinical pregnancy rates from the transfer of the normally developed blastocysts. DESIGN: Retrospective clinical study. SETTING: Private IVF unit of a university-affiliated center. PATIENT(S): Twenty-eight women aged 33.7 +/- 2.9 years who underwent IVF treatment for infertility. INTERVENTION(S): Bipronucleate oocytes obtained from IVF and intracytoplasmic sperm injection were cultured in vitro with P1 and blastocyst media for 96-120 hours. One to three embryos were transferred (2.1 +/- 0.2 for the patients who became pregnant and 1.5 +/- 0.3 for those who did not become pregnant). MAIN OUTCOME MEASURE(S): Total number and percentage of developed blastocysts, frequency of blastocysts of grades A and B, and implantation and pregnancy rates. RESULT(S): From 431 oocytes retrieved, 269 bipronucleate oocytes were cultured, producing 81 blastocysts that resulted in the transfer of 54 embryos in 27 procedures. Blastocysts developed in 39.7% +/- 5.5% of the pregnant group and 30.2% +/- 4.5% of the nonpregnant group. From 15 (15/27 = 55.6%) clinical pregnancies, 18 (18/54 = 33.3%) gestational sacs were visualized. The rate of implantation in the pregnant group was 58.1% (18/31). CONCLUSION(S): These results provide evidence for the benefits of extending human embryo culture with P1 and blastocyst media for all normally fertilized embryos in vitro.

Premature luteinizing hormone surges in menopausal gonadotropin-stimulated cycles in monkeys: lack of initiation by progesterone.

The occurrence of spontaneous luteinizing hormone (LH) surges in women receiving human menopausal gonadotropins (hMG) for in vitro fertilization-embryo transfer is a significant clinical problem. One hypothetical mechanism is that premature progesterone (P) secretion occurring in the high estradiol (E2) milieu produced by hMG triggers the spontaneous LH surge. To investigate this possibility, 11 rhesus and cynomolgus monkeys were stimulated with hMG. At maximal ovarian stimulation, monkeys were injected with 15 micrograms/kg P (n = 3), 30 micrograms/kg P (n = 3), or 1,000 IU human chorionic gonadotropin (hCG) (n = 5; controls). Blood for E2, P, and LH was drawn twice daily in the periovulatory period and daily before and after this period. Laparoscopy was performed after P or hCG injection. In the 6 monkeys receiving P, no LH surges were detected. Further, postinjection P profiles and laparoscopy showed no evidence of ovulation. Controls demonstrated laparoscopic and hormonal evidence of ovulation. These findings suggest that P does not trigger LH surges in hMG-stimulated cycles.

Levels of steroid and protein hormones in antral fluids of women treated with different combinations of gonadotropins, clomiphene citrate, and a gonadotropin-releasing hormone analog.

Levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, progesterone (P), and total protein in follicular fluids collected from 18 patients pretreated with a gonadotropin-releasing hormone analog (GnRHa), in association with human menopausal gonadotropin (hMG) and FSH, were compared with values for 69 patients treated with FSH, hMG, FSH/hMG, or clomiphene citrate (CC)/hMG in an in vitro fertilization (IVF) program. The authors have established a number of significant differences in chemical and physical properties of follicular fluids of patients treated by different regimen, and concur with earlier evidence that the volume of a follicle, and its P and total protein content, are related to the maturity of the oocyte nested within the follicle. Overall, however, differences in concentrations of gonadotropins in follicular fluids between groups were not consistent with differences in follicular fluid steroid levels, and levels of immunoactive gonadotropins in follicular fluids were not in accord with dosages of exogenous immunoactive gonadotropin administered during hyperstimulation. The most favorable outcomes of IVF (greater than 70% of oocytes fertilized) were established with oocytes collected from patients treated with FSH only or with CC/hMG, and patients treated with FSH only yielded the highest average number of oocytes which fertilized in vitro (6.2 per patient).

Interrelationships between plasma hormone levels and the content of total protein, gonadotropins and steroid hormones in antral fluids of women undergoing in vitro fertilization.

Follicle development was induced in 41 women with follicle-stimulating hormone (FSH) and human menopausal gonadotropin. Blood samples were drawn and follicular fluids (FF) were aspirated when two or more follicles attained diameters of 15 to 17 mm. Levels of estradiol (E2), progesterone (P), FSH, and luteinizing hormone (LH) were determined in samples by radioimmunoassay, and relationships between the measured parameters in antral fluids and in serum were examined by least-squares linear regression analysis. Levels of LH in serum correlated with LH and FSH levels in FF (P less than 0.005). Concentrations of FSH in serum were positively related to levels of LH, FSH, E2, and total protein in FF (P less than 0.005). E2 levels in serum were predictive of E2 levels in FF only, and levels of P in serum were directly correlated with P levels in FF (P less than 0.05). With respect to the peculiarly broad range of predictions that could be drawn from the FSH content of serum, peripheral FSH provided a better predictive index of the chemical composition of antral fluid than did the level of any other single hormone measured in serum.

The effect of spironolactone on genital skin 5 alpha-reductase activity.

The effect of spironolactone (S) on genital skin 5 alpha-reductase activity (5 alpha-RA) of hirsute women (HW) in vivo as well as in normal genital skin in vitro was evaluated. Thirteen HW (Ferriman-Gallwey score of 23.3 +/- 2.8) received S 100 mg twice a day for a month. Twenty-three non-hirsute women were selected as controls for the assessment of genital skin 5 alpha-RA. S was added to incubations of genital skin from 9 additional controls in vitro in concentrations from 1.2 X 10(-8) to 10(-5) M. HW had significantly higher conversion ratios (CR) of T to DHT compared to controls (P less than 0.05). Post treatment values for the CR T to DHT were significantly lower than prior to S (17.5 +/- 1.7 and 8.05 +/- 1.2%, P less than 0.05) and the mass of DHT produced also decreased by 37 +/- 9% (P less than 0.05). The CR T to 3 alpha-diol decreased by 30 +/- 9% (P less than 0.05). In 11 of 13 women, a significant reduction of 5 alpha-RA was demonstrated while in 2 patients the activity remained unchanged. The maximum in vitro inhibitory effect of S on the CR T to DHT occurred with a concentration of 1.2 X 10(-5) M (P less than 0.01). In conclusion, S has a direct inhibitory effect on 5 alpha-RA. The beneficial effect of S treatment in HW may be related, in part, to this inhibition of 5 alpha-RA.

Sites of paradoxical action of the LHRH agonist (D-Trp6)-LHRH.

Immature intact and hypophysectomized female rats, which were primed with gonadotropin, were injected subcutaneously with 0.9% saline or 0.2 or 2 microgram of (D-Trp6)-LHRH once daily for 7 days. Ovarian LH/hCG receptors and ovarian weight were measured 24 hours after the last analog or saline injection. A significant reduction (P < 0.01) of ovarian LH/hCG receptors in both intact and hypophysectomized rats was observed following administration of (D-Trp6)-LHRH in doses as low as 0.2 microgram/day. A significant decrease was observed in the ovarian weight of 2 microgram-treated rats (P < 0.05). The dramatic loss of ovarian LH/hCG receptors in hypophysectomized rats induced by (D-Trp6)-LHRH may indicate that the analog has a direct effect on the ovaries.

Chromosomal analysis of pregnancy losses in patients undergoing assisted reproduction.

Chromosomal analysis was performed on products of conception from 18 patients having early pregnancy loss after assisted reproduction. Sonographic findings prior to obtaining tissue varied from gestational sacs consistent with a blighted ovum to fetal poles with cardiac activity. The mean age of the patients was 36.3 years. There were nine (50%) normal karyotypes, five (28%) autosomal trisomies, two cases of tetraploidy, one case of monosomy, and a case with two pericentric inversions. The results of this study suggest that patients undergoing assisted reproduction are not at an increased risk for chromosomal abnormalities.

Detection and management of pathological, non-palpable, cystic adnexal masses.

Ten patients with normal bimanual pelvic examinations were found to have small, non-palpable adnexal cysts by transvaginal ultrasound examination. After failing to respond to a course of observation and suppressive therapy with combination oral contraceptives, surgical evaluation was performed. In each case, histological examination returned a pathological diagnosis (endometrioma, serous cystadenoma, mature cystic teratoma, inflammatory cyst). This series suggests that transvaginal ultrasonography may be used to detect adnexal pathology before it is clinically apparent. A scheme for management of this clinical entity is proposed.

PIP: 10 women being evaluated for infertility by intravaginal ultrasonography had small, non-palpable cystic adnexal masses, which after conservative management proved pathological. The women ranged from 22-35 years old, with infertility of 1-4 years' duration. The ultrasound exams were performed with the ADR 4000 or Ultramark IV with 3.5 mHz vaginal probe. Women were re-examined with ultrasound after 1 month's observation, then after each of 3 cycles of treatment with either Ortho-Novum 1/35 (norethindrone 1 mg, ethinyl estradiol 35 mcg) or Ovral (norgestrel 0.5 mg, ethinyl estradiol 50 mcg) combined oral contraceptives. After this period of suppression, 6 of the masses had grown, 3 were unchanged, and 1 was slightly smaller. After diagnostic laparoscopy and laparotomy, there were no functional cysts, but 6 endometriomas, 2 serous cystadenomas, 1 inflammatory cyst, and 1 mature cystic teratoma. This preliminary series suggests that small cysts seen on vaginal ultrasound be followed with observation, then with suppression for at least 2 cycles of combines, not triphasic, oral contraceptives. The prevalence of non-palpable pathologic cysts needs to be determined.