DNA fragmentation of sperm: a radical examination of the contribution of oxidative stress and age in 16 945 semen samples.

STUDY QUESTION: What is the relationship between sperm DNA fragmentation and oxidative stress (OS) with increasing male age? SUMMARY ANSWER: Sperm DNA fragmentation increases with age and is likely related to both defective spermatogenesis and increasing OS levels. WHAT IS KNOWN ALREADY: Sperm quality declines with age. The presence of DNA damage in a high fraction of spermatozoa from a raw semen sample is associated with lower male fertility in natural conception and intrauterine insemination. STUDY DESIGN, SIZE, DURATION: A retrospective cohort study of 16 945 semen samples analysed at a single reference laboratory between January 2010 and December 2018. PARTICIPANTS/MATERIALS, SETTING, METHODS: All males were undergoing an infertility evaluation. The cohort was divided into seven age categories: <30, 30-34, 35-39, 40-44, 45-49, 50 to <54 and ≥55 years. The mean age was 37.6 years (SD 6.8). Sperm DNA fragmentation index (DFI) and high DNA stainability (HDS) were calculated using flow cytometry. OS levels were measured using the oxidative stress adducts (OSA) test, by spectrophotometry. ANOVA with weighted polynomial contrast analysis was used to evaluate trends for DFI, OSA and HDS values across age categories. MAIN RESULTS AND THE ROLE OF CHANCE: Mean DFI significantly increased across all age groups (Ptrend < 0.001). OSA was lowest in patients <30 years old (mean 3.6, SD 1.0) and also increased as age increased (Ptrend < 0.001). There was a statistically significant difference between age groups for each of the three parameters (P < 0.001). There was a significant linear trend for DFI, OSA and HDS across the seven age categories (P < 0.001). Among patients with high DFI, there was a decreasing age-dependent trend in the patients observed with high OSA (P < 0.001). LIMITATIONS, REASONS FOR CAUTION: This is a retrospective study. All males included in the study were undergoing a work-up for infertility and may not be representative of a fertile population. Additional patient demographics and clinical data were not available. WIDER IMPLICATIONS OF THE FINDINGS: DNA and/or oxidative damage in sperm may be just as important to understand as the chromosomal aberrations that are carried in the oocyte. Further studies are needed to evaluate the effect of advancing paternal age on the male genome and, ultimately, on the health of the offspring. STUDY FUNDING/COMPETING INTEREST(S): No funding was obtained for this study. V.D. is an employee of Reprosource/Quest Diagnostics. D.S. reports he was a Scientific Advisor to Cooper Surgical. TRIAL REGISTRATION NUMBER: N/A.

Non-invasive imaging of mouse embryo metabolism in response to induced hypoxia.

PURPOSE: This study used noninvasive, fluorescence lifetime imaging microscopy (FLIM)-based imaging of NADH and FAD to characterize the metabolic response of mouse embryos to short-term oxygen deprivation. We investigated the response to hypoxia at various preimplantation stages. METHODS: Mouse oocytes and embryos were exposed to transient hypoxia by dropping the oxygen concentration in media from 5-0% over the course of ~1.5 h, then 5% O2 was restored. During this time, FLIM-based metabolic imaging measurements of oocyte/embryo cohorts were taken every 3 minutes. Experiments were performed in triplicate for oocytes and embryos at the 1- to 8-cell, morula, and blastocyst stages. Maximum hypoxia response for each of eight measured quantitative FLIM parameters was taken from the time points immediately before oxygen restoration. RESULTS: Metabolic profiles showed significant changes in response to hypoxia for all stages of embryo development. The response of the eight measured FLIM parameters to hypoxia was highly stage-dependent. Of the eight FLIM parameters measured, NADH and FAD intensity showed the most dramatic metabolic responses in early developmental stages. At later stages, however, other parameters, such as NADH fraction engaged and FAD lifetimes, showed greater changes. Metabolic parameter values generally returned to baseline with the restoration of 5% oxygen. CONCLUSIONS: Quantitative FLIM-based metabolic imaging was highly sensitive to metabolic changes induced by hypoxia. Metabolic response profiles to oxygen deprivation were distinct at different stages, reflecting differences in metabolic plasticity as preimplantation embryos develop.

In vitro fertilization in women under 35: counseling should differ by age.

PURPOSE: The aim of this study is to evaluate the outcomes of in vitro fertilization (IVF), including cumulative live birth rate, among women <25 years, 25 to <30 years, and 30 to <35 years. METHODS: A retrospective cohort study of all women 18 to <35 years of age at their first fresh-embryo, non-donor IVF cycle from January 1995 through December 2012 at a single center was conducted. A competing-risk regression model was used to estimate the cumulative probability and 95 % confidence interval (CI) of the first live birth in up to 6 cycles during the study period with IVF cycle number as the time metric. RESULTS: Among 7243 women who underwent 16,792 cycles, there were 163 (2.3 %) women <25 years, 1691 (23.3 %) women 25 to <30 years, and 5389 (74.4 %) women 30 to <35 years. Women <25 years had the lowest cumulative live birth rate after each cycle, followed by women 30 to <35 years. In both groups, the cumulative live birth rate after 6 cycles was significantly lower than that of women 25 to <30 years; these rates were 58 % (95 % CI 0.51-0.66) among women <25 years, 69 % (95 % CI 0.67-0.71) among women 25 to <30 years, and 64 % (95 % CI 0.63-0.65) among women 30 to <35 years. CONCLUSIONS: Our findings are consistent with other reports of less favorable IVF treatment outcomes in women <25 years of age following their first IVF cycle. This indicates that there are underlying factors in couples with a female <25 years of age that should lead to different treatment counseling when they attempt IVF.

No evidence that embryo selection by near-infrared spectroscopy in addition to morphology is able to improve live birth rates: results from an individual patient data meta-analysis.

STUDY QUESTION: What is the value of embryo selection by metabolomic profiling of culture medium with near-infrared (NIR) spectroscopy as an adjunct to morphology, compared with embryo selection by morphology alone, based on an individual patient data meta-analysis (IPD MA)? SUMMARY ANSWER: The IPD MA indicates that the live birth rate after embryo selection by NIR spectroscopy and morphology is not significantly different compared with the live birth rate after embryo selection by morphology alone. WHAT IS KNOWN ALREADY: Retrospective proof of principle studies has consistently shown that high NIR viability scores are correlated with a high implantation potential of embryos. However, randomized controlled trials (RCTs) have generally shown no benefit of the NIR technology over embryo morphology, although there have been some conflicting results between pregnancy outcomes on different days of embryo transfer. STUDY DESIGN, SIZE, DURATION: This IPD MA included all existing RCTs (n = 4) in which embryo selection by morphology was compared with embryo selection by morphology and the use of NIR spectroscopy of spent embryo culture medium by the Viametrics-E(™). PARTICIPANTS/MATERIALS, SETTING, METHODS: Searches of PubMed, the Cochrane Library and the WHO International Clinical Trials Registry were conducted and the sole manufacturer of the Viametrics-E(™) was consulted to identify clinics where an RCT comparing embryo selection by morphology to embryo selection by morphology and the use of the Viametrics-E(™) (NIR viability score) was performed. A total of 20 citations were potentially eligible for inclusion, two of which met the inclusion criteria. The manufacturer of the Viametrics-E(™) provided two additional clinical sites of use. In total, four RCTs were identified as eligible for inclusion. The IPD MA was based on a fixed effect model due to the lack of heterogeneity between included studies. Differences between study groups were tested and reported using logistic regression models adjusted for significant confounders. The pooled analysis of the primary outcome led to a total sample size of 924 patients: 484 patients in the control group (embryo selection by morphology alone) and 440 patients in the treatment group (embryo selection by morphology plus NIR spectroscopy). MAIN RESULTS AND THE ROLE OF CHANCE: The live birth rates in the control group and the NIR group were 34.7% (168 of 484) and 33.2% (146 of 440), respectively. The pooled odds ratio (OR) was 0.98 [95% confidence interval (CI) 0.74-1.29], indicating no difference in live birth rates between the two study groups. The data of the four studies showed no significant heterogeneity (I(2) = 26.2% P = 0.26). The multivariate regression analysis including all confounders show that maternal age (OR 0.90, 95% CI 0.87-0.94) and the number of previous IVF cycles (OR 0.83, 95% CI 0.71-0.96) were significantly related to live birth. The study group (i.e. embryo selection by morphology or embryo selection by morphology plus NIR) was not related to live birth (OR 0.97, 95% CI 0.73-1.29). LIMITATIONS AND REASONS FOR CAUTION: The availability of at least two similar best quality embryos as an inclusion criterion prior to transfer in the two largest RCTs might have caused a selection bias towards a better prognosis patient group. WIDER IMPLICATIONS OF THE FINDINGS: There is at present no evidence that NIR spectroscopy of spent embryo culture media in its current form can be used in daily practice to improve live birth rates.

Fresh transfer outcome predicts the success of a subsequent frozen transfer utilizing blastocysts of the same cohort.

The objective of this retrospective analysis was to assess whether the outcomes of fresh blastocyst transfer cycles are predictive of the chances for pregnancy and live birth in subsequent frozen blastocyst transfer cycles using sibling embryos from the same retrieval. Clinical pregnancy rate (CPR) and live birth rate (LBR) per fresh and frozen blastocyst transfer were assessed. All subgroups had similar patient and cycle characteristics. Overall, CPR and LBR in fresh cycles were 44% and 29%, and in frozen were 34% and 30%, respectively. However, the CPR and LBR in frozen cycles were significantly higher in patients who were not pregnant with their fresh cycles (CPR 43% versus 22%, P=0.01; and LBR 36% versus 17%, P=0.03, respectively). When fresh cycles are unsuccessful, the remaining frozen blastocysts of the same cohort have the same chance of success in producing a clinical pregnancy as the fresh cycle (43% versus 44%). Frozen cycles following successful fresh cycles have significantly lower CPR and LBR. These data reinforce the concept that only a few embryos per cohort are competent for a live birth. During IVF cycles, many patients are fortunate enough to have excess high-quality embryos remaining after their embryo transfer. These embryos can be frozen, or cryopreserved, for later transfer. The transfer of cryopreserved embryos increases the cumulative success rates after a single IVF stimulation. Many studies have examined success rates such as clinical pregnancy rate and live birth rate in frozen embryo transfer cycles. While these frozen embryo transfer cycles have excellent success rates, they are significantly lower than success rates in cycles where a "fresh", non-frozen, embryo is transferred. Few studies have carefully examined the impact of the result of the fresh embryo transfer (whether the patient became pregnant or not) on subsequent frozen embryo transfer success. Here we show that women who are not pregnant after a fresh embryo transfer have higher success rates in subsequent frozen embryo transfer cycles that use frozen embryos generated during a single IVF cycle. In these women (not pregnant after a fresh embryo transfer), frozen embryo transfer pregnancy rates are the same as rates using fresh embryos.

Correlation between follicular diameters and flushing versus no flushing on oocyte maturity, fertilization rate and embryo quality.

OBJECTIVE: To determine (a) the correlation between follicular sizes, oocyte maturity, normal fertilization rate, cleavage and embryo quality; and (b) to establish whether oocytes recovered with or without follicular flushing have different developmental competence. DESIGN: Prospective observational study. SETTING: Academic medical center. PATIENTS: Forty nine cycles (37 ICSI and 12 IVF). INTERVENTIONS: Measurement of 360 follicular diameters on the day of egg retrieval and classification into three groups Group A (mean diameter 12-14.5 mm.), group B (mean diameter 15-18 mm.) and group C (diameter >18.5 mm.). MAIN OUTCOME MEASURE: Correlation between follicular size at the time of retrieval and oocyte maturity, fertilization and cleavage rate in 226 oocytes (163 ICSI and 63 IVF). Developmental competence of oocytes retrieved with flushing versus non flushing. RESULTS: Almost all (99 %) of the oocytes recovered from follicles of group C were in metaphase II as opposed to 80 % in group A and 81 % in group B (p < 0.01). Overall there was a progressive and significant increase in fertilization rates from group A follicles to group C (47 % vs. 67 %, p 0.05). Overall 53 % of oocytes retrieved from group A follicles showed either no fertilization or abnormal fertilization versus 27 % in group C (p 0.05). The oocyte recovery rate with follicular flushing improved from group A to group B and to group C follicles (65 % vs. 49 % vs.37 % respectively p < 0.01). There were no differences in rates of immature oocyte, fertilization, abnormal or not fertilization and cleavage. CONCLUSIONS: The results of this study shows that: a) Follicles larger than 18 mm at retrieval have consistently mature oocytes with a higher rate of fertilization; b) Small size follicles are still capable of containing mature oocytes, but their rate of abnormal or no fertilization is high; c) Oocytes recovered with flushing are still able to produce embryos with full developmental competence.

Non-invasive metabolomic profiling of Day 2 and 5 embryo culture medium: a prospective randomized trial.

BACKGROUND: Near infrared (NIR) spectroscopy is a technology proposed to facilitate non-invasive screening for the most optimal human embryo for uterine transfer. It has been proposed that the NIR spectral profile of an embryo's spent culture medium can be used to generate a viability score that correlates to implantation potential. As the initial proof of principle studies were all retrospective, our aim was to investigate whether NIR spectroscopy on spent embryo culture medium in an on-site, prospective setting could improve the ongoing single embryo transfer (SET) pregnancy rate after Day 2 and 5 transfers. METHODS: We conducted a single-centre, double-blinded, randomized controlled trial in which the NIR group was compared with a control group. The primary outcome was the clinical pregnancy rate after 6-7 weeks of gestation per randomized patient. In the control group embryo selection was based only on traditional morphological evaluation while in the treatment group NIR spectroscopy was added to the morphological evaluation. RESULTS: The study was terminated early as the analysis of the Data Safety Monitoring Board showed a very low conditional power of superiority for the primary outcome. Of the 752 patients calculated to be included in the study, 164 and 163 patients were randomized into the NIR and control groups, respectively. No significant difference in the ongoing pregnancy rate per randomized patient was found between the NIR and the control group, 34.8 versus 35.6%, (P= 0.97). The proportional difference between the study groups mean was -0.8% (95% confidence interval -11.4 to 10.2). CONCLUSIONS: This study shows that adding NIR spectroscopy, in its present form, to embryo morphology does not improve the chance of a viable pregnancy when performing SET. The NIR technology appears to need further development before it can be used as an objective marker of embryo viability. CLINICAL TRIALS IDENTIFIER: ISRCTN23817363.

Epidemiological factors influencing IVF outcome: Evidence from the Yale IVF program.

Age, BMI, lifestyle, menstrual status and obstetric history can modulate the endocrine system and, therefore, have been hypothesised to play a role in in-vitro fertilisation (IVF) outcome. We designed a retrospective study, set in a medical school hospital. We evaluated the medical files of 297 infertile women who underwent laparoscopy and consecutive IVF-ET treatment in the Yale IVF unit between 1996 and 2002. The study group consisted of 151 women who conceived after IVF-ET and the control group of 146 women who underwent 288 IVF-ET cycles without pregnancy. The main outcome measure was the impact of epidemiological factors on the IVF outcome. There was no association between IVF outcome and race, BMI, age at menarche, length of cycle, duration and amount of flow, menstrual symptoms, other medical problems, medical history of allergies, and family history of endometriosis and cancer. We found that the degree of smoking and alcohol use was not a factor when comparing women with and without pregnancy after IVF (34.5% vs 29.5%, and 33.7% vs 27%, respectively). The rate of duration of infertility tended to be lower in pregnant women (35.9+/-23.4 months) vs (42.3+/-30.2) non-pregnant women. As expected, we also confirmed the inverse association between the age of women and IVF outcome. Overall, body attributes, lifestyle, family history, menstrual and reproductive factors were not related to IVF-ET outcome.

Correlation between sonographic follow-up of follicular growth, serum and salivary estradiol in women undergoing controlled ovarian stimulation (IVF/ICSI).

AIM OF THE STUDY: Investigation of the correlation between serum estradiol (E2), salivary E2 and sonographic measurements of follicles in women undergoing controlled ovarian stimulation (COS) for IVF/ICSI. METHODS: This is a prospective study performed at the Department of Reproductive Medicine of Ghent University Hospital (Belgium) between November 2016 and January 2017 over a total of 40 patients. During routine COS, two-dimensional measurements of the follicles were performed using transvaginal ultrasound (TVUS) and E2 was measured in saliva and serum. A linear Mixed-Effects model (MIXED) was built, using SPSS Statistics 24. RESULTS: Statistical analysis shows a strong linear correlation between serum and salivary E2. For every single unit increase in serum E2 (+ 1 ng/L) the estimated saliva E2 concentration is expected to increase with 0.011 pg/mL (95% CI [0.009 - 0.01]). Strong linear correlations between both saliva and serum E2 and follicular dimensions were also found. For every millimetre increase in follicle diameter the estimated serum E2 concentration is expected to increase with 8.32 ng/L (95% CI [7, 10-9, 54]). For every millimetre increase in follicle diameter the estimated saliva level of E2 is expected to increase with 0.11 pg/mL (95% CI [0.09 - 0.13]). CONCLUSIONS: A strong correlation between serum and salivary E2 concentrations was found. In addition, both are strongly correlated with the product of the number of follicles and their average diameter, measured by TVUS. More investigation needs to be done to find out if salivary E2 is an effective tool for monitoring IVF cycles.

Avoiding hypoglycemia: the use of insulin pump combined with continuous glucose monitor in type 1 diabetes crossing a Rocky Gorge.

BACKGROUND: Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring systems (CGMS) have been proven very effective in diabetes management. AIM: This study evaluated the usefulness of these devices during prolonged, intense physical activity in an uncontrolled natural environment away from the clinical research center. DESIGN: Non-randomized, prospective and observational study. METHODS: During the summer, 38 participants with type 1 diabetes crossed the Samaria gorge, the second largest gorge in Europe (17 km). Twenty subjects on CSII combined with real-time CGMS and 18 on multiple daily injections (MDI) combined with professional (retrospective) CGMS participated in the program. All participants were unsupervised during the event. RESULTS: All 38 participants managed to reach the destination point safely. There were no episodes of severe hypoglycemia. The duration of the exercise (mean ±SD) was 6.4 ± 1.3 h. The CSII group exhibited significantly lower hypoglycemic episodes during exercise (0.1 ± 0.3 vs. 0.4 ± 0.6; P = 0.047) as well as lower AUC below 70 mg/dl compared with the MDI, during the 24 h (0.61 ± 0.78 vs. 1.84 ± 1.55; P = 0.007). Individuals on CSII were significantly less likely to develop a hypoglycemic episode during exercise (P = 0.038). Exercise induced nocturnal hypoglycemia was not prevented effectively in neither group. CONCLUSIONS: CSII combined with CGMS is effective in controlling blood glucose levels in type 1 diabetics who perform prolonged strenuous exercise. The use of insulin pump technology in regions with hot Mediterranean climates is safe and can provide protection against exercise-induced hypoglycemia. Development of precise instructions for T1DM who occasionally get involved in exercise activities, requires further studies.

High rate of biological loss in assisted reproduction: it is in the seed, not in the soil.

The vast majority of embryos produced in vitro and transferred fail to develop into an infant, supporting the concept that only a small fraction of embryos is destined to become a live birth. One of the main reasons for such a low embryo-to-infant ratio is the remarkably high number of embryos that after preimplantation genetic diagnosis are found to have a chromosome imbalance. This study reports the overall biological wastage from oocytes inseminated to ongoing pregnancies in patients undergoing preimplantation genetic screening (PGS) because of advanced age, recurrent pregnancy losses or multiple failed IVF cycles. The analysis of biological wastage per oocyte showed that in this cohort of patients, of 333 eggs inseminated, 183 (55.0%) provided embryos for biopsy, and of these, only 33 (18.0% per embryo and 9.9% per oocyte) were normal. A total of 26 embryos were suitable for transfer (14% per embryo and 7.8% per oocyte), but only five (1.5%) implanted and three (1.0%) resulted in live births. In conclusion, there is enormous biological wastage during assisted reproduction, and the data obtained from both embryos and oocytes of patients undergoing PGS support the concept that many embryos and eggs obtained during IVF are intrinsically abnormal and thus fail to implant.

Clinical and cognitive factors affecting psychosocial functioning in remitted patients with bipolar disorder.

Impaired interpersonal, social, and occupational functioning is very often observed in patients with bipolar disorder, not only at the acute stages of the illness but in remission as well. This finding raises the question of multiple factors that might affect psychosocial functioning in bipolar patients, such as residual subsyndromal symptoms and neuropsychological deficits. Social cognition impairment, especially impaired Theory of Mind (ToM), might also play an important role in bipolar patients' every-day functioning, similarly to what was found in patients with schizophrenia. The present study aimed to investigate the potential effect of clinical and cognitive factors on the psychosocial functioning of patients with bipolar disorder during remission, assessing ToM along with a broad range of basic cognitive functions. Forty-nine patients with bipolar disorder type I in remission and 53 healthy participants were assessed in general intelligence, working memory, attention, speed processing, verbal learning and memory, and executive functions using a comprehensive battery of neuropsychological tests. The Faux Pas Recognition Test was used to assess ToM. The two groups were matched for gender, age and education level. The Hamilton Rating Scale for Depression (HDRS), the Young Mania Rating Scale (YMRS), and the Brief Psychiatric Rating Scale (BPRS) were also administered to the patients. Every-day functioning was assessed with the Global Assessment of Functioning (GAF). In order to examine the contribution of many factors in psychosocial functioning, we used hierarchical multiple regression analysis. Bipolar patients presented significant impairment compared to healthy participants in all the basic cognitive functions tested with the exception of verbal memory. Moreover, patients had significant poorer performance than healthy controls in overall psyand cognitive ToM but not in affective ToM as measured by Faux Pas. Psychosocial functioning in patient group was significantly correlated to symptom severity-especially depressive (p<0.001) and psychotic symptoms (p=0.001), history of psychotic episodes (p=0.031) and ToM, overall (p=0.001) as well as its cognitive (p=0.023) and affective (p=0.004) components. Only the contribution of ToM in psychosocial functioning remained significant in the final multiple regression model. The findings of the current study indicate that residual symptoms and cognitive dysfunctions, especially deficits in social cognition, negatively affect psychosocial functioning of remitted patients with bipolar disorder. Moreover, our results suggest that ToM may play a central role in these patients' functioning. ToM is a mediator of the relationship between other clinical or cognitive variables and functioning, while it has also significant effect on social skills independently of other factors. Therefore, specific therapeutic interventions targeting social cognitive dysfunction might improve functional outcome in bipolar disorder. Putative contribution of other clinical characteristics (comorbid personality disorders, substance abuse, anxiety) and psychosocial factors (stigma, self-stigma, lack of social network) in bipolar patients' functioning should be examined in future studies.

The relationship of Theory of Mind with symptoms and cognitive impairment in bipolar disorder: a prospective study.

Previous studies in bipolar disorder suggest patients' deficient performance in Theory of Mind tasks, both during manic or depressive episodes and in remission. However, most of the extant studies were cross-sectional and did not control for potential confounders such as residual symptoms or co-existent deficits in other cognitive functions. The present study is the first prospective study that assessed the effect of remission on Theory of Mind (ToM) in patients with Bipolar Disorder (BD) controlling for other cognitive deficits. ToM was assessed in 29 patients with BD type I during an episode of the illness and in remission as well as in 29 healthy controls. The two groups were pair-matched for gender, age and education level. Three tests with different levels of complexity were used to assess ToM: First Order False Belief Task, Hinting Task and Faux Pas Recognition Test. Concomitantly, a comprehensive battery of neuropsychological tests was administered to all participants assessing general intelligence, working memory, attention, speed processing, verbal learning, and memory and executive functions. The Hamilton Rating Scale for Depression, Young Mania Rating Scale, Brief Psychiatric Rating Scale, and GAF were also administered to the patients. Differences between patients--in acute phase and in remission--and the control group on neuropsychological tests were tested using one-way ANOVA with post hoc Bonferroni corrections. The effect of other cognitive deficits on patients' ToM dysfunction was controlled for using general linear models. The patients showed significantly lower performance in all ToM tests during the acute phases as compared to the control group (p values from 0.001 to 0.014). However, these impairments did not persist beyond acute mood episode, except patients' poor performance on Faux Pas (p=0.001). Additionally, patients had poorer performance compared to control group in verbal learning and memory (p<0.001) as well as visuospatial working memory (p<0.001) during both the acute and the euthymic phases of the illness. Patients also had poorer performance than healthy controls in immediate memory (p=0.026) and executive functions (p=0.001), however only during episodes of illness. Differences in Faux Pas did not remain statistically significant when the effect of verbal memory and visuospatial working memory was controlled for. Differences in other ToM tests during episodes did not remain statistically significant, when other cognitive functions that were found impaired in patients during episodes, were controlled for. The findings of this study support the hypothesis that ToM dysfunction in BD is associated with mood symptoms and it might reflect underlying cognitive deficits rather than representing a specific trait marker of the disorder.

Assessment of embryo viability: the ability to select a single embryo for transfer--a review.

By being able to select the most viable embryo(s) within a given cohort it will be possible to reduce the number of embryos transferred in a given IVF procedure. Several morphological scoring systems have been proposed for the successive stages of human embryo development. Other indicators of embryo viability include rate of cleavage. Finally, non-invasive methods of assessing nutrient uptake and utilization have been developed that can be used to measure the health of individual embryos. A sequential scoring system has therefore been proposed that uses the above parameters in order to create a history for each embryo during the preimplantation period. Such systems will help lead to single embryo transfers for the majority of IVF patients.

Co-culture of the early human embryo: factors affecting human blastocyst formation in vitro.

Co-culture systems have been designed to overcome the embryonic developmental arrest observed in vitro in conventional culture media. Oviduct and uterine epithelial cells can sustain embryonic development, as can trophoblastic tissue and transport epithelia of non-genital origin. Its benefits involve neither hormone dependency nor histo-specificity. Fibroblasts do not overcome the developmental arrest in most mammalian species, but whether they do in humans is still unsure. In all systems, the quality of the feeder cells and the co-culture medium are very important. Using the Vero cell line, 60% of human IVF embryos reach the blastocyst stage. The quality of the sperm seems to affect results. We have observed: For 10% of the patients with unexplained fertility, blastocyst stage is not attained; this probably involves a maternal (ovarian) problem. When at least one blastocyst is transferred, the pregnancy rate per transfer is 31%. The implantation rate in pregnant women is higher than after transfer at day 2. After repeated failures of transfer at early stages (2-6 cells), transfer at the blastocyst stage gives high pregnancy rates (40%). This indicates an in vitro selection. There is a strong paternal effect on blastocyst formation: poor quality sperm give lower rates of blastocyst. Co-culture helps to understand treatment failures related to male factors. Around 60% of the patients having spare embryos have had blastocysts frozen. Transfers of frozen-thawed blastocysts give a 20% pregnancy rate and an implantation rate per embryo of 11%. Co-culture is a new tool which has to be carefully evaluated in human IVF programs. It does not impair "a minima" embryo viability and it allows in vitro selection.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of sperm competence.

The predictive values of four categories of established sperm function assays--computer-assisted semen analysis (CASA), induced-acrosome reaction testing, sperm penetration assay, and sperm-zona pellucida binding assays--are still unsure. In this article we examine the evaluation of sperm competence. We propose that assessment of sperm competence should include investigations at the nuclear, organelle, and cytoskeletal levels. In light of this, we discuss the assessment of sperm nuclear integrity as an alternative new method of analysis. We also question the merit of having such tests, whereby it may be an easier choice to direct these patients straight to an assisted reproduction treatment.

Comparison of results after in vitro fertilized human embryos are cultured in routine medium and in coculture on Vero cells: a randomized study.

OBJECTIVE: To investigate whether coculture of human embryos on Vero cells improves embryo viability compared with a routine culture method. SETTING: In vitro fertilization Clinic of the Hôpital Cantonal Universitaire de Genève, Geneva, Switzerland. PATIENT SELECTION: Couples who had given informed consent, had undergone < 3 IVF cycles with ET and where the male had normal semen parameters were selected. Patients who had undergone > or = 3 IVF cycles with ET were allocated directly to coculture. DESIGN: Patients were randomly allocated to have their embryos cultured in a routine embryo culture medium or in coculture with Vero cells. RESULTS: There was no difference in pregnancy rates between the two culture groups. Coculture gave a high (> 50%) rate of blastocyst formation. In 16 cycles where patients had previously undergone > or = 3 IVF cycles 4 patients became pregnant. CONCLUSIONS: Coculture provides no benefit for patients that are performing their initial treatment cycles in IVF.

Subzonal sperm microinjection in cases of severe male factor infertility and repeated in vitro fertilization failure.

OBJECTIVE: To examine (1) fertilization rates obtained with subzonal sperm microinjection when different numbers of sperm are injected into the perivitelline space; (2) when subzonal sperm microinjection is combined with dilute insemination; and (3) the association of semen quality characteristics with fertilization. DESIGN: Subzonal sperm microinjection and subzonal sperm microinjection combined with dilute insemination was performed in 109 and 41 cycles on patients in two clinical trials in Melbourne, Australia, and Bologna, Italy, respectively. PATIENT PARTICIPANTS: Couples who have experienced repeated in vitro fertilization failure or in whom the husband has severe male factor infertility. PRIMARY OUTCOME MEASURES: The number of oocytes fertilized after injection of different numbers of sperm into the perivitelline space, the number of patients transferred, and pregnancy outcome. RESULTS: The injection of multiple numbers of sperm into the perivitelline space failed to improve monospermic fertilization rates but caused an increase in polyspermic fertilization. In patients with initial semen parameters exhibiting greater than 50% motility or greater than 50% normal morphology fertilization rates were improved when subzonal sperm microinjection-treated eggs were incubated in a dilute insemination medium. Six pregnancies were obtained, two of which have progressed to term. CONCLUSIONS: When applied to male factor patients, the subzonal sperm microinjection technique results in a 14% to 15% fertilization rate. However, of the 102 embryos transferred only three (2.9%) fetal heart beats were obtained.

Assessment of early cleaving in vitro fertilized human embryos at the 2-cell stage before transfer improves embryo selection.

OBJECTIVE: To determine the most viable embryos for transfer. DESIGN: Study 1: Preselection of early-cleaving 2-cell embryos for transfer. Study 2: Alternating weeks during which preselection was performed and not performed. SETTING: ART program, Birmingham Women's Hospital, Birmingham, United Kingdom. PATIENT(S): Patients undergoing IVF or ICSI cycles with transfer on day 2. INTERVENTION(S): Culture of all fertilized embryos. MAIN OUTCOME MEASURE(S): Number of fertilized embryos cleaving to the 2-cell stage on day 1, embryo quality, implantation rates, and pregnancy rates. RESULT(S): Patients with early-cleaving 2-cell embryos had significantly higher pregnancy and implantation rates (45 of 100 [45.0%] and 58 of 219 [25.5%], respectively) than did patients without early-cleaving 2-cell embryos (31 of 130 [23.8%] and 43 of 290 [14.8%], respectively). In weeks during which preselection was used, the overall pregnancy and implantation rates of the clinic improved. CONCLUSION(S): The presence of early-cleaving 2-cell embryos improves a patient's chance of achieving pregnancy. Use of more stringent embryo selection criteria can improve overall pregnancy rates.