A decade of the sperm-washing programme: correlation between markers of HIV and seminal parameters.

OBJECTIVES: The aim of the study was to use a decade of experience of sperm washing to assess the effect of HIV disease on semen parameters and to highlight the continuing importance of risk reduction when some controversially advocate the safety of timed unprotected intercourse for conception in the 'stable' HIV-positive man. METHODS: Semen parameters of 439 fresh samples used for sperm washing/intrauterine insemination (IUI) were correlated against markers of HIV disease [CD4 cell count, viral load (VL), duration of HIV infection and use of antiretroviral therapy] and the risk of detectable virus in semen was assessed. RESULTS: A significant positive correlation was observed between CD4 cell count and total sperm count, progressive motility, post-preparation/insemination concentration, progressive motility and total motile count inseminated (TMCI), and a significant negative correlation was observed between CD4 cell count and normal sperm morphology (Spearman's correlation; P<0.05). There was no significant difference in any parameter between samples in which VL was detectable and those in which it was undetectable. The use of highly active antiretroviral therapy (HAART) significantly decreased total sperm count, progressive motility, post-preparation count and TMCI and significantly increased proportion of abnormal forms (Mann-Whitney tests; P<0.05). There was a significant negative correlation between duration of HAART use and concentration, total sperm count and post-preparation motility and between years since diagnosis and post-preparation motility. In 9.7% of IUI cycles performed with fresh sperm in men on HAART with undetectable VL, detectable HIV was found in either pre- or post-wash seminal samples. CONCLUSION: Our data suggest a negative effect of low CD4 cell count and the use of HAART on semen. The significant proportion of 'stable'; men with undetectable serum VL but virus in semen confirms the continued importance of such risk reduction.

Fertility needs and funding in couples with blood-borne viral infection.

BACKGROUND: Couples infected with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) are increasingly seeking assisted conception. These couples avoid unprotected intercourse and use condoms at all times in order to minimize the risk of infecting their partner. As this practice inhibits pregnancy, assisted procreation is generally required for safe conception. For many couples, access to such services is restricted on ethical, geographical and financial grounds. OBJECTIVE: The aim of the study was to assess the fertility needs, geographical origin and state funding of patients with blood-borne viral infection. METHODS: A retrospective review of the medical records of couples referred for fertility treatment between January 1999 and December 2006, where one or both partners were infected with HIV, HBV and/or HCV, was carried out. RESULTS: Of the 205 couples included in the study, 44% lived in London, 51% came from elsewhere in the United Kingdom and 5% travelled from outside the United Kingdom to seek treatment. Genitourinary medicine clinics were the main source of referral. 85.8% of couples had HIV infection, 15.1% were infected with HBV and 13.6% had HCV infection. Fertility screening identified a high incidence of male factor infertility (33.3%) in HIV-infected men and tubal disease (40.8%) in HIV-infected women. Only 23.6% of HIV-infected couples, 20% of HBV-infected couples and 12.5% of HCV-infected couples obtained state funding for assisted conception. CONCLUSION: Fertility screening identified a high incidence of male and tubal factor subfertility among couples living with HIV, HBV and HCV. Limited access to specialist clinics equipped to cater for these couples and restricted funding may impact negatively on couples obtaining risk-reducing assisted reproduction treatment. This may have long-term public health implications as individuals attempt to conceive through unprotected intercourse.

The role of sperm aneuploidy as a predictor of the success of intracytoplasmic sperm injection?

BACKGROUND: We present the first powered prospective study to assess whether sperm aneuploidy can predict the outcome of ICSI. METHODS: Our null hypothesis was that aneuploidy rates (AR) are identical in men who achieve successful (Group A) and unsuccessful (Group B) ICSI outcome. A power calculation yielded a sample number of 56 to achieve 80% power to reject our hypothesis at the 5% significance level. Samples for testing were obtained on the day of embryo transfer and tests were performed on raw pre-preparation samples. Sperm AR of chromosomes 13, 18, 21, X/Y were assessed using fluorescence in-situ hybridization (FISH) techniques (mean of 1223 sperm). RESULTS: There was no significant difference in any patient, seminal, cycle or laboratory characteristic between groups that may have affected outcome. Total AR (2.37 versus 1.18%, P = 0.01), as well as AR of chromosomes 18, X/Y and 18 + X/Y (1.48 versus 0.67%, P = 0.005) were significantly higher in Group B compared with Group A. Regression analysis confirmed these differences to be independent of other variables and showed a 2.6-fold change in odds of achieving a pregnancy for every 1% change in total AR. CONCLUSIONS: Our findings confirm a potential role for aneuploidy testing in the work-up of ICSI patients as a predictor of success, as well as in future genetic counselling. If confirmed, there may also be a place for a study of preimplantation genetic screening to improve ICSI success in men found to have high AR and ICSI failure.

Hypersecretion of androstenedione by isolated thecal cells from polycystic ovaries.

The aim of this study was to examine the hypothesis that hypersecretion of ovarian androgens in polycystic ovary syndrome results from an intrinsic abnormality of androgen biosynthesis by thecal cells. Steroid accumulation by human thecal cells from normal and polycystic ovaries (PCO-theca) was examined under basal and LH-stimulated conditions. A method for dispersing and culturing human thecal cells as primary monolayers in serum-free medium was developed. LH increased androstenedione (A), progesterone (P), 17 alpha-hydroxyprogesterone, dehydroepiandrosterone, and estradiol accumulation in the overlying medium in a dose-dependent manner at a maximum effective dose of 2.5 ng/mL. The principal variables affecting the magnitude of steroid accumulation were plating density, duration of incubation, and follicle size. Using only theca from follicles less than 10 mm and keeping plating density constant, 48-h steroid production by theca from five normal ovaries was compared to that from nine polycystic ovaries isolated from both anovulatory and ovulatory women. There was a significant increase in both basal (median, 32.1 pmol/1000 cells.48 h; range, 18.7-250) and LH-stimulated (56 pmol/1000 cells; range, 40.7-406) A accumulation by PCO-theca compared to basal (1.7 pmol/1000 cells; range, 1.1-4.3) and LH-stimulated (2.8 pmol/1000 cells; range, 2.0-8.1) A accumulation by normal theca, with no overlap in values between the two. Although P production was also increased in the PCO-theca, the A to P ratios under both basal and LH-stimulated conditions were significantly higher in the PCO-theca [A/P ratio normal; PCO basal, 0.1 and 0.53 (P < 0.01); LH-stimulated, 0.04 and 0.65 (P < 0.001)], suggesting increased conversion of P to A. The steroid response to LH was similar in both groups. This is the first report of a difference in thecal androgen production between normal and polycystic ovaries and supports the hypothesis that there is a primary abnormality in the regulation of androgen production in PCOS.

Modulation by insulin of follicle-stimulating hormone and luteinizing hormone actions in human granulosa cells of normal and polycystic ovaries.

Anovulation in polycystic ovary syndrome (PCOS) is associated with hyperinsulinemia and insulin resistance, but it has been unclear whether the ovary is insulin resistant in women with PCOS. The aims of this study were, firstly, to determine whether human granulosa cells respond to physiological concentrations of insulin and, secondly, to investigate insulin and gonadotropin interactions in vitro in granulosa cells obtained from normal (N) and polycystic ovaries (PCO). Granulosa cells were incubated with insulin with or without gonadotropins for 48 h. Insulin augmented not only basal production of estradiol and progesterone, but also LH-stimulated steroid accumulation in granulosa cell cultures from N and PCO. Insulin enhanced FSH-stimulated progesterone production by granulosa cells from N and PCO, but the effect on FSH-stimulated estradiol production was variable, ranging from no effect for granulosa cells from N to synergistic for granulosa cells from PCO of anovulatory subjects. Preincubation with insulin for 48 h increased subsequent basal and LH-induced, but not FSH-stimulated, steroid production. These data demonstrate that granulosa cells from PCO respond to insulin despite the association, in vivo, of PCOS with peripheral insulin resistance. Insulin preincubation enhances the subsequent response of human granulosa cells to LH. We propose that in anovulatory women with PCOS, elevated levels of insulin interacting with LH may contribute to the mechanism of anovulation.

Insulin action in the normal and polycystic ovary.

Insulin has a stimulatory effect on steroidogenesis by granulosa cells of normal and polycystic ovaries and interacts with gonadotropins in an additive or, as in the case of LH, a synergistic manner. These actions seem to be mediated specifically by the insulin receptor rather than by cross-reaction with the type I IGF receptor, even in tissue obtained from women with PCOS with biochemical evidence of insulin resistance. The authors suggest that hyperinsulinemia makes a significant contribution to premature arrest of follicle growth, which is characteristic of anovulation in women with PCOS, and that the interaction of insulin with LH is a key element in this process. Insulin may also have a role in amplifying LH-induced androgen production by theca cells, which may help explain the prominence of symptoms of hyperandrogenism in obese subjects with PCOS. The results of recent clinical studies of insulin-sensitizing agents such as metformin and the thiazoladinedione troglitazone in PCOS have provided encouragement that improvement of insulin sensitivity and consequent lowering of circulating insulin levels by these agents may be of therapeutic value in the management of both anovulation and hirsutism.

Polycystic ovary syndrome: evidence for a primary disorder of ovarian steroidogenesis.

Polycystic ovary syndrome (PCOS) is a very common endocrinopathy of uncertain aetiology in which the most consistent biochemical abnormality is hypersecretion of androgens. In this review, evidence is presented to support the view that a primary abnormality of ovarian androgen biosynthesis provides the basis for the syndrome. PCOS is a familiar disorder and we demonstrate, in molecular genetic studies, that CYP11a, the gene coding for P450 side chain cleavage, is a key susceptibility locus for development of hyperandrogenism.

HIV prevention. Assisted reproduction in HIV-discordant couples.

Serodiscordant couples in whom the man is HIV-1-positive and the woman is negative have limited options if they wish to have children safely, because sexual intercourse carries a 1-in-500 risk of transmitting virus in semen to the female partner. Sperm washing is a risk-reduction option in which infected sperm are washed free of virus before insemination into the female partner at the time of ovulation. Absence of detectable HIV is verified before insemination using a polymerase chain reaction nucleic acid-based sequence amplification assay. Pregnancy rate per insemination is 14%, based on a European experience of more than 2000 inseminations; to date, there have been no seroconversions in either mother or child. Washed sperm have also been used in other assisted conception treatments, such as in vitro fertilization. In the United States, the CDC has recommended against insemination of women with semen from men infected with HIV. Current data from programs in Europe would suggest sperm washing to be a safe risk-reduction option for heterosexual couples wishing to bear a child. We suggest that sperm washing should only be carried out in dedicated units using a multidisciplinary approach to ensure that couples receive adequate preconceptual counseling, detailed sexual health and fertility assessment, and careful monitoring of the woman's HIV status during treatment and pregnancy.

Management of women presenting to the accident and emergency department with lower abdominal pain.

The diagnosis and management of lower abdominal pain is difficult, particularly for the inexperienced accident and emergency (A&E) or surgical trainee. In women, potential gynaecological causes may further confuse the picture. We analysed the incidence, spectrum of presentation and immediate management of 322 women presenting consecutively to an inner city A&E department over a 6-month period with lower abdominal pain. A standard questionnaire relating to history, examination, immediate investigations and preliminary diagnosis was completed by the attending A&E doctor. The cause of abdominal pain, according to the A&E doctor's diagnosis, was gynaecological in 61%, gastroenterological in 23%, urological in 7% and non-specific in 9% of cases. Of the women, 39% (124/322) were referred to a duty specialist, of whom 86% (107/124) required admission for investigation and/or treatment. Women initially diagnosed as having pain of gynaecological origin formed the largest group of patients to be referred. In 69% (67/97) of these cases, the A&E doctor's initial diagnosis was confirmed by the gynaecologist. This study shows that pain of gynaecological origin was the largest single cause of lower abdominal pain in women presenting to our A&E department and that, in the majority of cases, these women needed to be referred to the duty gynaecologist for immediate treatment. Although overall diagnostic accuracy rate was relatively high, the management of potentially life-threatening gynaecological conditions such as ectopic pregnancy was poor. These results emphasise the need to improve in-service gynaecological training in A&E departments.

HIV and reproductive care--a review of current practice.

In developed countries, antiretroviral treatment has increased life quality and expectancy of HIV-infected individuals and led to a drop in mother-to-child transmission (MCT) risk to below 1%. Fertility has been shown to be reduced in both men and women with HIV. As a result of these factors, the demand for reproductive care in this population is rising. In discordant couples where the man is positive, sperm washing significantly reduces viral transmission risk to the uninfected female partner over unprotected intercourse. Positive women do not necessarily need specialised fertility treatment but should be monitored closely during pregnancy to minimise MCT risk.

Early ovarian ageing: are women with polycystic ovaries protected?

Screening asymptomatic women in the general population for 'early ovarian ageing' will be more effective in high-risk groups. Recent findings support the hypothesis that women with polycystic ovaries (PCO) may have actually been born with a larger pool of resting follicles. The mechanism is almost certainly genetic and occurs in fetal life. If, as is widely accepted, the rate of depletion of the ovarian reserve depends primarily on the size of the remaining pool of small follicles, women with PCO will be unlikely to undergo an accelerated depletion of their follicle pool, normally seen in the late thirties, significantly earlier. In terms of asymptomatic screening for early ovarian ageing in the general population, women with PCO constitute a low-risk group and should therefore be excluded.

Advances in induction of ovulation.

The emphasis of this review is placed on the treatment of clomiphene-resistant women with polycystic ovary syndrome (PCOS) or with hypogonadotropic hypogonadism. There has been an increasing awareness of the need to avoid the consequences of multiple folliculogenesis, and this is reflected in the more widespread use of low-dose regimens for induction of ovulation, particularly in PCOS. The past 12 months have seen the first reports of the clinical applications of recombinant human follicle-stimulating hormone (FSH), and there is an intriguing suggestion that long-acting opiate agonists may have a part to play in the management of anovulation of hypothalamic origin.

Management of early pregnancy bleeding in the accident and emergency department.

Over a period of 6 months, from February to July 1987, 26,837 patients attended St Mary's A&E Department. Of these, 179 (0.7%) were complaining of bleeding in pregnancy of less than 20 weeks gestation. In May 1987 new management guidelines were introduced. These emphasised the importance of vaginal examination and the use of ultrasound to determine the viability of the pregnancy. As a result, the incidence of admission fell from 15 of 53 (28%) to 7 of 58 (12%), referral to the on-call gynaecologist from 23 of 53 (44%) to 13 of 58 (22%) and reattendance rates from 11 of 53 (15%) to 4 of 58 (4%) (all changes P less than 0.05).

Oestradiol feedback stimulation of androgen biosynthesis by human theca cells.

This study analysed the effect of oestradiol on basal and LH-stimulated production of androstenedione and progesterone by human theca cells in monolayer culture. Incubations were carried out for either 2 days (seven experiments) or 4 days (four experiments), in the presence or absence of luteinizing hormone (LH), oestradiol (10(-9)-10(-6) M) or inhibin. Medium collected at 48 and 96 h was stored until radioimmunoassay for steroid content. Theca pooled from small follicles (<10 mm) was used in all but two experiments; in these, ovaries were obtained from ovulatory women in the mid-follicular phase of their cycle and theca from small and large follicles was pooled. Oestradiol inhibited progesterone production in a dose-dependent manner in all experiments, irrespective of follicle size, ovulatory status and ovarian morphology, with maximum effect at 10(-6) M. At this dose, oestradiol had no effect on androstenedione production by theca from four anovulatory women with polycystic ovaries but produced a significant augmentation of both basal and LH-stimulated androstenedione production in theca from five of the seven ovulatory women, with maximal response in theca from the two pre-ovulatory subjects. During the 48-96 h period of incubation, oestradiol augmented androstenedione production in all four experiments and had a greater stimulatory effect than the physiological dose of inhibin (10 ng/ml). This is the first report of oestradiol regulating human theca cell steroidogenesis in a dose-dependent manner.