Factors associated with embryo mosaicism: a systematic review and meta-analysis.

PURPOSE: Evaluate which factors are involved in the increased rate of mosaicism in embryos. METHODS: A systematic review and meta-analysis was performed. After an exhaustive search of the literature, a total of seven papers were included in the analysis. In addition, data collected from IVF cycles performed in our fertility clinic were also analysed. Day of biopsy, embryo quality, maternal and paternal age and seminal quality were the chosen factors to be studied. RESULTS: The results of the meta-analysis show that neither embryo quality nor seminal quality were related to mosaic embryo rate (OR: 1.09; 95% CI: 0.94-1.28 and OR: 1.10; 95% CI: 0.87-1.37, respectively). A positive association was observed for the variable "biopsy day" with embryos biopsied at day 6 or 7 having the highest rate of mosaicism (OR: 1.06; 95% CI: 1.01-1.11). In opposite to what happens with aneuploidy rate, which increases with maternal age, embryo mosaicism is higher in younger women (<34 years) rather than in older ones (≥34 years) (OR: 0.95; 95% CI: 0.92-0.98). However, for the "paternal age" factor, no association with mosaicism was found (OR: 1.04; 95% CI: 0.90-1.21). CONCLUSIONS: With the present study, we can conclude that the factors related to the presence of mosaicism in embryos are the embryo biopsy day and maternal age. The rest of the studied factors showed no significant relationship with mosaicism. These results are of great importance as knowing the possible causes leading to mosaicism helps to improve the clinical results of reproductive treatments.

Capacitation and acrosome reaction changes α-tubulin immunodistribution in human spermatozoa.

Tubulin is a protein constituent of cytoskeletal microtubules, closely related to sperm motility. However, the changes in tubulin distribution following capacitation and acrosome reaction are poorly understood. This study immunolocalized and quantified the expression of α-tubulin in fresh, capacitated and acrosome-reacted samples. Immunocytochemical data showed that in capacitated and acrosome-reacted spermatozoa, α-tubulin is labelled throughout most of the flagellum (⩾66.66%). However, the mean α-tubulin-labelled area in these samples was significantly lower than in fresh samples (P<0.05). Thus, there are different sperm clusters distinguished by their α-tubulin immunoreactivity and this could be directly linked to structural changes following capacitation and acrosome reaction.

Intermediate and normal sized CGG repeat on the FMR1 gene does not negatively affect donor ovarian response.

BACKGROUND: Fragile X syndrome is associated with low ovarian reserve and poor ovarian response. The aim of this study was to investigate whether CGG repeats on the fragile X mental retardation 1 (FMR1) gene have predictive value for ovarian response to stimulation with gonadotrophins and for clinical outcome in our oocyte donation program. METHODS: Oocyte donor candidates were selected according to Instituto Bernabeu oocyte donation program requirements. Fragile X genetic screening was performed in 204 oocyte donors, defining 141 controls and 63 cases: 35-39 repeats (n = 34), 40-45 (n = 12) and >45 (n = 17). All the patients underwent ovarian stimulation using a GnRH antagonist protocol and received a GnRH agonist trigger. The main factors used to measure outcome were oocyte yields, days of stimulation, gonadotrophin dosages, biochemical pregnancy, ongoing pregnancy and miscarriage rates. RESULTS: No differences between the study group and controls were reported in oocyte yields (17.5 versus 18.9) or days of stimulation (11.40 versus 9.82). The control group used significantly more gonadotrophin (2212 versus 1850 IU) than the study group. Clinical outcome was not affected by the CGG repeats on the FMR1 gene in oocyte donors. CONCLUSIONS: No negative effect was observed for intermediate-sized CGG repeats on ovarian stimulation and clinical outcome using a non-confounding model of oocyte donation. These results disagree with previous studies performed on infertility patients. Owing to the present study, fragile X genetic screening should not be considered for prediction of response to ovarian stimulation.

Image retake analysis in digital radiography using DICOM header information.

A methodology to automatically detect potential retakes in digital imaging, using the Digital Imaging and Communications in Medicine (DICOM) header information, is presented. In our hospital, neither the computed radiography workstations nor the picture archiving and communication system itself are designed to support reject analysis. A system called QCOnline, initially developed to help in the management of images and patient doses in a digital radiology department, has been used to identify those images with the same patient identification number, same modality, description, projection, date, cassette orientation, and image comments. The pilot experience lead to 6.6% and 1.9% repetition rates for abdomen and chest images. A thorough analysis has shown that the real repetitions were 3.3% and 0.9% for abdomen and chest images being the main cause of the discrepancy being the wrong image identification. The presented methodology to automatically detect potential retakes in digital imaging using DICOM header information is feasible and allows to detect deficiencies in the department performance like wrong identifications, positioning errors, wrong radiographic technique, bad image processing, equipment malfunctions, artefacts, etc. In addition, retake images automatically collected can be used for continuous training of the staff.

Paediatric entrance doses from exposure index in computed radiography.

Over the last two years we have evaluated paediatric patient doses in projection radiography derived from exposure level (EL) in computed radiography (CR) in a large university hospital. Entrance surface air kerma (ESAK) for 3501 paediatric examinations was calculated from the EL, which is a dose index parameter related to the light emitted by the phosphor-stimulable plate, archived in the Digital Imaging and Communications in Medicine (DICOM) header of the images and automatically transferred to a database using custom-built dedicated software. Typical mean thicknesses for several age bands of paediatric patients was estimated to calculate ESAK from the EL values, using results of experimental measurements with phantoms for the typical x-ray beam qualities used in paediatric examinations. Mean/median ESAK values (in microGy) for the age bands of <1 year, 1-5 years, 6-10 years and 11-15 years have been obtained for chest without a bucky: 51/41, 57/34, 91/54 and 122/109; chest with a bucky (for only the last three age bands): 114/87, 129/105 and 219/170; abdomen: 119/91, 291/225, 756/600 and 1960/1508 and pelvis: 65/48, 455/314, 943/707 and 2261/1595. Sample sizes of clinical images used for the (indirect) measurements were 1724 for chest without a bucky, 799 for chest with a bucky, 337 for abdomen and 641 for pelvis. The methodology we describe could be applicable to other centres using CR as an imaging modality for paediatrics. Presently, this method is the only practical approach to automatically extract parameters contained in the DICOM header, for the calculation of patient dose values for the CR modality.

Quality control and patient dosimetry in digital radiology. On line system: new features and transportability.

New features have been added to a system (QCONLINE) for auditing patient dosimetric and technical parameters 'on line', working on a digital radiology department and using the information contained in the DICOM header of some modalities. The audit of other parameters than patient doses have been included, setting alarm conditions to alert on malfunction of the X-ray system or bad operation modes, in addition to the evaluation of patient doses. A new module to analyse, collect and process the relevant information transferred by the modality performed procedure step (MPPS) service has been launched. Several examples with the exploitation of the new features are presented. The transportability of the system has been tested in two remote hospitals during several months. The new MPPS module has demonstrated to be a good tool to complement the information existing in the DICOM header. The system allows to help in the optimisation of digital radiology departments managing patient dosimetry and procedure data in real time.

Comprehensive mitochondrial DNA analysis and IVF outcome.

STUDY QUESTION: Do mitochondrial DNA (mtDNA) copy number and heteroplasmy in human embryos affect the ongoing pregnancy rate? SUMMARY ANSWER: Our study suggests that mtDNA copy number above a specific threshold is associated with the ongoing pregnancy rate. WHAT IS KNOWN ALREADY: Mitochondria play a vital role in cell function. Recently, there has been increasing research on mtDNA as a biomarker of embryo implantation. Although reports showed that high levels of mtDNA in the blastocyst are associated with low implantation potential, other publications were unable to confirm this. Confounding factors may influence the mtDNA copy number in euploid embryos. On the other hand it has been speculated that both mtDNA heteroplasmy and copy number contribute to mitochondrial function. Next generation sequencing (NGS) allows us to study in depth mtDNA heteroplasmy and copy number simultaneously. STUDY DESIGN SIZE DURATION: A prospective non-selection study was performed. We included 159 blastocyst biopsies from 142 couples who attended our clinic for preimplantation genetic testing for aneuploidies (PGT-A), from January 2017 to December 2017. All embryos were biopsied on Day 5 or Day 6. The aneuploid testing was performed by NGS. All blastocysts were diagnosed as euploid non-mosaic and were transferred. The mtDNA analysis was performed once the embryo diagnosis was known. PARTICIPANTS/MATERIALS SETTING METHODS: Sequencing reads mapping to the mtDNA genome were extracted from indexed bam files to identify copy number and heteroplasmy. The relative measure of mtDNA copy number was calculated by dividing the mtDNA reads by the nuclear DNA value to normalize for technical variants and the number of cells collected at the biopsy. All the results were subjected to a mathematical correction factor according to the embryo genome. Heteroplasmy was assigned by MitoSeek. MAIN RESULTS AND THE ROLE OF CHANCE: The mean average copy number and SD of mtDNA per genome was 0.0016 ± 0.0012. Regarding heteroplasmy, 40 embryos were heteroplasmy carriers (26.32%). MtDNA variants were detected in coding and non-coding regions and the highest number of variants in an embryo was eight. With respect to IVF outcome for mtDNA copy number analysis, we set a threshold of 0.003 for the following analysis. The vast majority of the embryos were below the threshold (142/159, 89.31%) and 17 embryos were classified as having higher mtDNA levels. We showed a reduction in ongoing pregnancy rate associated with elevated mtDNA copy number (42.96% versus 17.65%, P < 0.05). This result was independent of maternal age and day of the biopsy: these factors were included as confounding factors because mtDNA copy number was negatively correlated with female age (25 -30 y: 0.0017 ± 0.0011, 30 -35 y: 0.0012 ± 0.0007, 35 -40 y: 0.0016 ± 0.0009, over 40 y: 0.0024 + 0.0017, P < 0.05). Embryos biopsied on Day 5 were more likely to have higher quantities of mtDNA compared with those biopsied on Day 6 (0.0017 versus 0.0009, P < 0.001). According to IVF outcome and heteroplasmy, a lower ongoing pregnancy rate was reported for embryos that carried more than two variants. However, this did not reach statistical significance when we compared embryos with a number of variants lower or higher than two (39.15 versus 20.0, P = 0.188). Finally, a clear positive association between the mtDNA variants and copy number was reported when we compare embryos with or without heteroplasmy (0.0013 ± 0.0009 versus 0.0025 ± 0.0014, P < 0.001) and among different numbers of variants (0:0.0013 ± 0.0009, 1-2:0.0023 ± 0.0012, >2:0.0043 ± 0.0014, P < 0.05). LIMITATIONS REASONS FOR CAUTION: A limitation may be the size of the sample and the high-throughput sequencing technology that might not have detected heteroplasmy levels below 2% which requires high sequence depth A clinical randomized trial comparing the clinical outcome after the transfer of embryos selected according to mtDNA levels or only by morphological evaluation will be necessary. More research into the impact of mtDNA heteroplasmy and copy number on IVF outcome is needed. WIDER IMPLICATIONS OF THE FINDINGS: Our results demonstrate that embryos with elevated mtDNA copy number have a lower chance of producing an ongoing pregnancy. MtDNA copy number is higher in older women and is dependent upon the number of cell divisions that preceded biopsy. Moreover, our data suggest that mitochondrial activity could be a balance between functional capacity and relative mtDNA copy number. STUDY FUNDING/COMPETING INTERESTS: There are no conflicts of interest or sources of funding to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Human sperm motility, capacitation and acrosome reaction are impaired by 2-arachidonoylglycerol endocannabinoid.

The endocannabinoids are cannabinoids synthesized by mammalian tissues. These compounds are closely related to the regulation of the male reproductive system. However, little is known about the effects produced by 2-arachidonoylglycerol (2AG) on in vitro human sperm functions. This study was undertaken to determine the effects produced by 2AG on fresh human sperm and in the capacitation technique. Semen samples from healthy young men were exposed to different concentrations of 2AG before and during capacitation technique. In this work, we have demonstrated that 2AG induces the spontaneous acrosome reaction and reduces progressive motility in fresh human sperm. During the capacitation technique, sperm becomes more sensitive to low concentrations of 2AG, triggering the acrosome reaction and inhibiting protein phosphorylation. In summary, 2AG affects the in vitro functionality of human sperm by reducing motility, inhibiting capacitation and triggering the acrosome reaction.

Patient dosimetry and image quality in digital radiology from online audit of the X-ray system.

The present work describes an online patient dosimetry and an image quality system in digital radiology. For the patient dosimetry audit, current mean values of entrance surface dose (ESD) were compared with local and national reference values (RVs) for the specific examination type evaluated. Mean values exceeding the RV trigger an alarm signal and then an evaluation of the technical parameters, operational practice and image quality was begun, using data available in the DICOM header to derive any abnormal settings or performance to obtain the image. The X-ray tube output for different kVp values is measured periodically, to allow for the automatic calculation of ESD. The system allows also for image audit, linking the dose imparted, the image quality and the alarm condition, if produced. Results and the benefits derived from this online quality control are discussed here.

A survey of patient dose and clinical factors in a full-field digital mammography system.

In this work, we analyse the dose to 5034 patients (20 137 images) who underwent mammographic examinations with a full-field digital mammography (FFDM) system over a 2-y period. The information relevant to this study has been extracted from the image Digital Imaging and Communications in Medicine (DICOM) headers. Entrance surface air-kerma (ESAK) without backscatter and average glandular dose (AGD) were estimated following the methodology proposed in the European Protocol on Dosimetry in Mammography. Mean values for patient age and compressed breast thickness were 56 +/- 11 y and 52 +/- 13 mm, respectively. The mean ESAK value was 8.1 mGy and the mean AGD was 1.9 mGy. In addition, the dose values from both FFDM and screening-film mammographic (SFM) examinations were compared. The third quartile (TQ) of the ESAK values delivered by the FFDM system was 33% lower and 32% higher than the TQ for SFM with slow and fast screen/film receptors. Differences between dose values for cranio-caudal (CC) and medio-lateral oblique (MLO) images (about 27% for SFM) decreased to 11% for FFDM.

On the use of DICOM cine header information for optimisation: results from the 2002 European DIMOND cardiology survey.

The paper explores the level of information contained within the DICOM header in images from various cardiology systems. Data were obtained in the European DIMOND survey on image quality (Italy, Ireland, Belgium, Greece and Spain). Images from five standard diagnostic cardiology procedures carried out in six European hospitals have been analysed. DICOM header information was extracted to a database in order to analyse how it could help in the optimisation of the procedures. The level of data contained in the headers differs widely between cardiology systems. None of the X-ray systems in the 2002 survey archives the dosimetric data in the DICOM header. The mean number of runs per procedure ranges between 7.5 and 15.4 and the mean number of frames per procedure between 575 and 1417. Differences in kVp, mA, pulse time, distances and C-arm angulations are substantial and suggest that there exists a wide range for optimisation.

Automatic patient dose registry and clinical audit on line for mammography.

The use of automatic registry systems for patient dose in digital mammography allows clinical audit and patient dose analysis of the whole sample of individual mammography exposures while fulfilling the requirements of the European Directives and other international recommendations. Further parameters associated with radiation exposure (tube voltage, X-ray tube output and HVL values for different kVp and target/filter combinations, breast compression, etc.) should be periodically verified and used to evaluate patient doses. This study presents an experience in routine clinical practice for mammography using automatic systems.

Benefits of an automatic patient dose registry system for interventional radiology and cardiology at five hospitals of the Madrid area.

The purpose of this article is to present the results of connecting the interventional radiology and cardiology laboratories of five university hospitals to a unique server using an automatic patient dose registry system (Dose On Line for Interventional Radiology, DOLIR) developed in-house, and to evaluate its feasibility more than a year after its introduction. The system receives and stores demographic and dosimetric parameters included in the MPPS DICOM objects sent by the modalities to a database. A web service provides a graphical interface to analyse the information received. During 2013, the system processed 10 788 procedures (6874 cardiac, 2906 vascular and 1008 neuro interventional). The percentages of patients requiring clinical follow-up due to potential tissue reactions before and after the use of DOLIR are presented. The system allowed users to verify in real-time, if diagnostic (or interventional) reference levels are fulfilled.

Experience in retake analysis for digital mammography at a university hospital.

Data from one digital mammograph (flat detector active area of 19.2 × 23 cm(2)) were collected over a 1-year period using locally developed software in order to evaluate retakes, their rates, their causes and the possible measures to reduce their occurrence. Among them, 7.1 % of the images were marked as repetitions, and in 16 % of the studies, at least one image was repeated. When evaluating causes of retakes, the primary cause was incorrect positioning (49 %), closely followed by additional retakes in cases of large breasts (44 %). When dealing with large breasts and using a small flat panel, additional images were necessary to fully visualise the breast, and as a consequence, some breast regions received repeated radiation exposure. Moreover, a small detector increases retakes in breasts slightly wrongly positioned. To try and reduce the retake rate, it is important to plan training sessions based on images selected from the retake analysis.

Short communication: Practical aspects for the evaluation of skin doses in interventional cardiology using a new slow film.

Mapping skin doses in complex fluoroscopy interventions is useful to determine the probability of a possible injury, to detect areas of overlapping irradiation fields and to obtain a permanent register of the most exposed patient skin areas. To fulfil this task, large films with slow X-ray response can be used. Recently, Kodak has introduced a new radiotherapy verification film, named EDR2 (Extended Dose Range). The aim of this paper is to analyse the possibilities of using this new film for estimating skin dose distributions in interventions with potentially higher doses, such as complex percutaneous transluminal coronary angioplasty (PTCA), intravascular brachytherapy procedures (IVB) or cardiac ablations. The EDR2 film by Kodak is an improved option to be used in interventional cardiology to obtain maps of patient skin doses and to estimate maximum skin doses up to 1400 mGy. Film kVp dependence is negligible and the processor conditions can be standardized to obtain skin dose estimations. The linear range for accurate dose measurements is from 50 mGy to 500 mGy.

Patient dosimetry in interventional radiology using slow films.

A method for the evaluation of patient doses in interventional radiology procedures is presented and discussed. The method requires the analysis of slow non-screen films such as those used in radiotherapy. Dose area product and patient skin dose can be estimated with fair accuracy depending on the interventional procedure type. The agreement between the slow film method and diamentor measurement is better than 5% after the application of appropriate corrections. The cost is reasonable (pounds 5 per film) making it a worthwhile option in patient dosimetry, especially when the X-ray equipment does not include any fixed dose-area measuring device. Additional valuable information which may be applied to optimization of procedures (e.g. irradiated areas, number and types of projections check of appropriate use of beam limiting devices) is achieved by examining the different irradiation fields on the film.

Radiation exposure to medical staff in interventional and cardiac radiology.

The aim of this work has been to determine typical occupational dose levels in interventional radiology and cardiology installations and to relate doses to patient and occupational dosimetry through the dose-area product. An experimental correlation between environmental dosimetric records and dose-area products in the centres studied was established. The study covered a sample of 83 procedures performed by 10 specialists in six laboratories. The radiologists and cardiologists monitored wore nine thermoluminescent chips next to eyes, forehead, neck, hands, left shoulder, left forearm and left arm during each single procedure. In addition, direct reading electronic devices for environmental dosimetry were placed in the C-arm of the X-ray system, to estimate roughly the occupational radiation risk level. Typical shoulder doses derived from electronic dosimetry range between 300 and 500 muSv per procedure, assuming no lead protective screens were used. Using these values and patient dose-area data from two laboratories, averaged ratios of 84 and 120 muSv per 1000 cGy cm2 are obtained for cardiology procedures. Finally, occupational dose reductions of approximately 20% when using highly filtered X-ray beams with automatic tube potential (kV) reduction (available in some facilities), and by a factor of about three when using ceiling mounted screens, have been found.

Skin dose and dose-area product values for interventional cardiology procedures.

Coronary angiography and percutaneous transluminal coronary angioplasty procedures performed in four different facilities were monitored in the present study by measuring maximum skin dose, dose-area product and other operational parameters. Radiographic slow film, thermoluminescent dosemeters and transmission ion chambers were used to measure dose related quantities. Values of 107-711 mGy for maximum skin dose and 27.3-370.6 Gy cm2 for dose-area product were found, together with cumulative skin dose estimates of 110-3706 mGy. A discussion of the relationship of measured dose-area product and skin dose values is made using a field concentration factor defined as a way to interpret the findings. No general correlation was observed between dose-area product and maximum skin dose. Cumulative skin dose estimates throughout a procedure should be discarded as a realistic method for assessing deterministic risk in cardiology procedures. Slow film in addition to thermoluminescent dosemeters for measurement of maximum skin dose is a good alternative, especially for complex interventional procedures. For repeated procedures, combining film and dose-area product monitoring favours optimization of radiation protection for the patient.

Skin radiation injuries in patients following repeated coronary angioplasty procedures.

This study investigates the incidence of skin injuries and retrospectively estimates skin doses in a sample of patients who had multiple coronary angiographies and who underwent more than four percutaneous transluminal coronary angioplasties (PTCAs), performed primarily by the same team of cardiologists in a university hospital. A database of 7824 PTCAs performed during the last 14 years was analysed. Patients were selected and reviewed by a cardiologist and two radiotherapists with experience in radiation-induced skin injuries. A retrospective analysis of skin doses was performed using data from the patients' files and from the quality assurance (QA) programme of the hospital, which includes periodic patient dose measurements. 14 patients were included in the study. Each patient had undergone between 4 and 14 coronary angiographies and between 5 and 10 PTCAs, performed over a period of 2-10 years. The estimated mean dose-area product per procedure was 46 Gy cm(2) for coronary angiography and 82 Gy cm(2) for PTCA. Mean values of maximum skin dose per procedure were 217 mGy for the diagnostic studies and 391 mGy for the PTCAs. Only a slight radiation skin injury was clinically demonstrated in one patient with a history of 10 coronary angiographies and 10 PTCAs (estimated maximum skin dose 9.5 Gy). Another patient who underwent 14 coronary angiographies and 10 PTCAs (estimated maximum skin dose 7.3 Gy) showed a slight telangiectasia and discrete pigmentation. Another patient with a cutaneous lupus erythematosus showed pigmentation in the area of the radiation field following seven coronary angiographies and six PTCAs (estimated maximum skin dose 5.6 Gy), as expected bearing in mind that skin tolerance to high doses may be altered for patients with this pathology. Each of the remaining 11 patients with no skin injuries had undergone between 5 and 7 PTCAs and between 5 and 14 additional angiographies. None of the 14 patients reported acute skin injuries and no necrosis or radiodermatitis was observed.

The use of dynamic phantoms in interventional radiology.

The authors have constructed a 2D motor-controlled test object phantom holder to simulate clinical situations in which patient movement could be a cause of image degradation. The PAtient MOvement SImulation Test Object (PAMOSITO) has been constructed with modular parts to use different mobile test objects and static structures. The system allows the programming of different cycles of movement along two axes. PAMOSITO has been used in X ray equipment dedicated to interventional radiology. Those systems usually allow for different values for frame rate, pulse width or weighted frame averaging methods. The influence of selecting different values of the parameters, patient movement and its relation to patient dose and image quality has been studied. Image blurring due to motion has been evaluated with Leeds test objects TO.10 and 18FG. Spatial resolution limits and the threshold contrast detail detectability performance have been studied.