The oviduct: a neglected organ due for re-assessment in IVF.

The oviduct has long been considered a 'pipeline', a tube allowing transit of spermatozoa and embryos; this perspective has been reinforced by the success of human IVF. Evidence accumulated over several decades, however, indicates that embryos can modulate the metabolism of tubal cells in their environment. Human IVF culture media is based on formulations that pass mouse embryo assays as quality control: the requirements of mouse embryos differ from those of human embryos, and therefore conditions for human IVF are far removed from the natural environment of the oviduct. The preimplantation environment, both in vitro and in vivo, is known to affect the health of offspring through mechanisms that influence imprinting. Recent studies also show that male accessory glands act in synergy with the oviduct in providing an optimal environment, and this represents a further perspective on the oviduct's contribution to harmonious embryo development and subsequent long-term health. The metabolism of the human embryo is far from being understood, and a 'return' to in-vivo conditions for preimplantation development is worthy of consideration. Although results obtained in rodents must be interpreted with caution, lessons learned from animal embryo culture must not be neglected.

In vitro fertilisation for unexplained subfertility.

BACKGROUND: One-third of subfertile couples have no identifiable cause for their inability to conceive. In vitro fertilisation (IVF) is a widely accepted treatment for this condition; however, this treatment is invasive and expensive and is associated with risks. OBJECTIVES: To evaluate the effectiveness and safety of IVF compared with expectant management, unstimulated intrauterine insemination (IUI) or intrauterine insemination along with ovarian stimulation with gonadotropins (IUI + gonadotropins) or clomiphene (IUI + CC) or letrozole (IUI + letrozole) in improving pregnancy outcomes. SEARCH METHODS: This review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, first quarter), MEDLINE (1946 to May 2015), EMBASE (1985 to May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (May 2015) and reference lists of articles. We searched the following trial registries: clinicaltrials.gov (http://www.clinicaltrials.gov) and the World Health Organization International Trials Registry Platform search portal (http://www.who.int/trialsearch/Default.aspx). We searched the Web of Science (http://wokinfo.com/) as another source of trials and conference abstracts, OpenGrey (http://www.opengrey.eu/) for unpublished literature from Europe and the Latin American Caribbean Health Sciences Literature (LILACS) database (http://regional.bvsalud.org/php/index.php?lang=en). Moreover, we handsearched relevant conference proceedings and contacted study authors to ask about additional publications.Two review authors independently assessed trial eligibility, extracted data and assessed risk of bias. The primary review outcome was cumulative live birth rate. Multiple pregnancy and other adverse effects were secondary outcomes. We combined data to calculate pooled risk ratios (RRs) and 95% confidence intervals (CIs). We assessed statistical heterogeneity by using the I(2) statistic. We assessed the overall quality of evidence for the main comparisons using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which the effectiveness of IVF in couples with unexplained subfertility was compared with that of other treatments, including expectant management, unstimulated IUI and stimulated IUI using gonadotropins or clomiphene or letrozole.Live birth rate (LBR) per woman was the primary outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility and quality of trials and evaluated the quality of the evidence by using GRADE criteria. MAIN RESULTS: IVF versus expectant management (two RCTs):Live birth rate per woman was higher with IVF than with expectant management (odds ratio (OR) 22.00, 95% confidence interval (CI) 2.56 to 189.37, one RCT, 51 women, very low quality evidence). Multiple pregnancy rates (MPRs), ovarian hyperstimulation syndrome (OHSS) and miscarriage were not reported. IVF versus unstimulated IUI (two RCTs):Live birth rate was higher with IVF than with unstimulated IUI (OR 2.47, 95% CI 1.19 to 5.12, two RCTs, 156 women, I(2) = 60%, low quality evidence). There was no evidence of a difference between the groups in multiple pregnancy rates (OR 1.03, 95% CI 0.04 to 27.29, one RCT, 43 women, very low quality evidence) IVF versus IUI + ovarian stimulation with gonadotropins (three RCTs) or clomiphene (one RCT) or letrozole (no RCTs):Data from these trials could not be pooled because of high statistical heterogeneity (I(2) = 93.3%). Heterogeneity was eliminated when studies were stratified by pretreatment status.In trials comparing IVF versus IUI + gonadotropins among treatment-naive women, there was no conclusive evidence of a difference between the groups in live birth rates (OR 1.27, 95% CI 0.94 to 1.73, four RCTs, 745 women, I(2) = 8.0%, moderate-quality evidence). In women pretreated with IUI + clomiphene, a higher live birth rate was reported among those who underwent IVF than those given IUI + gonadotropins (OR 3.90, 95% CI 2.32 to 6.57, one RCT, 280 women, moderate-quality evidence).There was no conclusive evidence of a difference in live birth rates between IVF and IUI + CC in treatment-naive women (OR 2.51, 95% CI 0.96 to 6.55, one RCT, 103 women, low quality evidence).In treatment-naive women, there was no evidence of a difference in rates of multiple pregnancy between women who underwent IVF and those who received IUI + gonadotropins (OR 0.79, 95% CI 0.45 to 1.39, four RCTs, 745 women, I(2) = 0%, moderate quality evidence). There was no evidence of a difference in MPRs between women who underwent IVF compared with those given IUI + CC (OR 1.02, 95% CI 0.20 to 5.31, one RCT, 103 women, low-quality evidence).There was no evidence of a difference in ovarian hyperstimulation syndrome rate between treatment-naive women who underwent IVF and those given IUI + gonadotropins (OR 1.23, 95% CI 0.36 to 4.14, two RCTs, 221 women, low quality evidence). There was no evidence of a difference in OHSS rates between groups receiving IVF versus those receiving IUI + CC (OR 1.02, 95% CI 0.20 to 5.31, one RCT, 103 women, low-quality evidence).In treatment naive women, there was no evidence of a difference in miscarriage rates between IVF and IUI + CC (OR 1.16, 95% CI 0.44 to 3.02, one RCT, 103 women, low-quality evidence), nor between women treated with IVF versus those receiving IUI+ gonadotropins (OR 1.16, 95% CI 0.44 to 3.02, one RCT, 103 women).No studies compared IVF with IUI + letrozole.The quality of the evidence ranged from very low to moderate. The main limitation was serious imprecision resulting from small study numbers and low event rates. AUTHORS' CONCLUSIONS: IVF may be associated with higher live birth rates than expectant management, but there is insufficient evidence to draw firm conclusions. IVF may also be associated with higher live birth rates than unstimulated IUI. In women pretreated with clomiphene + IUI, IVF appears to be associated with higher birth rates than IUI + gonadotropins. However in women who are treatment-naive there is no conclusive evidence of a difference in live birth rates between IVF and IUI + gonadotropins or between IVF and IUI + clomiphene. Adverse events associated with these interventions could not be adequately assessed owing to lack of evidence.

Intrauterine insemination versus fallopian tube sperm perfusion for non-tubal infertility.

BACKGROUND: Intrauterine insemination (IUI) is a common treatment for couples with subfertility that does not involve the fallopian tubes. It is used to bring the sperm close to the released oocyte. Another method of introducing sperm is fallopian tube sperm perfusion (FSP). Fallopian tube sperm perfusion ensures the presence of higher sperm densities in the fallopian tubes at the time of ovulation than does standard IUI. These treatments are often used in combination with ovarian hyperstimulation. OBJECTIVES: To compare intrauterine insemination versus fallopian tube sperm perfusion in the treatment of non-tubal subfertility, for live birth and pregnancy outcomes. SEARCH METHODS: We searched the Menstrual Disorders and Subfertility Group Trials Register, MEDLINE, CINAHL and EMBASE from inception to September 2013. We also searched study reference lists and trial registers. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing IUI with FSP in couples with non-tubal subfertility were included. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, assessed study quality and extracted the data. If studies were sufficiently similar, data were combined using a fixed-effect model to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). A random-effects model was used if substantial statistical heterogeneity was detected. Studies that included participants with unexplained or mixed (non-tubal) subfertility were analysed separately from studies restricted to participants with mild or moderate male factor subfertility. The overall quality of evidence for the main outcomes was summarised using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. MAIN RESULTS: The review included 16 RCTs. Fourteen RCTs (1745 women) were included in the meta-analysis. Only three studies reported live birth per couple. No evidence of a statistically significant difference was noted between IUI and FSP in live birth (OR 0.94, 95% CI 0.59 to 1.49, three RCTs, 633 women, I(2) = 0%, low-quality evidence) or clinical pregnancy (OR 0.75, 95% CI 0.49 to 1.12, 14 RCTs, 1745 women, I(2) = 52%, low-quality evidence). These findings suggest that for a couple with a 13% chance of live birth using FSP, the chance when using IUI will be between 8% and 19%; and that for a couple with a 19% chance of pregnancy using FSP, the chance of pregnancy when using IUI will be between 10% and 20%. Nor was evidence found of a statistically significant difference between IUI and FSP in per-pregnancy of multiple pregnancy (OR 0.96, 95% CI 0.44 to 2.07, eight RCTs, 197 women, I(2) = 0%, low-quality evidence), miscarriage (OR 1.23, 95% CI 0.60 to 2.53, seven RCTs, 199 women, I(2) = 0%, low-quality evidence) or ectopic pregnancy (OR 1.71, 95% CI 0.42 to 6.88, four RCTs, 111 women, I(2) = 0%, very low quality evidence). Substantial heterogeneity was noted for the outcome of clinical pregnancy (I(2) = 54%), for which no clear explanation was provided. AUTHORS' CONCLUSIONS: Currently no clear evidence suggests any difference between IUI and FSP with respect to their effectiveness and safety for treating couples with non-tubal subfertility. However, a high level of uncertainty is evident in the findings, and additional research may be useful.

Unexplained infertility: an update and review of practice.

Of the couples unable to conceive without any identifiable cause, 30% are defined as having unexplained infertility. Management depends on duration of infertility and age of female partner. This review describes and comments on the definition and evidence for the management of unexplained infertility. A literature search was conducted in EMBASE, Medline, Ovid and Cochrane Database of Systematic reviews using the terms 'infertility', 'unexplained infertility', 'idiopathic infertility', 'definition of infertility', 'treatment options', 'intrauterine insemination', 'ovulation induction', 'Fallopian tube sperm', 'GIFT' and 'IVF'. There is no uniform definition for unexplained infertility. This varies in the literature depending on the duration of infertility and the age of the female partner. The treatment of unexplained infertility is empirical and many different regimens have been used. Among these are expectant management, ovulation stimulation with clomiphene citrate, gonadotrophins and aromatase inhibitors, Fallopian tube sperm perfusion, tubal flushing, intrauterine insemination, gamete intra-Fallopian transfer and IVF. The standard protocol is to progress from low-technology to high-technology treatment options. On the best available evidence, an algorithm for management is suggested. There is a definite need for multicentre randomized controlled trials to identify the best treatment option in unexplained infertility using a standard definition.

Ovarian stimulation and intrauterine insemination in women aged 40 years or more.

Fertility decreases with advancing age. This study retrospectively reviewed the results of ovarian stimulation and intrauterine insemination (IUI) in women 40 years old with diminished ovarian reserve or unexplained infertility who underwent treatment with ovarian stimulation/IUI with clomiphene citrate or gonadotrophin and compared them with the results of IVF and in-vitro maturation (IVM) treatments. The main outcome measures were pregnancy and live-birth rates. The profiles of the patients in ovarian stimulation, IVM and IVF groups were comparable. There were no clinical pregnancies in the clomiphene citrate and IVM groups. The clinical-pregnancy rates in the gonadotrophin and IVF groups were 2.6% and 16.9% and the live-birth rates were 2.6% and 13.7%, respectively. Compared with ovarian stimulation, IVF is most effective for women aged 40 years or more. Attempting success with ovarian stimulation or IVM will delay conception unnecessarily.

Successful pregnancy outcome following gamete intra-Fallopian transfer in a patient with Müllerian dysgenesis.

A 29-year-old lady with Müllerian dysgenesis was keen to have a baby. Clinically, she was medium built with well-developed secondary female sexual characteristics. There was a short and blind vagina. She had undergone surgery for an imperforated hymen. Her FSH and LH concentrations were normal. Laparoscopy revealed a patent right Fallopian tube, a rudimentary right uterus and extensive pelvic endometriosis. She subsequently underwent gamete intra-Fallopian transfer (GIFT). Oocyte retrieval was carried out laparoscopically and a total of nine oocytes were retrieved. Four of the oocytes were transferred together with motile spermatozoa into the right Fallopian tube and the remaining five oocytes were inseminated with spermatozoa for IVF. Three embryos resulted and were frozen. She subsequently developed moderate ovarian hyperstimulation syndrome. Serum ß-human chorionic gonadotrophin concentration 14 days after GIFT was 1612 IU/l. Her antenatal care was relatively uneventful until 31 weeks of gestation when she was diagnosed to have intrauterine growth retardation and oligohydramnios. She then underwent an emergency Caesarean section at 32 weeks of pregnancy delivering a normal baby. This case study describes a successful pregnancy outcome following gamete intra-Fallopian transfer (GIFT) in a woman with malformation of the vagina (Müllerian dysgenesis). A 29-year-old lady with Müllerian dysgenesis diagnosed at 16 years of age was keen to become pregnant. Upon examination, a decision was made for a William's vulvovaginoplasty but as the patient was indecisive the surgery was deferred. Clinically, she is a medium-built lady with well-developed secondary female sexual characteristics. There was a short and blind vagina. Her serum FSH and LH concentrations were normal. Laparoscopy revealed a patent right Fallopian tube, a rudimentary right uterus and extensive pelvic endometriosis. She subsequently underwent GIFT. Nine oocytes were retrieved through laparoscopy. Four of the oocytes were transferred together with motile sperm into the right Fallopian tube and the remaining five oocytes were inseminated with sperm for IVF. Three embryos resulted and were frozen. Serum ß human chorionic gonadotrophin concentration measured 14 days after GIFT was 1612 IU/l. An abdominal ultrasonography performed at 5 weeks showed one intrauterine gestational sac. Her antenatal care was uneventful until 31 weeks of gestation when she developed a deficiency of amniotic fluid in the amniotic sac. She then underwent an emergency Caesarean section at 32 weeks of pregnancy. She delivered a healthy, normal 1.24 kg baby boy. Her post-natal care was uneventful.

In vitro fertilisation for unexplained subfertility.

BACKGROUND: In vitro fertilisation (IVF) is a widely accepted treatment for unexplained infertility (NICE 2004), which affects up to a third of all infertile couples. With estimated live birth rates (LBRs) per cycle varying from 33.1% in women aged under 35 years down to 12.5% in women aged between 40 and 42 years (HFEA 2011), its effectiveness has not been rigorously evaluated in comparison with other treatments. With increasing awareness of the role of expectant management, less-invasive procedures such as intrauterine insemination (IUI), and concerns about multiple pregnancies and costs associated with IVF, it is important to evaluate the effectiveness of IVF against other treatment options in couples with unexplained infertility. OBJECTIVES: To evaluate the effectiveness and safety of IVF compared to expectant management, clomiphene citrate, IUI alone and intrauterine insemination plus controlled ovarian stimulation (IUI+SO). SEARCH METHODS: Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched July 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, first quarter), MEDLINE (1970 to July 2011), EMBASE (1985 to July 2011) and reference lists of articles were searched. Relevant conference proceedings were handsearched. Authors were contacted. SELECTION CRITERIA: Randomised controlled trials (RCTs) were included. LBR per woman was the primary outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligibility and quality of trials. MAIN RESULTS: Six RCTs were included in the final analysis. LBR per woman was significantly higher with IVF (45.8%) than expectant management (3.7%) (odds ratio (OR) 22.00, 95% confidence interval (CI) 2.56 to 189.37, 1 RCT, 51 women). There were no comparative data for clomiphene citrate. There was no evidence of a significant difference in LBR between IVF and IUI alone (OR 1.96, 95% CI 0.88 to 4.36, 1 RCT, 113 women), 40.7% with IVF versus 25.9% with IUI. In studies comparing IVF versus IUI+SO, LBR per woman did not differ significantly between the groups among treatment-naive women (OR 1.09, 95% CI 0.74 to 1.59, 2 RCTs, 234 women) but was significantly higher in a large RCT of women pretreated with IUI + clomiphene citrate (OR 2.66, 95% CI 1.94 to 3.63, 1 RCT, 341 women). These three studies could not be pooled due to high heterogeneity (I(2) = 84%). There was no evidence of a significant difference in multiple pregnancy rate (MPR) or ovarian hyperstimulation syndrome (OHSS) between the two treatments (OR 0.64, 95% CI 0.31 to 1.29, 3 RCTs, 351 women; OR 1.53, 95% CI 0.25 to 9.49, 1 RCT, 118 women, respectively). AUTHORS' CONCLUSIONS: IVF may be more effective than IUI+SO. Due to paucity of data from RCTs the effectiveness of IVF for unexplained infertility relative to expectant management, clomiphene citrate and IUI alone remains unproven. Adverse events and the costs associated with these interventions have not been adequately assessed.

[Gamete intrafallopian transfer in the treatment of infertility: knowledge, attitude and perception of students at the Faculty of Health and Medical Sciences in Cotonou- Benin]. / Le don de gamètes dans la prise en charge de l'infertilité du couple: connaissances, attitudes et perception des étudiants en médecine de la Faculté des Sciences de la Santé de Cotonou-Bénin.

Introduction: infertility is a real public health problem. Medically Assisted Procreation (MAP) with donor gametes is one of the possible solutions. In Benin, despite a well-defined legislative framework (children´s code), MAP using donated gametes has not been studied. The purpose of this study was to assess knowledge, attitudes and perceptions of students at the Faculty of Health and Medical Sciences in Cotonou about the donation of gametes. Methods: we conducted a cross-sectional and descriptive study among second or third-year medical students at the Faculty of Health and Medical Sciences (FHMS) in Cotonou. Results: the surveyed sample consisted of 236 students, of whom 54% (n=127) were male and 46% (n=109) were female; the representative age range was between 18 and 24 years (87%). The knowledge of MAP using donated gametes was 90.6% (n=214). The possibility that this treatment might be performed in Benin was known to be 55.6% (n=131). More that eighty-eight percent (n=209) of respondents were unaware of the existence of legislation in force since 2015 on this matter and 69.5% (n=164) refused to donate gametes. Among the reasons mentioned, the ethical reason dominated. Conclusion: in Benin, students´ knowledge about MAP using donated gametes is adequate but there is a widespread refusal to donate their gametes among them, mainly because of ethical issues.

WITHDRAWN: Human menopausal gonadotropin versus recombinant follicle stimulation hormone for ovarian stimulation in assisted reproductive cycles.

BACKGROUND: hMG and recombinant FSH, have both been used successfully for controlled ovarian hyperstimulation in in vitro fertilization and embryo transfer (IVF-ET). OBJECTIVES: To compare the effectiveness of hMG with rFSH in ovarian stimulation protocols in IVF or ICSI treatment cycles. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 3rd Jan 2002), PubMed, MEDLINE, Web of Science (all searched 1985 to May 15 2002), and reference lists of articles. We also contacted manufacturers and researchers in the field. SELECTION CRITERIA: Randomised trials comparing hMG with rFSH for ovarian stimulation in IVF or ICSI treatment for treatment of infertility in normogonadotrophic women. DATA COLLECTION AND ANALYSIS: The main outcome measure was ongoing pregnancy/live birth per woman.Secondary outcomes included total gonadotrophin dose used, cancellation, number of oocytes retrieved, implantation, clinical pregnancy per woman, multiple pregnancy, spontaneous abortion and ovarian hyperstimulation syndrome. Peto odds ratios (OR) for hMG relative to rFSH were calculated after testing for homogeneity of treatment effect across all trials. Analyses were performed separately for the three different GnRHa protocols used: (1) without GnRHa down-regulation, (2) with GnRHa down-regulation using a short protocol and (3) with GnRHa down-regulation using a long protocol. MAIN RESULTS: Eight trials that met the inclusion criteria could be identified. One trial did not use down-regulation, one trial used a short protocol and six trials used a long down-regulation protocol. In the one trial with non-down-regulated women and in the one trial that used a short down-regulation protocol there was no evidence of a difference between hMG and rFSH in any clinical outcome. Data of four truly randomised trials in women down-regulated using a long protocol could be pooled. There was no evidence of a difference between hMG and rFSH in ongoing pregnancy/live birth per woman (OR 1.27; 95% CI 0.98 to 1.64). Furthermore there was no clear difference on any of the secondary outcomes, although the clinical pregnancy rate per woman was of borderline significance in favour of hMG (summary OR 1.28; 95% CI 1.00 to 1.64). The other secondary outcomes were comparable for both gonadotrophins. AUTHORS' CONCLUSIONS: For all three GnRHa protocols analysed there is insufficient evidence of a difference between hMG and rFSH on ongoing pregnancy or live birth. More large randomised trials are needed to estimate the difference between hMG and rFSH more precisely. Such trials should preferably (1) use a consistent long GnRHa protocol and (2) use a fixed dose of gonadotrophin such to prevent potentially subjective decisions of the clinician in dosing and (3) take live birth as primary endpoint. At this moment in time however, in prescribing gonadotrophins for ovarian hyperstimulation in IVF one should use the least expensive medication.

Assisted reproductive technologies in Thailand: 2001-2007 results generated from the ART Registry, Royal Thai College of Obstetricians and Gynaecologists.

AIM: To present the results of assisted reproductive technology (ART) performed in Thailand during 2001-2007. METHODS: All licensed ART centers are obliged to submit annual reports on the number of patients, cycles, ART techniques and treatment outcomes to the Reproductive Medicine Subcommittee of the Royal Thai College of Obstetricians and Gynaecologists. Data from all centers were aggregated and analyzed retrospectively. RESULTS: Cycles were categorized into fresh and frozen/thawed embryo transfer (FET) cycles. Initiated cycles in the first category for 2001 to 2007 were 2183, 2112, 2780, 2717, 3458, 3579 and 4288, respectively. FET cycles during the same period were 467, 558, 733, 768, 1136, 1210 and 1473, respectively. The average pregnancy rate for in vitro fertilization (IVF) was 28.9% per retrieval (range, 26-32.3%) or 33.8% per transfer (range, 30.7-38.6%). Multiple pregnancies (of which 89.3% were twins) from all treatment procedures during this period were 11.4% (range, 9.2-14.5%). A congenital abnormality was reported in 0.56% of live births. The number of embryos per transfer in IVF decreased from 4.1 to 2.9, with no drop in pregnancy rates. Oocyte insemination by intracytoplasmic sperm injection (ICSI) was utilized more often than standard IVF, while gamete intrafallopian transfer and zygote intrafallopian transfer were almost completely replaced by IVF/ICSI. There was a significant difference in pregnancy rates (P < 0.01) when clinics were classified by cycle volumes (<100, 100-400 and >400 cycles/year). CONCLUSIONS: Despite many limitations, the data provided in this report will help patients, clinicians and policy makers understand the current situation of ART practice in Thailand.

Assessment of actin cytoskeleton and nuclei in bovine blastocysts developed under different culture conditions using a novel computer program.

This study was performed to investigate the effects, in terms of nuclear material and actin cytoskeleton quantities (fluorescent pixel counts), of four different bovine blastocyst culturing techniques (in vitro, stepwise in vitro-to-in vivo, or purely in vivo). Cumulus oocyte complexes from abattoir-sourced ovaries were matured in vitro and allocated to four groups: IVP-group embryos developed up to blastocyst stage in vitro. Gamete intra-fallopian transfer (GIFT)-group oocytes were co-incubated with semen for 4 h before transfer to oviducts of heifers. Following in vitro fertilization, cleaved embryos (day 2 of embryo development, day 2-7 group) were transferred into oviducts on day 2. Multiple ovulation embryo transfer (MOET)-group embryos were obtained by superovulating and inseminating heifers; the heifers' genital tracts were flushed at day 7 of blastocyst development. Within each group, ten blastocysts were selected to be differentially dyed (for nuclei and actin cytoskeleton) with fluorescent stains. A novel computer program (ColorAnalyzer) provided differential pixel counts representing organelle quantities. Blastocysts developed only in vivo (MOET group) showed significantly more nuclear material than did blastocysts produced by any other technique. In terms of actin cytoskeleton quantity, blastocysts produced by IVP and by day 2-7 transfer did not differ significantly from each other. Gamete intra-fallopian transfer- and MOET-group embryos showed significantly larger quantities of actin cytoskeleton when compared with any other group and differed significantly from each other. The results of this study indicate that culturing under in vitro conditions, even with part time in vivo techniques, may adversely affect the quantity of blastocyst nuclear material and actin cytoskeleton. The software employed may be useful for culture environment evaluation/developmental competence assessment.

Factors affecting low birthweight after assisted reproduction technology: difference between transfer of fresh and cryopreserved embryos suggests an adverse effect of oocyte collection.

BACKGROUND: Data show that differences exist in the birthweight of singletons after frozen embryo transfer (FET) compared with fresh transfer or gamete intra-Fallopian transfer (GIFT). Factors associated with low birthweight (LBW) after assisted reproduction technology (ART) were studied. METHODS: Birthweight, distribution of birthweight, z-score, LBW (<2500 g), gestation and percentage preterm (<37 weeks) for singleton births >19 weeks gestation, conceived by ART or non-ART treatments (ovulation induction and artificial insemination) between 1978 and 2005 were analysed for one large Australian clinic. RESULTS: For first births, the mean birthweight was significantly (P < 0.005) lower, and LBW and preterm birth more frequent for GIFT (mean = 3133 g, SD = 549, n = 109, LBW = 10.9% and preterm = 10.0%), IVF (3166, 676, 1615, 11.7, 12.5) and ICSI (3206, 697, 1472, 11.5, 11.9) than for FET (3352, 615, 2383, 6.5, 9.2) and non-ART conceptions (3341, 634, 940, 7.1, 8.6). Regression modelling showed ART treatment before 1993 and fresh embryo transfer were negatively related to birthweight after including other covariates: gestation, male sex, parity, birth defects, Caesarean section, perinatal death and socio-economic status. CONCLUSIONS: Birthweights were lower and LBW rates higher after GIFT or fresh embryo transfer than after FET. Results for FET were similar to those for non-ART conceptions. This suggests IVF and ICSI laboratory procedures affecting the embryos are not causal but other factors operating in the woman, perhaps associated with oocyte collection itself, which affect endometrial receptivity, implantation or early pregnancy, may be responsible for LBW with ART.

A Catholic ethical approach to human reproductive technology.

This article presents the Catholic Christian tradition and teaching on the moral respect due to human life from conception, supported by natural law moral philosophical reasoning. This approach contrasts with the ethical views of secular philosophers on human embryo research for therapeutic purposes. The challenges for Catholic healthcare institutions is to find ethical ways of using suitable pluripotent stem cells for therapies without creating or destroying human embryos. Catholic teaching on infertility treatment and reproductive technology are presented with emphasis given to the ethical need for children to be conceived and born of the marriage union compared with alterative ethical approaches for the use of infertility treatment and reproductive technology.

WITHDRAWN: Gonadotrophin-releasing hormone agonist protocols for pituitary desensitization in in vitro fertilization and gamete intrafallopian transfer cycles.

BACKGROUND: Gonadotropin releasing hormone agonists (GnRHa) are used in assisted reproduction cycles to reversibly block pituitary function and prevent a luteinizing hormone surge. In the short and ultrashort protocols of GnRHa administration, injection of gonadotropins is commenced a few days after the start of GnRHa. In the long protocols (with GnRHa started either in the midluteal phase or in the early follicular phase) gonadotropin administration is delayed until pituitary desensitization has been achieved, usually 2-3 weeks. OBJECTIVES: To conduct a systematic overview of available data comparing short or ultrashort and long GnRHa protocols for pituitary desensitization in in vitro fertilization (IVF) and gamete intra-fallopian transfer (GIFT) treatment cycles. SEARCH STRATEGY: Search strategies included on-line searching of the MEDLINE and EMBASE data bases and the Cochrane Menstrual Disorders and Subfertility Group's Specialised Register from 1982 to 1998, and hand searching of bibliographies of relevant publications and reviews, and abstracts of scientific meetings. SELECTION CRITERIA: Randomized trials of short or ultrashort versus long (follicular or luteal phase start) GnRHa protocols in IVF or GIFT treatment cycles. DATA COLLECTION AND ANALYSIS: Data were extracted into 2 x 2 tables. For the primary outcome, clinical pregnancy per cycle started, the overall common odds ratio (OR) and the risk difference with 95% confidence interval (CI) were calculated after verifying the presence of homogeneity of treatment effect across all trials. The following subgroup comparisons were performed: ultrashort versus long protocols, short versus long protocols and, within each of these comparisons, subgroups of studies which used the long protocol with follicular phase start or the long protocol with luteal phase start. Secondary outcomes considered were clinical pregnancy per oocyte retrieval and per embryo transfer, spontaneous abortion, ongoing/delivered pregnancy per cycle started, number of ampoules of gonadotropin used, number of oocytes retrieved, and fertilization rate. MAIN RESULTS: Twenty-six trials met the inclusion criteria. The common OR for clinical pregnancy per cycle started was 1.32 (95% CI , 1.10 - 1.57) in favour of the long GnRHa protocol. The studies were subgrouped, depending on whether, in the long protocol, the GnRHa was commenced in the follicular phase (8 trials) or luteal phase (16 trials). The respective ORs were 1.54 (95% CI, 1.11 - 2.13) and 1.21 (95% CI, 0.98 - 1.51). After excluding the four trials using the ultrashort protocol, the OR for long versus short protocols (22 trials) was 1.27 (95% CI, 1.04 - 1.56). A comparison of long versus ultrashort protocols (4 trials) produced an OR of 1.47 (95% CI, 1.02 - 2.12). AUTHORS' CONCLUSIONS: On the basis of clinical pregnancy rate per cycle started, this meta-analysis demonstrates the superiority of the long protocol over the short and ultrashort protocols for GnRHa use in IVF and GIFT cycles.

A prospective study of the effects of female and male marijuana use on in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT) outcomes.

OBJECTIVE: This study was undertaken to examine whether marijuana use affects in vitro fertilization and gamete intrafallopian transfer (IVF/GIFT). STUDY DESIGN: Prospective study of 221 IVF/GIFT couples. RESULTS: Amount of lifetime heavy marijuana use adversely affected IVF/GIFT. Women smoking more than 90 times in their lifetime had 27% fewer oocytes retrieved (P = .03) and 1 fewer embryo transferred (P < .05). Women smoking marijuana more than 10 times in their lifetime had infants 17% (P = .01) smaller at birth. If men smoked marijuana 11 to 90 times in their lifetime, there was a 15% decrease in infant birth weight (P = .03); if this increased to more than 90 times, there was a 23% decrease (P = .01). Timing also played a role. Women smoking marijuana 1 year before IVF/GIFT had 25% fewer oocytes retrieved (P = .03), whereas couples had 28% (P = .04) fewer oocytes fertilized. Women and men who smoked in the past 15 years, had 12% (P = .04) and 16% (P = .03) smaller infants, respectively. CONCLUSION: Both timing and amount of marijuana use negatively affected IVF/GIFT.

In vitro fertilisation for unexplained subfertility.

BACKGROUND: In vitro fertilisation (IVF) is now a widely accepted treatment for unexplained infertility (RCOG 1998). However, with estimated live-birth rates per cycle varying between 13% and 28%, its effectiveness has not been rigorously evaluated in comparison with other treatments. With increasing awareness of the role of expectant management and less invasive procedures such as intrauterine insemination, concerns about multiple complications and costs associated with IVF, it is extremely important to evaluate the effectiveness of IVF against other treatment options in couples with unexplained infertility. OBJECTIVES: The aim of this review is to determine, in the context of unexplained infertility, whether IVF improves the probability of live-birth compared with (1) expectant management, (2) clomiphene citrate (CC), (3) intrauterine insemination (IUI) alone, (4) IUI with controlled ovarian stimulation, and (5) gamete intrafallopian transfer (GIFT). SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 23 March 2004), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 3, 2004), MEDLINE (1970 to August 2004), EMBASE (1985 to August 2004) and reference lists of articles. We also handsearched relevant conference proceedings and contacted researchers in the field. SELECTION CRITERIA: Only randomised controlled trials were included. Live-birth rate per woman was the primary outcome of interest. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility and quality of trials. MAIN RESULTS: Ten randomised controlled trials were identified. In two we could not extract data separately for unexplained infertility cases, two were non-randomised, one did not report valid rates (included in the review but not in the meta-analysis); leaving four trials for analysis. One trial compared two different interventions (IVF versus IUI with or without ovarian stimulation) and one study compared three interventions (IVF versus IUI with ovarian stimulation and GIFT). The numbers of trials assessing the effectiveness of IVF with the other treatments were as follows: IVF versus expectant management (two), IVF versus IUI (one), IVF versus IUI with ovarian stimulation (two) and IVF versus GIFT (three). Live-birth rate per woman was reported in three studies and three studies determined clinical pregnancy rate per woman. Multiple pregnancy rate was reported in three trials. Two studies reported ovarian hyperstimulation syndrome (OHSS) as an outcome measure. There were no comparative data for clomiphene citrate and no comparative data on live-birth rates for GIFT. There was no evidence of a difference in live-birth rates between IVF and IUI either without (OR 1.96; 95% CI 0.88 to 4.4) or with (OR 1.15; 95% CI 0.55 to 2.4) ovarian stimulation. There were significantly higher clinical pregnancy rates with IVF in comparison to expectant management (OR 3.24; 95% CI 1.07 to 9.80). There was no significant difference between IVF and GIFT for the one RCT that reported live-birth rates (OR 2.57; 95% CI 0.93 to 7.08). However, there was a significant difference in the clinical pregnancy rates between IVF and GIFT, with pregnancy rates greater for IVF (OR 2.14; 95% CI 1.08 to 4.2). There was no evidence of a difference in the multiple pregnancy rates between IVF and IUI with ovarian stimulation (OR 0.63; 95% CI 0.27 to 1.5), however, IVF had a higher rate than GIFT (OR 6.3; 95% CI 1.7 to 23). Clinical heterogeneity was present among the studies included. However, there was no evidence of statistical heterogeneity, which allowed the studies to be combined for statistical analysis. AUTHORS' CONCLUSIONS: Any effect of IVF relative to expectant management, clomiphene citrate, IUI with or without ovarian stimulation and GIFT in terms of live-birth rates for couples with unexplained subfertility remains unknown. The studies included are limited by their small sample size so that even large differences might be hidden. Live-birth rates are seldom reported. Periods of follow up are inadequate and unequal. Adverse effects such as multiple pregnancies and ovarian hyperstimulation syndrome have also not been reported in most studies. Larger trials with adequate power are warranted to establish the effectiveness of IVF in these women. Future trials should not only report rates per woman/couple but also include adverse effects and costs of the treatments as outcomes. Factors that have a major effect on these outcomes such as fertility treatment, female partner's age, duration of infertility and previous pregnancy history should also be considered.

Intrafallopian transfer of gametes and early stage embryos for in vivo culture in cattle.

It may be possible to avoid inadequate in vitro culture conditions by incubating gametes or embryos in the oviducts for a short time. Ideally, an optimized procedure should be devised, combining in vitro and in vivo systems, in order to achieve synchronization in cattle. We transferred gametes as well as embryos in various stages of development and placed them into the oviducts. Embryos were recovered on Day 7 by flushing of oviducts and uterine horns. Blastocyst rates were determined on Day 7 and on Day 8. Experimental designs included transfer of in vitro matured cumulus oocyte complexes into previously inseminated heifers (COCs group), transfer of in vitro matured COCs simultaneously with capacitated spermatozoa (GIFTs group), transfer of four to eight cell stage embryos developed in vitro after IVM/IVF (Cleaved Stages group) and a group of solely in vitro produced embryos (IVP control group). Our results indicate that in vivo culture of IVM/IVF embryos in the homologous bovine oviduct has a positive influence on subsequent pre-implantation development. In addition, we have evidence that in vitro maturation and in vivo fertilization cannot be synchronized.

Ethnic background and in vitro fertilization outcomes.

OBJECTIVE: To compare IVF outcomes among women of different ethnic backgrounds. METHOD: This was a retrospective cohort study. Between August 1994 and March 1998, the first IVF cycles of 1039 white, 43 African American, 18 Hispanic, and 35 Asian women were examined. RESULT: Ages and day 3 FSH levels did not differ significantly among patients. African Americans weighed more than other ethnic groups and were also more likely to have tubal factor infertility than whites. IVF cycle characteristics did not vary among the ethnic groups with the exception that African Americans had a higher level of estradiol on day of HCG than whites. Pregnancy outcomes did not differ among the ethnic groups. The percentage of ectopic pregnancies, spontaneous abortions, and successful live births was similar among the groups. CONCLUSION: Our data showed no significant difference in pregnancy outcomes with IVF among the ethnic groups.

Human reproductive technologies and the law: a select committee report.

The House of Commons Science & Technology Committee has reviewed the Human Fertilisation and Embryology Act. It considered a) the balance between legislation, regulation and reproductive freedom; b) the role of Parliament in human reproductive technologies; and c) the foundation, adequacy and appropriateness of the ethical framework for legislation. It also considered the Act itself and the workings of the Human Fertilisation and Embryology Authority. Its report is written from a very liberal perspective, but is a very thorough overview of current issues and debate in the field. There follow, slightly abridged, the conclusions and recommendations of the 200-page report.

Is the luteo-placental shift a myth? Analysis of low progesterone levels in successful art pregnancies.

Progesterone (P4) is considered vital to the maintenance of human pregnancy, but the minimal concentration of P4 necessary to sustain human pregnancy remains unclear. The aim of this study was to examine endocrine profiles for serum P4, 17 beta-estradiol (E2), and human (h) beta-CG in early pregnancy from a group of assisted reproductive technologies (ART) patients. These subjects delivered normally but had P4 concentrations below the fifth percentile of the normal singleton pregnancy range from 2 weeks after ART. Normal ranges of these hormones were determined from 118 consecutive ART pregnancies which resulted in singleton births. Values below the fifth percentile (P4 < 35.9 nmol/L at 4 weeks gestation) were considered abnormal. Eight patients who subsequently delivered normally, with serum P4 values below this criterion at 4 weeks gestation, were found. They had serum P4 values at 4 weeks gestation ranging from 1.9-29.9 nmol/L, and their mean P4 values at 5 weeks (30.2 +/- 9.2 nmol/L; mean +/- SE) and 6 weeks gestation (48.0 +/- 10.2 nmol/L) remained below the fifth percentile. No statistically significant increase in serum P4 concentrations occurred between 7 and 11 weeks gestation in these women. Their mean E2 value in serum at 4 weeks gestation (382 +/- 73 pmol/L) was also below the fifth percentile but their mean beta-hCG concentration was within the normal range. We conclude that successful human pregnancy is possible with serum P4 values within the anovulatory range in early gestation and that, in individual patients, serum P4 concentration of 2 nmol/L can be sufficient to maintain human pregnancy.