The clinical effectiveness of CBT-based guided self-help interventions for anxiety and depressive disorders: a systematic review.

BACKGROUND: Cognitive-behavioural therapy (CBT)-based guided self-help (GSH) has been suggested to be an effective intervention for mild to moderate anxiety and depression, yet the evidence seems inconclusive, with some studies reporting that GSH is effective and others finding that GSH is ineffective. GSH differs in important respects from other levels of self-help, yet the literature regarding exclusively guided self-help interventions for anxiety and depression has not been reviewed systematically. METHOD: A literature search for randomized controlled trials (RCTs) examining CBT-based GSH interventions for anxiety and depressive disorders was conducted. Multiple electronic databases were searched; several journals spanning key disciplines were hand-searched; reference lists of included review articles were scanned and relevant first authors were contacted. RESULTS: Thirteen studies met the inclusion criteria. Meta-analysis indicated the effectiveness of GSH at post-treatment, although GSH was found to have limited effectiveness at follow-up or among more clinically representative samples. Studies that reported greater effectiveness of GSH tended to be of lower methodological quality and generally involved participants who were self-selected rather than recruited through clinical referrals. CONCLUSIONS: Although there is support for the effectiveness of CBT-based GSH among media-recruited individuals, the finding that the reviewed RCTs had limited effectiveness within routine clinical practice demonstrates that the evidence is not conclusive. Further rigorous evidence based on clinical populations that examines longer-term outcomes is required before CBT-based GSH interventions can be deemed effective for adults accessing primary care services for treatment of anxiety and depression.

First Irish pregnancies after IVF with gestational carrier.

In this report, our early experience with screening, monitoring and coordinating IVF utilising gestational carrier treatment is described. Although congenital and iatrogenic etiologies for uterine factor infertility manifest distinctly different reasons for considering a gestational carrier approach, we outline a unified management strategy for both conditions. One patient had congenital absence of the uterus and proximal vagina (Mayer-Rokitansky-Kuster-Hauser syndrome variant), while another patient presented post-hysterectomy and adjuvant brachytherapy for invasive squamous cervical carcinoma. Conception was established for both patients, the first pregnancies to be achieved using an IVF/gestational carrier technique in Ireland. As demonstrated here, selected patients with at least one intact ovary who suffer from uterine factor infertility can be excellent candidates for IVF with embryo transfer to a carefully screened gestational carrier. The role of individual and group counselling is reviewed; professional legal advice is prudent in complex cases.

Blastocyst transfer for multiple prior IVF failure: a five year descriptive study.

Patients with recurrent IVF failure are generally regarded as having a poor prognosis, and when female age exceeds 35 yrs such patients face a particularly bleak outlook. This study reported on blastocyst transfer (BT) performed over a five-year interval in patients seeking "second opinion" after multiple failed IVF cycles. Clinical features and reproductive outcomes were compared between two sets of poor-prognosis IVF patients undergoing BT for the first time, the initial group underwent treatment in 2002 (n=66) and a second group presented five years later (n=392). The two clinical sets had no patients in common. The 2002 group had an average of 3.5 (+/- 1.1) prior failed IVF cycles at baseline, and mean (+/- SD) patient age was 36.4 (+/- 3.9) yrs. Average number of oocytes retrieved in this group was 10.4 (+/- 5.3) with a fertilisation rate of 58.8%. Although embryo arrest resulted in no transfer for 19 patients (28.8%), clinical pregnancy was achieved for 59.6% of transfers. Five years later, 392 patients underwent BT, but this group had an average of 4.5 (+/- 2.3) prior failed IVF cycles. Mean (+/- SD) female age was 36.0 (+/- 3.9) yrs, and the average number of oocytes retrieved in this group was 9.1 (+/- 5.4); the fertilisation rate was 59.5%. No blastocysts were available for transfer in 99 cases (25.3%); clinical pregnancy was achieved for 50.0% of transfers. The number of blastocysts transferred was similar in the two groups (1.6 vs. 1.3; p=0.06); the twinning rate rose slightly from 8.2% to 15.1% (p=0.12) despite an increased utilisation of single embryo transfer in 2007 (19.7% vs. 22.2%; p=0.40). Comparisons from 2002 and 2007 found no important differences between the two patient groups, except for a significantly higher rate of prior failed cycles in the 2007 group (p<0.001). This refractoriness was accompanied by a somewhat reduced blastocyst cryopreservation rate in 2007, compared to 2002 (27.6% vs. 29.5%; p=0.44). Clinical pregnancy rates are not adversely affected by application of BT in patients with multiple prior unsuccessful IVF cycles. For these patients, our data suggest that extended embryo culture and BT should be considered. Further controlled studies are needed to document more precisely the role of BT in this sub-set of refractory IVF patients.

First reported deliveries in Ireland using surgically retrieved sperm for non-obstructive azoospermia.

Couples presenting with male factor infertility comprise an important proportion of clinical reproductive endocrinology consultations. Indeed, a problem with the male is the only cause, or a contributing cause, of infertility in ~40% of infertility evaluations. Here we present the first published deliveries obtained from IVF utilising surgically retrieved sperm in Ireland; pregnancy and delivery are also described following transfer of cryopreserved/thawed embryos derived from such sperm. Finding no sperm from a semen analysis in a man without a vasectomy can be a devastating event, and substantially influences the scope of the reproductive endocrinology consultation. Successful treatment of non-obstructive azoospermia is possible without reliance on anonymous donor sperm.

Internalization of cellular fragments in a human embryo: time-lapse recordings.

An observation is reported of internalization of a cellular fragment into a blastomere from a human embryo, as documented by time-lapse photography. The fragment, created during the first mitotic cleavage was reabsorbed into one of the mother blastomeres in less than 5 min. The time-lapse sequence, shown here as a series of still photographs, provides the first direct evidence that cellular fragments in human embryos can 'disappear' during the culture period, a phenomenon that is common in human IVF. The time-lapse sequence itself may be viewed on the internet at www.rbmonline.com/Article/633.

Fatty acid composition of lipids in immature cattle, pig and sheep oocytes with intact zona pellucida.

Cattle, pig and sheep oocytes isolated from healthy cumulus-oocyte complexes were pooled, within species, to provide samples of immature denuded oocytes with intact zona pellucida (n = 1000 per sample) for determination of fatty acid mass and composition in total lipid, constituent phospholipid and triglyceride. Acyl-containing lipid extracts, transmethylated in the presence of a reference penta-decaenoic acid (15:0), yielded fatty acid methyl esters which were analysed by gas chromatograph. Mean (+/- SEM) fatty acid content in samples of pig oocytes (161 +/- 18 micrograms per 1000 oocytes) was greater than that in cattle (63 +/- 6 micrograms; P < 0.01) and sheep oocytes (89 +/- 7 micrograms; P < 0.05). Of 24 fatty acids detected, palmitic (16:0; 25-35%, w/w), stearic (18:0; 14-16%) and oleic (18:1n-9; 22-26%) acids were most prominent in all three species. Saturated fatty acids (mean = 45-55%, w/w) were more abundant than mono- (27-34%) or polyunsaturates (11-21%). Fatty acids of the n-6 series, notably linoleic (18:2n-6; 5-8%, w/w) and arachidonic acid (20:4n-6; 1-3%), were the most abundant polyunsaturates. Phospholipid consistently accounted for a quarter of all fatty acids in the three species, but ruminant oocytes had a lower complement of polyunsaturates (14-19%, w/w) in this fraction than pig oocytes (34%, w/w) which, for example, had a three- to fourfold greater linoleic acid content. An estimated 74 ng of fatty acid was sequestered in the triglyceride fraction of individual pig oocytes compared with 23-25 ng in ruminant oocytes (P < 0.01). It is concluded that the greater fatty acid content of pig oocytes is primarily due to more abundant triglyceride reserves. Furthermore, this species-specific difference, and that in respect of polyunsaturated fatty acid reserves, may underlie the contrasting chilling, culture and cryopreservation sensitivities of embryos derived from pig and ruminant (cattle, sheep) oocytes.