Endometrial preparation protocols prior to frozen embryo transfer - convenience or safety?

The number of frozen embryo transfer (FET) cycles is increasing rapidly worldwide. Different endometrial preparations for FET result in comparable live birth rates. However, several recent publications have reported higher maternal risks for hypertensive disorders of pregnancy (HDP), pre-eclampsia and postpartum haemorrhage (PPH) in programmed cycles (PC-FET) compared with natural cycles and modified natural cycles with an intact corpus luteum. Nevertheless, PC-FET is frequently used in ovulatory women despite the increased risks for HDP, pre-eclampsia and PPH. Although randomized controlled studies have been suggested, PC-FET raises several methodological problems. Large study populations would be required to investigate the outcomes in question, and the inclusion of ovulatory women, where the intervention may increase the risk of a negative outcome, is ethically troublesome. In the authors' opinion, the existing evidence from large observational studies and systematic reviews is sufficiently strong to recommend an endometrial preparation strategy that aims to maintain or stimulate the corpus luteum to minimize the risk of HDP and pre-eclampsia after FET cycles.

A study of the experience of Norwegian IVF physicians in evaluating the parenting capacity of patients.

RESEARCH QUESTION: How do Norwegian fertility doctors assess the parenting capacity of applicants, and how do they experience and evaluate the assessment practice? DESIGN: Qualitative interview study with 14 Norwegian fertility doctors. Interviews were analysed with systematic text condensation, a qualitative analysis framework. RESULTS: Norwegian fertility doctors deem parenting capacity assessments of applicants to be straightforward and simple in most cases. Yet, some cases of doubt pose difficulties. Physicians can then draw on resources such as colleagues, physicians from other specialties who know the patient and patient records. All the participating physicians agreed with the principle of parenting capacity assessment for patients seeking fertility treatment. The assessment enabled physicians to refuse patients whom they thought should definitely not have responsibility for children. The physicians' main argument was their own felt responsibility for the future child. Even though assessments could be challenging, the participants all thought of themselves as competent to perform them. Indeed, some thought that delegating the assessments would imply abdicating a responsibility that was properly theirs. Although national guidelines might aid decision-making, the physicians would not want guidelines to curtail the significant discretion that they exercised. CONCLUSIONS: Whether societies should assess applicants' capacity for parenthood before fertility treatment is an ethical and political question. Although sometimes a difficult task, Norwegian fertility doctors see it as important, and as something they are competent and suited to undertake.

The demographics of assisted reproductive technology births in a Nordic country.

STUDY QUESTION: What are the socio-demographic characteristics of families in Norway who have children after assisted reproductive technology (ART), and have these characteristics changed over time? SUMMARY ANSWER: Parents who conceive through ART in Norway tend to be advantaged families, and their socio-demographic profile has not changed considerably over the period 1985-2014. WHAT IS KNOWN ALREADY: A small number of studies show that couples who conceive through ART tend to be socio-economically advantaged. STUDY DESIGN, SIZE, DURATION: Norwegian Population Register, the Medical Birth Register and the national data bases were linked to study all live births in Norway between 1985 and 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS: The sample consisted of 1 757 768 live births. Simple bivariate analyses were performed to describe the socio-demographic characteristics of parents who conceived through ART and changes in these characteristics over the time period 1985-2014. We used linear probability models to estimate the association between parental income and giving birth after ART from 2000 to 2014, before and after adjustment for maternal age at delivery, education and area of residence. MAIN RESULTS AND THE ROLE OF CHANCE: Parents conceiving through ART were more likely to be older, with the highest levels of income and education, and married. Their socio-demographic profiles did not change considerably during the period 1985-2014. In the unadjusted model, parents belonging to the top income quartile were 4.2 percentage points more likely (95% CI: 4.1 to 4.3) to have conceived through ART than parents who belonged to the bottom income quartile. Adjustment for maternal age only partially reduced the income disparities (for the top income quartile by 35% (ß = 2.7 with 95% CI: 2.5 to 2.8)). Additional adjustment for maternal education, marital status and area of residence did not further attenuate the associations. LIMITATIONS, REASONS FOR CAUTION: The data does not enable us to tell whether the lower numbers of children conceived through ART amongst more disadvantaged individuals is caused by lower success rates with ART treatment, lower demand of ART services or barriers faced in access to ART. The study focuses on Norway, a context characterised by high subsidisation of ART services. WIDER IMPLICATIONS OF THE FINDINGS: Even though in Norway access to ART services is highly subsidised, the results highlight important and persisting social inequities in use of ART. The results also indicate that children born after ART grow up in resourceful environments, which will benefit their development and well-being. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by European Research Council agreement n. 803959 (to A.G.), by Economic and Social Research Council grant ES/M001660/1 and by the Research Council of Norway through its Centres of Excellence funding scheme, project number 262700. The authors have no conflict of interest to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Next-generation sequencing of the monogenic obesity genes LEP, LEPR, MC4R, PCSK1 and POMC in a Norwegian cohort of patients with morbid obesity and normal weight controls.

BACKGROUND: Rare sequence variants in at least five genes are known to cause monogenic obesity. In this study we aimed to investigate the prevalence of, and characterize, rare coding and splice site variants in LEP, LEPR, MC4R, PCSK1 and POMC in patients with morbid obesity and normal weight controls. METHOD: Targeted next-generation sequencing of all exons in LEP, LEPR, MC4R, PCSK1 and POMC was performed in 485 patients with morbid obesity and 327 normal weight population-based controls from Norway. RESULTS: In total 151 variants were detected. Twenty-eight (18.5%) of these were rare, coding or splice variants and five (3.3%) were novel. All individuals, except one control, were heterozygous for the 28 variants, and the distribution of the rare variants showed a significantly higher carrier frequency among cases than controls (9.9% vs. 4.9%, p=0.011). Four variants in MC4R were classified as pathogenic or likely pathogenic. CONCLUSION: Four cases (0.8%) of monogenic obesity were detected, all due to MC4R variants previously linked to monogenic obesity. Significant differences in carrier frequencies among patients with morbid obesity and normal weight controls suggest an association between heterozygous rare coding variants in these five genes and morbid obesity. However, additional studies in larger cohorts and functional testing of the novel variants identified are required to confirm the findings.

Can IVF influence human evolution?

IVF, a procedure in which pharmacological and technological manipulation is used to promote pregnancy, offers help to infertile couples by circumventing selection at the most fundamental level. Fertility is clearly one of the key fitness-promoting drivers in all forms of sexually reproducing life, and fertilization and pregnancy are fundamental evolutionary processes that involve a range of pre- and post-zygotic screening mechanisms. Here, we discuss the various selection and screening factors involved in fertilization and pregnancy and assess IVF practices in light of these factors. We then focus on the possible consequences of these differences in selection pressures, mainly at the individual but also at the population level, to evaluate whether changes in the reproducing genotype can affect human evolution. The aim of the article is not to argue for or against IVF, but to address aspects of assisted reproduction in an evolutionary context.

Telomere length in relation to fecundability and use of assisted reproductive technologies: the Norwegian Mother, Father, and Child Cohort Study.

In women, shorter telomeres have been reported to be associated with conditions such as endometriosis and polycystic ovary syndrome, whereas other studies have reported the opposite. In men, studies mostly report associations between shorter telomeres and sperm quality. To our knowledge, no studies have thus far investigated the associations between TL and fecundability or the use of ART. This study is based on the Norwegian Mother, Father, and Child Cohort (MoBa) Study and uses data from the Medical Birth Registry of Norway (MBRN). We included women (24,645 with genotype data and 1,054 with TL measurements) and men (18,339 with genotype data and 965 with TL measurements) participating between 1998 and 2008. We investigated the associations between leukocyte TL and fecundability, infertility, and the use of ART. We also repeated the analyses using instrumental variables for TL, including genetic risk scores for TL and genetically predicted TL. Approximately 11% of couples had experienced infertility and 4% had used ART. TL was not associated with fecundability among women (fecundability ratio [FR], 0.98; 95% confidence interval [CI], 0.92-1.04) or men (FR, 0.99; CI, 0.93-1.06), nor with infertility among women (odds ratio [OR], 1.03; CI, 0.85-1.24) or men (OR, 1.05; CI, 0.87-1.28). We observed an increased likelihood of using ART with increasing TL among men (OR, 1.22; CI, 1.03-1.46), but not among women (OR, 1.10; CI, 0.92-1.31). No significant associations were observed using the instrumental variables. Our results indicate that TL is a poor biomarker of fecundability, infertility and use of ART in MoBa. Additional studies are required to replicate the association observed between TL and ART in men.

Reproductive outcomes in women and men conceived by assisted reproductive technologies in Norway: prospective registry based study.

Objectives: To determine whether the perinatal outcomes of women or men who were conceived by assisted reproductive technologies are different compared with their peers who were naturally conceived. Design: Prospective registry based study. Setting: Medical Birth Registry of Norway. Participants: People born in Norway between 1984 and 2002 with a registered pregnancy by the end of 2021. Exposure: People who were conceived by assisted reproductive technologies and have had a registered pregnancy. Main outcome measures: Comparing pregnancies and births of people who were conceived by assisted reproductive technologies and people who were naturally conceived, we assessed mean birth weight, gestational age, and placental weight by linear regression, additionally, the odds of congenital malformations, a low 5 min Apgar score (<7), transfer to a neonatal intensive care unit, delivery by caesarean section, use of assisted reproductive technologies, hypertensive disorders of pregnancy and pre-eclampsia, preterm birth, and offspring sex, by logistic regression. The occurrence of any registered pregnancy from people aged 14 years until age at the end of follow-up was assessed using Cox proportional regression for both groups. Results: Among 1 092 151 people born in Norway from 1984 to 2002, 180 652 were registered at least once as mothers, and 137 530 as fathers. Of these, 399 men and 553 women were conceived by assisted reproductive technologies. People who were conceived by assisted reproductive technologies had little evidence of increased risk of adverse outcomes in their own pregnancies, increased use of assisted reproductive technologies, or any difference in mean birth weight, placental weight, or gestational age. The only exception was for an increased risk of the neonate having a low Apgar score at 5 min (adjusted odds ratio 1.86 (95% confidence interval 1.20 to 2.89)) among women who were conceived by assisted reproductive technologies. Odds were slightly decreased of having a boy among mothers conceived by assisted reproductive technologies (odds ratio 0.79 (95% confidence interval 0.67 to 0.93)). People conceived by assisted reproductive technologies were slightly less likely to have a registered pregnancy within the follow-up period (women, adjusted hazard ratio 0.88 (95% CI 0.81 to 0.96); men, 0.91 (0.83 to 1.01)). Conclusions: People conceived by assisted reproductive technologies were not at increased risk of obstetric or perinatal complications when becoming parents. The proportion of people conceived by assisted reproductive technologies with a registered pregnancy was lower than among people who were naturally conceived, but a longer follow-up is required to fully assess their fertility and reproductive history.

Increased risk of ovarian hyperstimulation syndrome following controlled ovarian hyperstimulation in patients with vascular endothelial growth factor +405 cc genotype.

Ovarian hyperstimulation syndrome (OHSS) is a serious complication following controlled ovarian hyperstimulation (COH) for in vitro fertilization. OHSS has a range of clinical features from mild abdominal distention to severe thromboembolic events. Several clinical manifestations of OHSS such as ascites and hemoconcentration can be attributed to increased vascular permeability. Vascular endothelial growth factor (VEGF) and its receptor VEGFR2 have been identified as an important signaling system in mediating this increase. There is considerable genetic variation in the VEGF/R2 signaling system. We present the first study to examine if single nucleotide polymorphisms (SNPs) in the genes encoding the VEGF/R2 signaling system are associated with OHSS following COH. Blood samples from 53 OHSS patients and 100 controls were analyzed for six SNPs of interest. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated by a multivariate logistic regression model. We found an association between the VEGF +405cc genotype and OHSS (OR 3.4, 95% CI 1.01-11.7). This finding requires confirmation from other patient populations.

[Results after assisted reproduction at a public fertility clinic]. / Resultater etter assistert befruktning i en offentlig fertilitetsklinikk.

BACKGROUND: Assisted reproduction is traditionally regarded as effective when it results in a high pregnancy rate per started treatment cycle. For the patients, it is more interesting to know how high the probability is of giving birth during a full course of assisted reproduction treatment. MATERIAL AND METHOD: Retrospective series of 546 patients followed for three years of assisted reproduction at a public fertility clinic. RESULTS: During the follow-up period, 347 of the patients (63.6%) gave birth by means of assisted reproduction. Of the 199 remaining patients, 70 (12.8% of 546) stopped treatment because they had completed the three treatment cycles that are covered by public funding. Thirty seven patients (6.8% of 546) conceived without assisted reproduction. INTERPRETATION: Assisted reproduction at public fertility clinics in Norway is as effective as that in our neighbouring countries. Over the past 18 years, the effectiveness of assisted reproduction has increased by about 50%.

IVF and human evolution.

Humans are shaped by evolution through natural selection, as are all species. While evolution is central to all biological processes, the key stage for competition and selection is reproduction, which encompasses various events from courtship and mating to fertilization and pregnancy. In humans, IVF is used to aid the intrinsically inefficient reproduction by coitus, and in several countries, the proportion of children born after IVF is increasing. While IVF is an enabling technology for infertile patients, it also circumvents reproductive barriers and changes selection pressures. This grand theme review describes the systematic differences between IVF and coitus in selection pressures on reproducing cells, individuals and populations. At the cellular unit of selection, for example, IVF favours different traits in spermatozoa (fast swimmers over short distances) than coitus does (forward mobility over longer distances). Similarly, a male with low sperm quality and a female who decides to delay her first birth to an advanced age, can both increase their reproductive fitness by IVF compared to if reproduction by coitus is their only option. In as much as delayed reproduction is a cultural trait, IVF thus enables cultural practices that may in their turn affect human evolution. A main point in this review is to discuss the interactive effects of biological and cultural traits in the context of IVF, and how they act in concert as drivers towards increased demand for IVF. It is not the aim of this review to argue against IVF, which no doubt is a major medical advancement, but rather to examine IVF and human evolution from a broad perspective, including potential longer-term impacts. Since IVF is a young technology, the empirical data indicative of evolutionary effects of IVF in humans are sparse. In general, we argue that IVF facilitates the redirection of resources away from reproduction in humans, since reproduction by IVF bypasses some of the resource-demanding processes that reproduction by coitus entails. Hence, IVF sets the evolutionary stage for a human species increasingly reliant on, and adapted to, technological means of reproduction.

A single nucleotide polymorphism in BMP15 is associated with high response to ovarian stimulation.

There is substantial variability in ovarian response to exogenous gonadotrophins in women undergoing ovarian stimulation for IVF. Genetic variation in signalling pathways of the ovary may influence ovarian stimulation outcome. One previous study showed an association between single nucleotide polymorphisms (SNP) in the gene for bone morphogenetic protein 15 (BMP15) and ovarian hyperstimulation syndrome (OHSS). This article presents a retrospective case-controlled genetic-association study designed to test the association between SNP in the BMP15 gene and two clinically important outcomes of ovarian stimulation: low and high response. Blood samples from 53 high responders, 38 low responders and 100 controls were analysed for five SNP of interest. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated by a multivariate logistic regression model. We found an association between the BMP15 -9G allele and high response to ovarian stimulation (OR=2.7, 95% CI=1.3-5.7). This association confirms previous findings in a different population and strengthens the case for an association between this SNP and ovarian stimulation outcome.

Single nucleotide polymorphisms in the anti-Müllerian hormone signalling pathway do not determine high or low response to ovarian stimulation.

There is substantial variability in ovarian response to exogenous gonadotrophins in women undergoing ovarian stimulation for IVF. Genetic variation in signalling pathways of the ovary could influence ovarian stimulation outcome. Studies have shown a correlation between the serum concentration of anti-Müllerian hormone (AMH) and ovarian stimulation outcome. This paper present a retrospective case-controlled genetic association study designed to test the association between single nucleotide polymorphisms (SNP) in the AMH signalling pathway and two clinically important outcomes of ovarian stimulation: low and high response. Blood samples from 53 high responders, 38 low responders and 100 controls were analysed for eight SNP of interest. Odds ratios and 95% confidence intervals were estimated by a binary logistic regression model adjusting for age and body mass index. As far as is known, this is the first report on the influence of these SNP, present in approximately 19% of women, on ovarian stimulation outcome. No statistically significant association was found between any of the SNP studied and high or low response to ovarian stimulation. It seems unnecessary to detect these SNP when applying the serum concentration of AMH as a predictor of ovarian response to stimulation. Many infertile couples are treated by IVF. Part of this treatment is to pharmacologically stimulate the ovaries to develop many oocytes simultaneously. This process is called ovarian stimulation. Some women respond either too little (low responders) or too much (high responders) to ovarian stimulation. Both these situations are unfavourable to the woman. This study evaluates whether these chances of having one of these two outcomes of ovarian stimulationare influenced by variation in the gene for anti-Müllerian hormone (AMH) or its receptor. This is done by taking blood samples from three groups of patients: low responders, high responders and controls with a normal response. These blood samples were analysed to see if the variation in the genes for AMH or its receptor were different in the three groups. They were not, and so we conclude that the genetic variation that exists in the AMH and receptor signalling pathway is not a major determinant of ovarian stimulation outcome.

[Sperm retrieval for assisted fertilization in azoospermia]. / Spermieuthenting fra testikkel for assistert befruktning ved azoospermi.

BACKGROUND: Couples where the man presents azoospermia, could not be helped to become genetic parents by assisted reproduction in Norway until recently. A temporary permission to perform techniques that can help these couples was granted with a change in the Norwegian laws on biotechnology in 2004. Our experience with intra cytoplasmic sperm injection (ICSI) using sperm retrieved by testicular sperm extraction (TESE) is presented. MATERIAL AND METHODS: 94 couples (man with azoospermia) who had undergone examination and work-up at Fertilitetsklinikken Sør in the period 2004-06, were followed. Of these couples, 60 had been treated with TESE-ICSI. TESE is performed in an out-patient setting under local anaesthesia as an open testicular biopsy. By a special technique, sperm cells are retrieved from the biopsy and then used for fertilizing oocytes from the partner. RESULTS AND INTERPRETATION: 100 ovarian stimulation-cycles for TESE-CSI have been performed at our clinic. This has led to 82 Embryo Transfers (ET) using fresh embryos and 40 ET using frozen/thawed embryos. 39 clinical pregnancies have been achieved. Thus, there is a 39% chance for pregnancy per started stimulation-cycle. These results are comparable to those from ICSI using ejaculated sperm cells. The TESE-ICSI treatment seems to be a good method to help couples become genetic parents when the man presents azoospermia.

Body Mass Index Is Associated with Impaired Semen Characteristics and Reduced Levels of Anti-Müllerian Hormone across a Wide Weight Range.

There is still controversy as to how body mass index (BMI) affects male reproduction. We investigated how BMI is associated with semen quality and reproductive hormones in 166 men, including 38 severely obese men. Standard semen analysis and sperm DNA integrity analysis were performed, and blood samples were analysed for reproductive hormones. Adjusted for age and time of abstinence, BMI was negatively associated with sperm concentration (B = -0.088, P = 0.009), total sperm count (B = -0.223, P = 0.001), progressive sperm motility (B = -0.675, P = 0.007), normal sperm morphology (B = -0.078, P = 0.001), and percentage of vital spermatozoa (B = -0.006, P = 0.027). A negative relationship was observed between BMI and total testosterone (B = -0.378, P < 0.001), sex hormone binding globulin (B = -0.572, P < 0.001), inhibin B (B = -3.120, P < 0.001) and anti-Müllerian hormone (AMH) (B = -0.009, P < 0.001). Our findings suggest that high BMI is negatively associated with semen characteristics and serum levels of AMH.

Improved diagnostic accuracy of testicular biopsies for infertility through simplified criteria and a dedicated pathologist.

OBJECTIVE: To examine whether simplified histopathologic criteria and a dedicated pathologist could influence the diagnostic accuracy of testicular biopsy. STUDY DESIGN: Original reports from general pathologists on 99 consecutive testicular biopsies were retrospectively classified according to reported presence or absence of mature spermatids. A dedicated pathologist rediagnosed the material blindly according to the same criterion. The resulting data were compared with testicular sperm extraction (TESE) results from the in vitro fertilization laboratory. RESULTS: General pathologists' diagnoses predicted TESE results with a positive predictive value (PPV) of 0.97 and a negative predictive value (NPV) of 0.78. The dedicated pathologist's diagnoses yielded a PPV of 1.0 and a significantly improved NPV of 0.96. CONCLUSION: Visualization of mature spermatids in a testicular biopsy is an excellent predictor of TESE results, especially in the hands of a dedicated pathologist. We therefore recommend simplified pathology reporting on testicular biopsies from azoospermic men and examination by a dedicated pathologist.