A multi-centre phase 3 study comparing efficacy and safety of Bemfola(®) versus Gonal-f(®) in women undergoing ovarian stimulation for IVF.

Bemfola (follitropin alfa) (Finox AG, Switzerland), a new recombinant FSH, has a comparable pharmacological profile to that of Gonal-f (Merck Serono, Germany), the current standard for ovarian stimulation. A randomized, multi-centre, Phase 3 study in women undergoing IVF or intracytoplasmic sperm injection (n = 372) showed Bemfola yielding similar efficacy and safety profiles to Gonal-f. Women aged 20-38 years of age were randomized 2:1 to receive a single, daily, subcutaneous 150 IU dose of either Bemfola or Gonal-f. This study tested equivalence in the number of retrieved oocytes using a pre-determined clinical equivalence margin of ±2.9 oocytes. Compared with Gonal-f, Bemfola treatment resulted in a statistically equivalent number of retrieved oocytes (Bemfola 10.8 ± 5.11 versus Gonal-f 10.6 ± 6.06, mean difference: 0.27 oocytes, 95% confidence interval: -1.34, 1.32) as well as a similar clinical pregnancy rate per embryo transfer in first and second cycles (Bemfola: 40.2% and 38.5%, respectively; Gonal-f: 48.2% and 27.8%, respectively). No difference in severe ovarian hyperstimulation syndrome was observed between treatment groups (Bemfola: 0.8%; Gonal-f: 0.8%). This study demonstrates similar clinical efficacy and safety profiles between Bemfola and Gonal-f, and suggests that Bemfola can be an appropriate alternative in ovarian stimulation protocols.

Efficacy of a sperm-selection chamber in terms of morphology, aneuploidy and DNA packaging.

Since most current techniques analysing spermatozoa will inevitably exclude these gametes from further use, attempts have been made to enrich semen samples with physiological spermatozoa with good prognosis using special sperm-processing methods. A particular sperm-selection chamber, called the Zech-selector, was found to be effective in completely eliminating spermatozoa with DNA strand breaks. The aim of this study was to further analyse the subgroup of spermatozoa accumulated using the Zech-selector. In detail, the potential of the chamber to select for proper sperm morphology, DNA status and chromatin condensation was tested. Two samples, native and processed semen, of 53 patients were analysed for sperm morphology (×1000, ×6300), DNA packaging (fragmentation, chromatin condensation) and chromosomal status (X, Y, 18). Migration time (the time needed for proper sperm accumulation) was significantly correlated to fast progressive motility (P=0.002). The present sperm-processing method was highly successful with respect to all parameters analysed (P<0.001). In particular, spermatozoa showing numeric (17.4% of patients without aneuploidy) or structural chromosomal abnormalities (90% of patients without strand-breaks) were separated most effectively. To summarize, further evidence is provided that separating spermatozoa without exposure to centrifugation stress results in a population of highly physiological spermatozoa.

Planar embryos have poor prognosis in terms of blastocyst formation and implantation.

Normally, day-2 embryos show a crosswise arrangement of four cells with three blastomeres lying side by side. Cleavage anomalies include embryos that are characterized by a particular planar constellation of four blastomeres with presumed incomplete cleavage. Since little is known on the developmental fate of such conceptuses, within a 10-month period all consecutive patients were screened for day-2 planar embryos. A total of 64/2070 embryos with suboptimal blastomere configuration were detected (3.1%). In conventional IVF, planar embryos were significantly less frequent (0.7%) as compared with intracytoplasmic sperm injection (2.8%; P<0.05) and cases of testicular sperm extraction (5.4%; P<0.01). Interestingly, embryos with a cleavage anomaly showed better morphology both on day 2 (P<0.005) and day 3 (P<0.001). In contrast, blastocyst formation (P<0.001) and blastocyst quality (P=NS) was higher in tetrahedral embryos. There was a significant increase in implantation rate if tetrahedral embryos could be transferred compared with when planar embryos had to be transferred (P<0.01). It may be postulated that, in planar embryos, the mitotic spindle might have been affected, e.g. sperm centrosome composition or function, which in turn might have led to the observed cleavage anomaly. Normally, day-2 embryos show a crosswise arrangement of four cells with three blastomeres lying side by side. Cleavage anomalies include more planar embryos that are characterized by a particular flat constellation of four blastomeres with presumed premature cleavage (like a tetrafoliate clover). Since little is known on the developmental fate of such embryos within a 10-month study period, all consecutive patients were screened for the presence of day-2 planar embryos (study group). A total of 64 (out of 2070) embryos with abnormal blastomere configuration were detected (3.1%). Interestingly, in conventional IVF (0.7%), the presence of planar embryos was significantly less frequent as compared with intracytoplasmic sperm injection (2.8%; P<0.05) and cases of testicular biopsy (5.4%; P<0.01). Embryos from the study group showed better morphology both on day 2 (P<0.005) and day 3 (P<0.001). In contrast, blastocyst formation (survival to day 5 of preimplantation development) was higher in the normally cleaved control group (P<0.001) and so was blastocyst quality; however, the latter parameter did not reach level of significance. This was also reflected in a significantly higher implantation rate in the control group (P<0.01). Based on present data, it may be postulated that, in planar embryos, the mitotic spindle (which involves the sperm centrosome) might have been affected, which in turn might have led to an incomplete cleavage.

A plea for a more physiological ICSI.

Intracytoplasmic sperm injection (ICSI) can be considered the most 'revolutionary' in vitro insemination technique because it has efficiently allowed the treatment of male factor infertility. Although ICSI has been successfully and safely applied worldwide for almost 20 years, currently, we have no real knowledge regarding the hypothetical long-term side effects on ICSI adults, given the increased likelihood of spermatozoa with defective nuclear content fertilising the oocytes. The aim of this review article is to investigate the most recent advances of performing ICSI in the safest possible manner, thus, minimising the theoretical hazards of this procedure. To allow for substantiated recommendation which male gametes to choose for physiological ICSI an updated search was performed in Medline and Embase, from 1996 to June 2011. Recent technical advances allow operators to more or less simulate physiological conditions in the laboratory, reducing potential damage to the gametes. It seems possible to prevent fertilisation by DNA-damaged and chromosomal-unbalanced spermatozoa by selecting ICSI sperm by motility and/or maturation markers such as hyaluronic acid or other zona pellucida receptors. Furthermore, novel non-invasive imaging techniques can be valid tools for helping in the morphological selection of ICSI spermatozoa.

Easy sperm processing technique allowing exclusive accumulation and later usage of DNA-strandbreak-free spermatozoa.

Sperm DNA fragmentation is increased in poor-quality semen samples and correlates with failed fertilization, impaired preimplantation development and reduced pregnancy outcome. Common sperm preparation techniques may reduce the percentage of strandbreak-positive spermatozoa, but, to date, there is no reliable approach to exclusively accumulate strandbreak-free spermatozoa. To analyse the efficiency of special sperm selection chambers (Zech-selectors made of glass or polyethylene) in terms of strandbreak reduction, 39 subfertile men were recruited and three probes (native, density gradient and Zech-selector) were used to check for strand breaks using the sperm chromatin dispersion test. The mean percentage of affected spermatozoa in the ejaculate was 15.8 ± 7.8% (range 5.0­42.1%). Density gradient did not significantly improve the quality of spermatozoa selected(14.2 ± 7.0%). However, glass chambers completely removed 90% spermatozoa showing strand breaks and polyethylene chambers removed 76%. Both types of Zech-selectors were equivalent in their efficiency, significantly reduced DNA damage (P < 0.001) and,with respect to this, performed better than density gradient centrifugation (P < 0.001). As far as is known, this is the first report ona sperm preparation technique concentrating spermatozoa unaffected in terms of DNA damage. The special chambers most probably select for sperm motility and/or maturity.

Experimental demonstration of novel beam characterization using a polarizable X-band transverse deflection structure.

The PolariX TDS (Polarizable X-Band Transverse Deflection Structure) is an innovative TDS-design operating in the X-band frequency-range. The design gives full control of the streaking plane, which can be tuned in order to characterize the projections of the beam distribution onto arbitrary transverse axes. This novel feature opens up new opportunities for detailed characterization of the electron beam. In this paper we present first measurements of the Polarix TDS at the FLASHForward beamline at DESY, including three-dimensional reconstruction of the charge-density distribution of the bunch and slice emittance measurements in both transverse directions. The experimental results open the path toward novel and more extensive beam characterization in the direction of multi-dimensional-beam-phase-space reconstruction.

Group culture of human zygotes is superior to individual culture in terms of blastulation, implantation and life birth.

This prospective study tested a new type of culture dish for the effects of individual culture and autotrophic factors. Within a 6-month period, 72 patients with nine or more fertilized eggs were enrolled in this prospective evaluation. Their 936 zygotes were split into three subgroups (individual culture, individual culture with contact to neighbours, group culture). All concepti were cultured in 30 µl drops (medium change on day 3) until blastocyst stage. On day 5, a single-blastocyst transfer was performed and the remaining blastocysts of good quality were vitrified. Fertilization rates were 69% for IVF and 81% for intracytoplasmic sperm injection. Blastulation was 48%. Single-blastocyst transfer resulted in a clinical pregnancy rate of 54%. Group culture was superior in terms of compaction (P<0.01) and blastulation (P<0.001) as compared with individual culture. A better blastocyst quality was observed in group culture (P<0.05). As a trend, more life births were achieved with blastocysts derived from group culture. As far as is known, this is the first evidence that grouping embryos improves preimplantation development in human and it is recommended that culture volume should be reduced or embryo density increased.

Morphological analysis at compacting stage is a valuable prognostic tool for ICSI patients.

In terms of treatment outcome, little prognostic power is attributed to day-4 morphology. A day-4 score was applied to 56 patients separating non-compacting embryos from compacting (some areas of compaction) and fully compacted embryos. The latter were further subdivided according to the morphology of compaction. Grade C1 embryos represented optimal quality, while grades C2 (exclusion of fragments) and C3 (exclusion of blastomeres) were characterized by a loss of cytoplasm. Grade 4 embryos (C4) showed incomplete compaction with several blastomeres not yet incorporated into cell mass. Pooled embryos without compaction showed a reduced (P < 0.001) blastulation (28.8%) as compared with compacting embryos with the same cell number (68.8%), which, in turn, revealed lower (P < 0.05) rates of blastulation as compared with concepti that completed compaction process (84.6%). Among fully compacted embryos grade C1 had a better (P < 0.01) blastocyst formation rate (94.4%) as compared with grade C3 (68.2%). Grade C1 embryos showed significantly higher rates of top-quality blastocysts as compared with grade C2 (P < 0.05) and C3 (P < 0.01). Blastocysts deriving from grade C1/C4 embryos led to a higher pregnancy rate as compared with the C2/C3 counterparts (P < 0.05). This modified score allows for adequate prediction of both blastocyst formation/quality and pregnancy.

Morphology of vitrified/warmed day-5 embryos predicts rates of implantation, pregnancy and live birth.

Although some post-thaw morphological predictors of pregnancy have been investigated in slow freezing of blastocysts, no such data have been published for vitrified and warmed blastocysts. Therefore, a prospective four-part score was applied to vitrified/warmed day-5 embryos to evaluate whether certain morphological parameters could serve as predictors of implantation, pregnancy and live birth. All morulae/blastocysts that were considered to be viable after warming were scored according to a previously unpublished grading system based on re-expansion, hatching (out of an artificial gap in the zona pellucida), extensive cytoplasmic granulation and presence of necrotic foci. Overall, 74% (202/273) of the vitrified concepti were found to be viable after warming. Early blastocysts showed better survival versus extended/hatching blastocysts (P < 0.01). Of the morphological parameters analysed, immediate re-expansion (P < 0.05) and hatching (P < 0.001) were positive predictors of the rates of implantation, pregnancy and live birth. The opposite holds for extensive cytoplasmic granulation (P < 0.05), which was negatively related. Accurate scoring of warmed blastocysts (within the first 2 h) allows for prediction of pregnancy outcome, and thus will help to further reduce the number of transferred embryos.

The role of mode of conception in the outcome of twin pregnancies.

Artificial reproductive techniques (ART) have become a routine and successful treatment of infertility. Twin pregnancies are more frequent after ART compared to spontaneous conception. Varying findings have been reported for the obstetric and perinatal outcome of ART twin pregnancies as compared to spontaneously conceived twin pregnancies. To evaluate the specific risks of twin pregnancies achieved through ART, literature has been reviewed for obstetric and perinatal risks and differences between artificially and spontaneously conceived twin pregnancies. Eleven studies have been involved in this review. Three of the studies were matched and eight were non-matched studies. Results of analysed studies differed widely. Twin pregnancies resulting from ART showed an increased rate of Caesarean section and tend toward higher risk for preterm birth and low birthweight compared to spontaneously conceived twin pregnancies. Various conditions can influence twin pregnancies outcome after ART. In in-vitro fertilization programs twin pregnancies should be avoided and physicians have to inform patients of the specific risks when transferring more than one embryo.

Developmental fate of ovoid oocytes.

BACKGROUND: Irregularities in composition, thickness and/or color of the zona pellucida may impair optimal function and result in reduced outcome. Anomalies of oocyte shape have not been investigated in detail in this respect. METHODS: Therefore, all patients attending our clinic within a period of 1 year were screened for the presence of ovoid gametes and the corresponding developmental potential was evaluated. For all elongated gametes, a roundness index (RI; length divided by width) was calculated in order to quantify shape. RESULTS: RI did not affect fertilizability (P > 0.05). The degree of dysmorphism was found to be related to cleavage pattern. The more ovoid a gamete was, the higher was the risk of the corresponding zygote not cleaving like a tetrahedron (P < 0.01). Abnormal cleavage (a rather flat array of blastomeres) was associated with delayed compaction (P < 0.01) and blastocyst formation (P < 0.001). The quality of blastocysts was not affected at any stage in ovoid concepti (P > 0.05). CONCLUSIONS: Ovoid oocytes with abnormal cleavage pattern show delayed preimplantation development, probably due to a reduced number of cell-to-cell contacts.

Blood clots in the cumulus-oocyte complex predict poor oocyte quality and post-fertilization development.

Assessment of oocyte maturity and quality (morphological appearance) at the time of retrieval is difficult as the egg is obscured by a large cumulus mass that hinders adequate scoring. Since no data are available on the possible relationship between the cumulus-oocyte complex (COC) and oocyte morphology, this prospective intracytoplasmic sperm injection study was set up in 87 consecutive patients. COC were grouped according to expansion of both corona radiata and cumulus matrix. Special emphasis was placed on recording morphological anomalies of COC (inclusion of blood clots and amorphous clumps). For all mature ovae, quality was assessed and preimplantation development followed up to blastocyst stage if fertilized. The risk of not harvesting an oocyte was higher in COC with blood clots compared with normal cumulus matrices (P = 0.004). COC expansion did not allow for prediction of either nuclear status or quality of the egg. The presence of blood clots within the cumulus matrix was associated with reduced oocyte quality (dense central granulation), fertilization rate and blastocyst formation, compared with unaffected COC (P < 0.05). It may be postulated that COC showing blood inclusions derive from poor quality follicles, which has a detrimental effect on oocyte quality and further cleavage to blastocyst stage. Consequently, mechanical removal of blood clots cannot rescue the corresponding embryo.

[Multiple pregnancies after ART: problems and possible solutions]. / Mehrlingsschwangerschaften nach ART: Probleme und Losungsansatze.

Multiple pregnancies following an assisted reproduction technique (ART) should be seen as a complication, and for that reason they should be avoided. In contrast to singleton pregnancies following ART, the multiple pregnancies are associated with a higher prenatal, neonatal and maternal risk; furthermore this results in a financial burden for the health care system. This paper gives an overview of the latest literature and different attempts of European countries, trying to reduce the multiple pregnancy rate. An efficient reduction is only possible by single-embryo transfers. There should be strict and cross-national regulation for the choice of women who should have a transfer of more than one embryo.

Role of three-dimensional ultrasonographic measurement of endometrium volume as a predictor of pregnancy outcome in an IVF-ET program: a preliminary study.

OBJECTIVE: To evaluate the role of three-dimensional (3D) ultrasonographic measurement of the endometrium in predicting pregnancy in an IVF-ET program. DESIGN: Prospective study. SETTING: Center for assisted reproductive techniques. PATIENT(S): 65 women undergoing controlled ovarian hyperstimulation for IVF. INTERVENTION(S): Ultrasonographic examination on the day of hCG administration. MAIN OUTCOME MEASURE(S): Endometrial volume, endometrial thickness, and pregnancy rate. RESULT(S): The mean (+/-SD) endometrium volume (4.16 +/- 1.97 mL), endometrium thickness (11 +/- 2 mm), and estradiol level (1686.82 +/- 1057.10 pg/mL) in 21 pregnant women on the day of hCG administration did not differ statistically differ from the respective values in 44 nonpregnant women (4.53 +/- 1.79 mL; 11 +/- 2 mm, 1883.56 +/- 1147.21 pg/mL). Receiver-operating characteristic curves showed that the area under curve (AUC) was 0.57 for endometrial volume and 0.48 for endometrial thickness. Using a cut-off value of 2.5 mL for endometrial volume to predict pregnancy, results of the Fisher exact test were statistically significant. No significant cut-off value was found for endometrial thickness. CONCLUSION(S): Endometrial volume and thickness on the day of hCG administration did not predict occurrence of pregnancy. A minimum volume of 2.5 mL appeared to favor pregnancy. The predictive value of 3D ultrasonographic measurement of endometrial volume and thickness was better than that of 2D measurement.

Embryo fragmentation in vitro and its impact on treatment and pregnancy outcome.

OBJECTIVE: To determine the impact of embryo fragmentation on pregnancy, obstetric, and perinatal outcome. DESIGN: Retrospective analysis of embryo transfers that were homogeneous in regard to the degree of fragmentation. SETTING: Fertility center. PATIENT(S): A cohort of 460 fresh embryo transfers. INTERVENTION(S): A total of 164 pregnancies were analyzed for the incidence of antepartum complications during gestation, obstetric (multiple pregnancy, preterm delivery, cesarean section), and perinatal outcome (sex, birth weight, admission to neonatal intensive care unit, malformations). MAIN OUTCOME MEASURE(S): Implantation and clinical pregnancy rate, obstetric and perinatal outcome. RESULT(S): Embryo fragmentation and number of embryos per transfer showed a significant influence on clinical pregnancy and implantation rate. No such relation was found concerning complications, multiple pregnancy rate, incidence of cesarean section, gestation week, birth weight, and average time at the neonatology. On the other hand, pregnancies derived from bad-quality embryos had a significantly higher rate of malformations. CONCLUSION(S): The higher percentage of malformations found in bad-quality embryos may be due to a higher percentage of apoptotic features and chromosomal disorders. For ethical reasons, the transfer of embryos with >50% fragmentation should be considered only after consultation with the patient.

Elective transfer of embryos selected on the basis of first polar body morphology is associated with increased rates of implantation and pregnancy.

OBJECTIVE: To determine the relationship between first polar body morphology and implantation rate and pregnancy rate (PR), to facilitate decision making concerning elective ET. DESIGN: Prospective, randomized study. SETTING: Fertility center. PATIENT(S): One hundred fifty-eight consecutive patients (173 intracytoplasmic sperm injection cycles) resulting in embryo transfers. INTERVENTION(S): In our study group, priority in ET was given to embryos derived from well-shaped first polar bodies, whereas selection of embryos for transfer in the control group was based exclusively on the degree of embryo fragmentation. MAIN OUTCOME MEASURE(S): Total numbers of implantations and pregnancies, PR and implantation rate, and rates of multiple pregnancy and miscarriage. RESULT(S): In the study cohort, 212 embryos were transferred. In the control group, 313 embryos were transferred. The implantation rate and PR were significantly lower in the control group than in the study cohort. In addition, the rate of multiple pregnancy was significantly higher in the study group. CONCLUSION(S): Elective transfer of embryos selected on the basis of first polar body morphology results in higher implantation and pregnancy rates. Multiple pregnancy can be avoided by transferring a reduced number of embryos selected on the basis of first polar body morphology.

[3 pregnancies carried to term following vaginal administration of 3 mg prostaglandin E 2 in the 1st trimester]. / Drei ausgetragene Schwangerschaften nach vaginaler Applikation von 3 mg Prostaglandin E 2 im I. Trimenon.

In the years 1985 and 1986 three women decided in the last minute not to undergo a planned abortion after vaginal application of prostaglandin E 2 twenty-four hours before the intended operation. These women came to our genetic clinic in order to obtain some information on the teratogenic risks of prostaglandins applied during early pregnancy. On the basis of these consultation and risk assessment, all three women decided to continue their pregnancy, resulting in the delivery of a healthy child in each case.

[Harmful effects in early pregnancy--results of a teratological counseling center]. / Schädliche Einflüsse in der Frühschwangerschaft--Ergebnisse eines teratologischen Beratungszentrums.

In the years 1986, 1987, and 1988 altogether 132 consultations were conducted during pregnancy at the Landesfrauenklinik Linz. These pregnant women had all been exposed to potentially harmful influences (drugs, maternal diseases and as infections or cancer, X-rays or pregnancy despite IUD). In most of the cases we recommended carrying the pregnancy to full term; only a few were interrupted, sometimes against on recommendation to proceed with the pregnancy. The rate of abortion and the frequency of ectopic pregnancies were within normal limits. Due to personal investigations after birth we registered postnatal findings in nearly all cases. No serious malformations were recorded. Detailed teratological knowledge is necessary for correct advice at consultation after exposure to harmful influences during early pregnancy. In most cases it is possible to avoid interruption without risking an increased rate of malformations.

[Tubal rupture after prostaglandin instillation despite decreasing beta-HCG values]. / Tubarruptur nach Prostaglandininstillation trotz abfallender beta-HCG-Werte.

Over the past years laparoscopic surgery has become widely accepted in the treatment of tubal pregnancy and instillation of prostaglandin is well established. However, the failure rate is around 20%. This report describes a case of tubal pregnancy treated according to this procedure where the therapy initially seemed to be successful. Instillation of prostaglandin F2 alpha was followed by decreasing beta-HCG values, which continued to decrease after discharge. Thus, rupture of the operated tube on day 17 after surgery was completely unexpected.

[Fetal outcome in reduced flow in the ductus venosus during atrial contraction]. / Das Schicksal des Feten mit reduziertem Fluss des Ductus venosus während der Vorhofkontraktion.

OBJECTIVE: To document the fetal outcome in cases with pathologic Doppler findings in the fetal ductus venosus. METHODS: The outcome of 12 fetuses with reduced velocities in the ductus venosus during atrial contraction was analyzed retrospectively and compared with that of a group of 57 fetuses with normal flow velocities in the umbilical artery and in the fetal ductus venosus. RESULTS: The perinatal mortality was higher in the group with pathologic Doppler findings. There was no significant difference of pH (7.20 vs. 7.24) and Apgar scores (7.57 vs. 8.36) of survivors between the two groups. All 12 fetuses showed increased retrograde velocities in the inferior vena cava. Seven fetuses showed umbilical vein pulsations. CONCLUSIONS: The diagnosis of altered velocities in the ductus venosus may influence prenatal decisions. Therefore Doppler examinations of the fetal ductus venosus should be performed in high-risk pregnancies.