The impact of letrozole administration on oocyte morphology in breast cancer patients undergoing fertility preservation.

ABSTRACT: Patients submitted to oncological fertility preservation with letrozole and gonadotropins seem to present a higher rate of immature oocytes and lower fertilization rates in comparison to infertile patients submitted to IVF cycles with gonadotropins. The aim of this study was to evaluate the influence of letrozole on oocyte morphology in patients with breast cancer submitted to fertility preservation. METHODS: Retrospective analysis performed at a public tertiary hospital in São Paulo, Brazil. The oocytes were retrieved from patients with breast cancer undergoing fertility preservation (n=69), and from infertile women undergoing in vitro fertilization (n=92). We evaluated 750 oocytes obtained from breast cancer patients submitted to ovarian stimulation with letrozole and gonadotropins, and 699 oocytes from patients without breast cancer submitted to ovarian stimulation for in vitro fertilization with gonadotropins only due to male factor infertility. The mature oocytes retrieved were analyzed for the presence of refractile bodies, ooplasm color and regularity, central granulation degree, cortical granules, zona pellucida staining and regularity, perivitelline space, presence of vacuoles or abnormal smooth-surfaced endoplasmic reticle and oocyte retraction. RESULTS: There was a higher incidence of alterations in oocyte morphology in the letrozole group when compared to the control group: increased perivitelline space (p=0.007), irregular zona pellucida (p<0.001), refractile bodies (p<0.001), dark ooplasm (p<0.001), granular ooplasm (p<0.001), irregular ooplasm (p<0.001) and dense central granulation (p<0.001). CONCLUSION: Letrozole is a risk factor for worse oocyte morphology. However, the clinical impact of ovarian stimulation protocol with combined use of gonadotropins and letrozole for fertility preservation remains unclear in this setting. These data underline the importance of establishing the predictive potential of morphological dimorphisms of human oocytes in IVF outcomes.

Cervical ectopic pregnancy after in vitro fertilization: case report successfully treated with cervical electric aspiration.

Cervical ectopic gestation is a serious and potentially lethal condition considered exceptional in in vitro fertilization. Early diagnosis is critical to successful treatment and preservation of fertility. We report a rare case of cervical pregnancy after in vitro fertilization and embryo transfer, successfully treated exclusively with electrical aspiration. Case report: A 36-year-old patient attended the Department of Human Reproduction at Pérola Byington Hospital in 2015 due to primary infertility with no apparent cause for seven years. Subjected to ovulation induction with recombinant depot FSH and GnRh analogue, triggered with chorionic gonadotropin. It evolved with the collection of ten oocytes and transfer of two embryos, with cryopreservation of the remaining ones. The control with serial ultrasound showed a gestational sac in uterine cervix topography, indicating gestation of six weeks, confirmed after 24 hours by a second operator. The treatment was successfully performed by electric aspiration with an EasyGrip® cannula of 6 mm in diameter, without the occurrence of hemorrhage or the need for other procedures. Early diagnosis allowed successful conservative treatment with only cervical aspiration. The literature review confirms the rarity of the case, but does not indicate consensus on the best treatment of cervical ectopic pregnancy.

ANDRO-IVF: a novel protocol for poor responders to IVF controlled ovarian stimulation.

OBJECTIVE: This study aimed to assess a novel protocol designed to improve poor ovarian response through intra-ovarian androgenization. The endpoints were: number of oocytes and mature oocytes retrieved, fertilization, cancellation and pregnancy rates. METHODS: This prospective crossover study enrolled poor responders from previous ovarian stimulation cycles submitted to a novel protocol called ANDRO-IVF. The protocol included pretreatment with transdermal AndroGel(r) (Besins) 25 mg, oral letrozole 2.5 mg and subcutaneous hCG 2500 IU; cycle control was performed with estradiol valerate and micronized progesterone; ovarian stimulation was attained with gonadotropins FSH/LH 450 IU, GnRH antagonist and hCG 5000 IU. RESULTS: Fourteen poor responders were enrolled. One patient did not meet the inclusion criteria. Thirteen patients previously summited to the standard protocol were offered the ANDRO-IVF Protocol.-Standard Protocol: Mean age: 35.30 years; cancellation rate: 61.53%; mean number of MII oocytes retrieved per patient: 1.8; fertilization rate: 33.33%. Only two patients had embryo transfers, and none got pregnant.-ANDRO-IVF Protocol: Mean age: 35.83 years; cancellation rate: 7.69%; mean number of oocytes retrieved per patient: 5.58, MII oocytes: 3.91. ICSI was performed in 84.61% of the patients and a mean of 1.5 embryos were transferred per patient. Fertilization rate: 62.5%; cumulative pregnancy rate: 16.66%; mean duration of stimulation: 9.77 days. CONCLUSION: ANDRO-IVF allows intra-ovarian androgenization by increasing serum and intra-follicular androgen levels and preventing androgen aromatization. This protocol apparently improved clinical outcomes of poor responders in parameters such as number of oocytes retrieved and clinical pregnancy rates. Further randomized controlled trials are needed to confirm these findings.

Preimplantation genetic diagnosis for a patient with multiple endocrine neoplasia type 1: case report.

Preimplantation genetic diagnosis was carried out for embryonic analysis in a patient with multiple endocrine neoplasia type 1 (MEN1). This is a rare autosomal-dominant cancer syndrome and the patients with MEN1 are characterized by the occurrence of tumors in multiple endocrine tissues, associated with germline and somatic inactivating mutations in the MEN1 gene. This case report documents a successful preimplantation genetic diagnosis (PGD) involving a couple at-risk for MEN1 syndrome, with a birth of a healthy infant. The couple underwent a cycle of controlled ovarian stimulation and intracytoplasmic sperm injection (ICSI). Embryos were biopsied at the blastocyst stage and cryopreserved; we used PCR-based DNA analysis for PGD testing. Only one of the five embryos analyzed for MEN1 syndrome was unaffected. This embryo was thawed and transferred following endometrial preparation. After positive ßHCG test; clinical pregnancy was confirmed by ultrasound, and a healthy infant was born. PGD for single gene disorders has been an emerging therapeutic tool for couples who are at risk of passing a genetic disease on to their offspring.

A specific controlled ovarian stimulation (COS) protocol for fertility preservation in women with breast cancer undergoing neoadjuvant chemotherapy.

AIM OF THE STUDY: The authors present a novel and specific controlled ovarian stimulation protocol for fertility preservation in women with estrogen-positive receptor breast cancer undergoing neoadjuvant chemotherapy. The protocol foresees random start ovarian stimulation and the use of letrozole associated to tamoxifen. MATERIAL AND METHODS: Forty breast cancer patients were included in the study. COS was performed either with recombinant FSH or hMG. Concomitantly with COS, letrozole in a dose of 5 mg and tamoxifen in a dose of 20 mg were given orally on a daily basis. The trigger was performed with 0.2 mg of triptorelin, in the presence of follicles ≥ 19 mm. Oocyte retrieval was scheduled 35-36 hours after triptorelin injection. Our main outcome measures were the number of oocytes collected and number of oocytes vitrified, the length of ovarian stimulation, total dose of gonadotropins administered, and levels of estradiol on the day of the trigger. RESULTS: The mean age of patients was 30.43 ±4.25 years. Nineteen women commenced COS in the luteal phase, eleven in the early follicular phase and ten in the late follicular phase. The mean number of collected oocytes was 11.78 ±9.12 and the mean number of vitrified oocytes was 9.72 ±7.36. The mean duration of COS was 10.03 ±1.33 days. The mean estradiol concentrations on the triggering day was 623.10 ±441.27, and the mean dose of gonadotropins administered was 2540 ±713.10. CONCLUSIONS: The authors suggest that the protocol is efficient and may be a safe option for oocyte vitrification in these patients.

Indução de ovulação em pacientes com tumor estrogênio­dependente: diretrizes clínicas da Sociedade Brasileira de Reprodução Humana / Ovulation induction in patients with estrogen­dependent tumors: a Brazilian Society of Human Reproduction clinical practice guideline

A oncofertilidade é um campo de interesse interdisciplinar de desenvolvimento recente que busca mesclar os conhecimentos em oncologia e medicina reprodutiva, com a contribuição das técnicas de reprodução assistida, para o desenvolvimento de estratégias de preservação da função gonadal e oferecer a possibilidade da procriação biológica aos sobreviventes de câncer. As estratégias de preservação da fertilidade feminina em pacientes oncológicas atualmente aceitas para a prática rotineira são a criopreservação de embriões e a criopreservação de oócitos maduros. Ocorre que, para execução de ambos, a indução de ovulação é obrigatória e, com ela, vêm os riscos teóricos de estimulação do crescimento de tumores estrogênio­dependentes e a postergação do início do tratamento antineoplásico. Os protocolos de estimulação ovariana de início aleatório contemplam a intenção de se minimizar o atraso no início da quimioterapia ou radioterapia e o bloqueio ao crescimento tumoral e oferecem resultados satisfatórios, semelhantes aos obtidos em protocolos de início habitual. Apresentamos neste artigo as diretrizes clínicas da Sociedade Brasileira de Reprodução Humana para indução de ovulação em pacientes com tumor estrogênio­dependente.(AU)

Oncofertility is an interdisciplinary interest field of recent development, which aims to merge the knowledge in oncology and reproductive medicine, with the help of assisted reproductive technologies, to develop strategies for gonadal function preservation and to offer the possibility of biological procreation to cancer survivors. Preservation strategies of female fertility in oncological patients currently accepted for routine practice are the cryopreservation of embryos and cryopreservation of mature oocytes. It happens that ovulation induction is mandatory for executing both strategies, and with it the theoretical risk of stimulation of estrogen­dependent tumors growth and the postponement of anti­neoplastic treatment. Random­start ovarian stimulation protocols include the intention of minimizing the delay in onset of chemo­radiotherapy and to block tumor growth, providing satisfactory results, similar to those obtained in the usual beginning protocols. This article presents the clinical guidelines of the Brazilian Society of Human Reproduction for ovulation induction in patients with estrogen­dependent tumors.(AU)

Criação de um banco de dados personalizado de baixo custo em um serviço público de reprodução humana / Created a customized database for human reproduction at a low cost for the public service

Todo serviço de reprodução humana necessita de um banco de dados para arquivar e manejar avaliações estatísticas. O serviço público de Reprodução Humana do Hospital Pérola Byington usava uma planilha Excel™ que se mostrou insuficiente para o adequado gerenciamento de informações, evidenciou a necessidade de um programa específico que facilitasse uma consulta rápida ao resumo dos ciclos de FIV, sem que houvesse qualquer probabilidade de erro no preenchimento e nas estatísticas posteriormente feitas. Considerando a inexistência de recursos para compra de um programa, tornava­se necessária a criação de uma plataforma a partir de um software de uso livre. Optamos por usar a plataforma fornecida pelo Centers for Disease Control and Prevention e assim originou­se o CRSMinfo, composto de formulários com subdivisões dos procedimentos, incluindo todas as informações relevantes para consulta e levantamento automatizado de dados. Seu uso mostrou­se extremamente eficiente, aprimorou os protocolos laboratoriais e possibilitou estudos e pesquisas.(AU)

Efficient software it's absolutely necessary for any human assisted reproduction (ART) lab. Perola Byington Public Hospital's ART center has used a spreadsheet in Excel with more than 200 columns for data storage of all in vitro fertilization cycles for years, making it very difficult to create complex statistics to analyze data and lead to quick statistic evaluation. Since we are working with a very tight budget, we selected an open source software created by the Centers for Disease Control and Prevention, and after months of programming we created CRSMinfo, which contains a form with subdivision of procedures, including all the information for research and automatic sorting of the data. The use of CRSMinfo software at Perola Byington Hospital has been extremely efficient, improving the protocols for the realization of studies and researches.(AU)

Crianças nascidas após vitrificação de oócitos em reprodução assistida em hospital público / Infants live born after oocytes vitrification in assisted reproduction public hospital

A criopreservação de oócitos contribuiu para o avanço das técnicas em reprodução humana nas últimas décadas. A metodologia tem sua aplicação na preservação da fertilidade, em programas de ovodoação, como estratégia para redução do número de embriões extranumerários criopreservados com manipulação de menor número de oócitos a fresco e para acúmulo de oócitos em ciclos com reduzida resposta ovariana. A partir do princípio de que todo cidadão tem direito a saúde, é dever do Estado garantir o acesso a todos os tipos de tratamento. O Centro de Referência da Saúde da Mulher ­ Hospital Pérola Byington implantou a técnica de vitrificação de oócitos em 2010, aprimora os protocolos continuamente e busca melhores taxas de sobrevida, fertilização, clivagem e gestação. Relatamos as duas primeiras gestações, com nascimento, obtidas a partir de oócitos vitrificados em nosso Centro, que comprovam a viabilidade da aplicação dessa técnica e oferecem, assim, atendimento ao público com equidade e gratuidade integral.(AU)

The oocytes cryopreservation contributed substantially to a breakthough in Assisted Human Reproduction techniques over the last three decades. The methodology has been applied in the fertility preservation, through oocyte donation programmes, as strategy to reduce the number of supernumerary embryos cryopreserved by manipulating the least amount of fresh oocytes, and in the accumulation of oocytes in cycles with poor ovarian responders. Assuming the principle that every citizen has the right to health, it is the duty of the State to ensure access to all types of treatment. The Woman's Health Reference Center ­ Pérola Byington Hospital has implemented the technique of oocytes vitrification since 2010, and has been improving our protocol continuously: aiming at improvements in the rates of survival, fertilization, cleavage and pregnancy. We reported the first two pregnancies, infants live born after oocytes vitrification, at our Center, proving the feasibility of the oocytes vitrification protocol applied, offering service to the public with equity and no cost for the patient.(AU)

Association between leukaemia inhibitory factor gene polymorphism and pregnancy outcomes after assisted reproduction techniques.

Certain gene polymorphisms are associated with implantation failure and pregnancy loss. Studies of leukaemia inhibitory factor (LIF) gene polymorphisms are scarce. The LIF single nucleotide polymorphism (SNP) thymine (T)/guanine (G) (rs929271) was studied in women to determine whether an association existed with pregnancy outcomes after intracytoplasmic sperm injection (ICSI); 411 women who underwent ICSI were recruited. DNA was extracted from the peripheral blood, and the LIF gene SNP T/G (rs929271) was genotyped using real-time polymerase chain reaction. Participants were divided into three groups according to their LIF genotype: T/T (n = 168), T/G (n = 202) and G/G (n = 41). All IVF and ICSI procedures were carried out under the same clinical and laboratory conditions. The ICSI cumulative results (from fresh plus frozen cycles) of each genotype group were analysed. The G/G genotype in women was associated with a higher implantation rate (T/T: 15.9%, T/G: 16.2%, G/G: 27.0%; P < 0.05), ongoing pregnancy rate/patient (T/T: 31.5%, T/G: 36.1%, G/G: 53.7%; P < 0.05) and ongoing pregnancy rate/transfer (T/T: 18.5%, T/G: 20.2%, G/G: 36.7%; P < 0.05). LIF SNP T/G (rs929271) seems to be a susceptibility biomarker capable of predicting implantation efficiency and pregnancy outcomes.

The Relationship between Vascular Endothelial Growth Factor 1154G/A Polymorphism and Recurrent Implantation Failure.

OBJECTIVE: The aim of this study was to investigate the relationship between herpesvirus-associated ubiquitin-specific protease (HAUSP A/G, rs1529916), tumor protein p53 (TP53 Arg/Pro, rs1042522), leukemia inhibitory factor (LIF G/T, rs929271), glycoprotein 130 (gp130 A/T, rs1900173) and vascular endothelial growth factor (VEGF G/A, rs1570360) polymorphisms and recurrent implantation failure (RIF) in Brazilian women. SUBJECTS AND METHODS: A total of 120 women with RIF (i.e. those with ≥5 cleaved embryos transferred and a minimum of 2 failed in vitro fertilization/intracytoplasmic sperm injection attempts) were included. The control group involved 89 women who had experienced at least 1 live birth (without any infertility treatment). DNA was extracted from the peripheral blood of all participants, and the abovementioned single-nucleotide polymorphisms (SNPs) were genotyped by real-time polymerase chain reaction. The data were evaluated using Fisher's test. RESULTS: A significant difference between the RIF and control groups was found in the VEGF gene where the GG genotype showed a 2.1-fold increased chance of not being included in the RIF group, while the presence of an A allele increased this risk 1.6-fold. No significant differences were found for the other polymorphisms. CONCLUSION: This study showed an association between the VEGF -1154G/A polymorphism and RIF in Brazilian women.

The TP73 gene polymorphism (rs4648551, A>G) is associated with diminished ovarian reserve.

It's known that the members of the TP53 family are involved in the regulation of female reproduction. Studies in mice showed that the TP73 gene (member of this family) plays a role in the size of follicular pool, ovulation rate and maintenance of genomic stability. In the present study we analyzed data from 605 patients with ≤ 37 years attending their first intracytoplasmic sperm injection (ICSI). The association between the TP73 polymorphism (rs4648551, A>G) and the following parameters related to ovarian reserve, like age, antral follicular count (AFC), anti-Mullerian hormone levels (AMH) and ovarian response prediction index (ORPI) was evaluated. Our results showed an association of the AA genotype with diminished ovarian reserve (AMH <1, AFC ≤9). Women presenting the AA genotype had a 2.0-fold increased risk for having AMH <1 and AFC ≤9 (OR 2.0, 95% CI 1.23-3.31, P = 0.005). Patients presenting AA genotype had the lowest levels of AMH (P = 0.02), the lowest number of antral follicles (P = 0.01) and the lowest ORPI (P = 0.007). Analyzing the alleles, we can see an enrichment of the A allele in the group of diminished ovarian reserve (OR 1.4, 95%CI 1.02-1.83, P = 0.04). To the best of our knowledge, the present study is the first to analyze this polymorphism in humans for assessing the numbers of ovarian follicles and AMH levels and, therefore, the ovarian reserve. Our findings can contribute to the use of this polymorphism as a potential marker of diminished ovarian reserve.

Administration of progesterone on the day of oocyte retrieval to reverse accumulation of fluid in the endometrial cavity during assisted reproductive techniques.

OBJECTIVE: To determine whether administration of progesterone on the day of oocyte retrieval may reverse accumulation of fluid in the endometrial cavity. METHODS: A total of 50 patients who underwent assisted reproductive technology (ART) cycles with endometrial cavity fluid (ECF) observed by ultrasound at the time of oocyte retrieval were included. Upon the identification of ECF, vaginal administration of natural progesterone was started. Two days later, the endometrial cavity was re-evaluated, and embryo transfer was performed in the absence of ECF. RESULTS: ECF was absent two days after administration of vaginal progesterone in 47 of the 50 patients (94%). ECF persisted in 3 of the 50 patients (6%). The clinical pregnancy rate per transfer was 34.0%, and the implantation rate was 21.6%. CONCLUSION: Our data suggest that, in the presence of ECF, administration of intravaginal progesterone in ART cycles must be initiated on the day of follicle aspiration to reverse ECF and to avoid the deleterious effects of fluid on the blastocyst-endometrial interaction.

Efficacy of sperm motility after processing and incubation to predict pregnancy after intrauterine insemination in normospermic individuals.

BACKGROUND: Intrauterine insemination (IUI) is widely used to treat infertility, and its adequate indication is important to obtain good pregnancy rates. To assess which couples could benefit from IUI, this study aimed to evaluate whether sperm motility using a discontinuous gradient of different densities and incubation in CO2 in normospermic individuals is able to predict pregnancy. METHODS: A total of 175 couples underwent 175 IUI cycles. The inclusion criteria for women were as follows: 35 years old or younger (age range: from 27 to 35 years) with normal fallopian tubes; endometriosis grades I-II; unexplained infertility; nonhyperandrogenic ovulatory dysfunction. Men with normal seminal parameters were also included. All patients underwent ovarian stimulation with clomiphene citrate and human hMG or r-FSH. When one or (at most) three follicles measuring 18 to 20 mm were observed, hCG (5000 UI) or r-hCG (250 mcg) was administered and IUI performed 36-40 h after hCG. Sperm processing was performed using a discontinuous concentration gradient. A 20 microliters aliquot was incubated for 24 h at 37 degrees C in 5% CO2 following a total progressive motility analysis. The Mann-Whitney and Chi-square tests, as well as a ROC curve were used to determine the cutoff value for motility. RESULTS: Of the 175 couples, 52 (in 52 IUI cycles) achieved clinical pregnancies (CP rate per cycle: 29.7%). The analysis of age, duration and causes of infertility did not indicate any statistical significance between pregnancy and no pregnancy groups, similar to the results for total sperm count and morphology analyses, excluding progressive motility (p < 0.0001). The comparison of progressive motility after processing and 24 h after incubation between these two groups indicated that progressive motility 24 h after incubation was higher in the pregnancy group. The analysis of the progressive motility of the pregnancy group after processing and 24 h after incubation has not shown any motility difference at 24 h after incubation; additionally, in couples who did not obtain pregnancy, there was a statistically significant decrease in progressive motility 24 h after incubation (p < 0.0001). The ROC curve analysis generated a cutoff value of 56.5% for progressive motility at 24 h after incubation and this cutoff value produced 96.1% sensitivity, 92.7% specificity, 84.7% positive predictive value and 98.3% negative predictive value. CONCLUSIONS: We concluded that the sperm motility of normospermic individuals 24 h after incubation at 37 degrees C in 5% CO2, with a cutoff value of 56.5%, is predictive of IUI success.

Ovarian hiperstimulation syndrome: incidence in a public service of assisted reproduction and literature review / Síndrome de hiperestímulo ovariano: incidência em um serviço públicode reprodução assistida e revisão da literatura

lntroduction: The ovarian hyperstimulation syndrome (OHSS), although uncommon, is an important complieation of assisted reproduction because of its morbidity and possible lethal outcome. Objective: To verify the incidence of OHSS in publie service of assisted reproduction and review the literature. Method: A deseriptive retrospective study of patients enrolled in the Assisted Reproduetion Laboratory of Hospital Pérola Byington who had 15 or more oocytes retrieved during controlled ovarian stimulation cycle, period 2010-2012. A literature search was condueted in the databases Medline, Scopus and SciELO including articles indexed between 2010 and 2013. Results: OHSS was observed in 17 eyeles (1.9%) of 857 performed. The mean age was 33.2 years, with a mean of 21.6 oocytes retrieved and 11.5 mature ooeytes. Hospitalization and ascites puncture was required in five cases. There was no fatal outcome. The literature suggests that methods used to prediet the ovarian response help to prevent OHSS, as antralfollicle count, serum estradiol and anti-mullerian hormone. Evidence indicates that stimulation with GnRH antagonist and triggering with GnRH agonist, with ar without vitrification of embryos are safe strategies for patients with high risk for OHSS.

Introdução: A síndrome de hiperestímulo OVariano (SHO), apesar de pouco frequente, é complicação importante na reprodução assistida devido sua morbidade e possibilidade de desfecho letal. Objetivo: Verificar a incidência da SHO em serviço público de reprodução assistida e revisara literatura. Método: Estudo descritivo retrospectivo com prontuários de pacientes matriculadas no Laboratório de Reprodução Assistida do Hospital Pérola Byington de 2010 a 2012, que apresentaram 15 ou mais oócitos aspirados durante ciclo de estimulação ovariana controlada. Consulta nas bases de dados do Medline, Scopus e Scielo incluindo artigos indexados entre2010 e 2013.Resultados: SHO foi verifica da em 17 ciclos (1,9%) dos 857 realizados. A média etáría foi de 33,2anos, com média de 21,6 oócitos aspirados e 11,5 oócitos maduros. Intemação foi necessária em cinco casos. Não houve desfecho fatal. A literatura aponta que métodos empregados para prever a resposta ovariana auxiliam na prevenção da SHO, como contagem de folícu-105 antrais, dosagem de estradiol e hormônio anti-mulleriano. Evidências indicam que a estimulação com antagonista do GnRH e desencadeamento da ovulação com agonista do GnRH, com ou sem vitrificação de embriões, como estratégias seguras para pacientes com alto risco para SHO.Conclusão: A incidência da SHO mostrou-se dentro da variação da literatura. Embora nenhuma das abordagens de prevenção da SHO seja totalmente eficaz, a maioria demonstra diminuição da incidência em pacientes de alto risco.

Protocolos de estimulação ovariana controlada para criopreservação de oócitos em pacientes com câncer de mama / Controlled ovarian stimulation protocols for cryopreservation of oocytesin patients with breast cancer

Os autores apresentam os protocolos de estimulação ovariana usados no Centro de Referência da Saúde da Mulher para captação e vitrificação de oócitos em pacientes com câncer de mama que desejam preservar a fertilidade antes de se submeter a quimioterapia.

The authors present the ovarian stimulation protocols employed at the Women's Health Reference Center in order to retrieve oocytes for vitrification in breast cancer patients wishing fertility preservation prior to chemotherapy.

Importância do hormônio anti-Mülleriano na infertilidade / The importance of anti-Müllerian hormone in infertility

O hormônio anti-Mülleriano (HAM) é um marcador da reserva ovariana usado em técnicas de reprodução assistida com o objetivo de predizer a resposta inadequada à estimulação ovariana controlada. Também pode ser útil na predição de hiper-respostas em pacientes com síndrome dos ovários policísticos e colaborar para individualizar protocolos de estimulaçãomais adequados ao perfil de cada paciente e para o sucesso final do tratamento, muitas vezes dispendioso. Além do HAM existem outros marcadores da reserva ovariana, comocontagem de folículos antrais (CFA) e hormônio folículo estimulante (FSH), juntamente com o Estradiol (E2) e a Inibina B.

The Anti-Müllerian Hormone (AMH) is a marker of ovarian reserve used in assisted reproductive technologies, aiming at predict the response to controlled ovarian stimulation. Itmay also be useful for the prediction of hyperresponse to ovarian stimulation, as frequently observed in patients with Polycystic Ovary Syndrome. Being so, it is useful to individualize ovarian stimulation protocols, making the treatment more cost-effective. Besides AMH, there are other markers of ovarian reserve, as antral follicle count (AFC), Follicle Stimulating Hormone (FSH) along with Estradiol (E2) and inhibin B.

A new ovarian response prediction index (ORPI): implications for individualised controlled ovarian stimulation.

BACKGROUND: The objective was to present a new ovarian response prediction index (ORPI), which was based on anti-Müllerian hormone (AMH) levels, antral follicle count (AFC) and age, and to verify whether it could be a reliable predictor of the ovarian stimulation response. METHODS: A total of 101 patients enrolled in the ICSI programme were included. The ORPI values were calculated by multiplying the AMH level (ng/ml) by the number of antral follicles (2-9 mm), and the result was divided by the age (years) of the patient (ORPI=(AMH x AFC)/Patient age). RESULTS: The regression analysis demonstrated significant (P<0.0001) positive correlations between the ORPI and the total number of oocytes and of MII oocytes collected. The logistic regression revealed that the ORPI values were significantly associated with the likelihood of pregnancy (odds ratio (OR): 1.86; P=0.006) and collecting greater than or equal to 4 oocytes (OR: 49.25; P<0.0001), greater than or equal to 4 MII oocytes (OR: 6.26; P<0.0001) and greater than or equal to 15 oocytes (OR: 6.10; P<0.0001). Regarding the probability of collecting greater than or equal to 4 oocytes according to the ORPI value, the ROC curve showed an area under the curve (AUC) of 0.91 and an efficacy of 88% at a cut-off of 0.2. In relation to the probability of collecting greater than or equal to 4 MII oocytes according to the ORPI value, the ROC curve had an AUC of 0.84 and an efficacy of 81% at a cut-off of 0.3. The ROC curve for the probability of collecting greater than or equal to 15 oocytes resulted in an AUC of 0.89 and an efficacy of 82% at a cut-off of 0.9. Finally, regarding the probability of pregnancy occurrence according to the ORPI value, the ROC curve showed an AUC of 0.74 and an efficacy of 62% at a cut-off of 0.3. CONCLUSIONS: The ORPI exhibited an excellent ability to predict a low ovarian response and a good ability to predict a collection of greater than or equal to 4 MII oocytes, an excessive ovarian response and the occurrence of pregnancy in infertile women. The ORPI might be used to improve the cost-benefit ratio of ovarian stimulation regimens by guiding the selection of medications and by modulating the doses and regimens according to the actual needs of the patients.

GnRH agonist versus GnRH antagonist in IVF/ICSI cycles with recombinant LH supplementation: DNA fragmentation and apoptosis in granulosa cells.

OBJECTIVE: To compare the level of apoptosis and DNA fragmentation in the human granulosa cell (GC) layer exposed to an agonist or antagonist of GnRH in intracytoplasmic sperm injection (ICSI) cycles supplemented with recombinant LH (rLH). STUDY DESIGN: Patients without ovulatory dysfunction, aged ≤37 years and in their first ICSI cycle were prospectively randomised to receive either a long GnRH agonist protocol or a multi-dose antagonist protocol. In both groups, recombinant FSH supplemented with rLH was used for ovarian stimulation, and the GCs were collected during oocyte denudation. The GCs were then analysed for DNA fragmentation by TUNEL assay and for apoptosis using the annexin-V assay. The outcomes were given as the percentage of GCs with DNA fragmentation and apoptosis out of the total number of GCs analysed. Comparison of the agonist versus the antagonist group was performed using the Mann-Whitney test. RESULTS: DNA fragmentation: 32 patients were included in either the GnRH agonist group (n=16) or the antagonist group (n=16). The percentage of GCs with positive DNA fragmentation did not differ significantly (P=0.76) between the agonist group (15.5 ± 9.4%) and the antagonist group (18.8 ± 13.3%). Apoptosis: 28 patients were included in either the GnRH agonist group (n=14) or the antagonist group (n=14). The percentage of GCs positive for apoptosis did not differ significantly (P=0.78) between the agonist group (34.6 ± 14.7%) and the antagonist group (36.5 ± 22%). CONCLUSIONS: The results suggest that therapy with either an agonist or antagonist of GnRH is associated with comparable levels of DNA fragmentation and apoptosis in granulosa cells in ICSI cycles supplemented with rLH.

The influence of leukocytospermia on the outcomes of assisted reproductive technology.

BACKGROUND: It is not well established whether the increased number of leukocytes in the seminal fluid impairs the outcomes of assisted reproductive technology (ART). This investigation analysed the outcomes of the intracytoplasmic sperm injection (ICSI) and intracytoplasmic morphologically selected sperm injection (IMSI) cycles in couples in which the male partner exhibited leukocytospermia. METHODS: A total of 100 cycles in 100 couples were included in this study. For the ICSI or IMSI procedures, the patients were divided into two groups according to the presence or absence of leukocytospermia and then matched by (female) age: ICSI: Group I (n = 25): Leukocytospermia - semen samples with a leukocyte count of greater than or equal to 1 × 10(6)/mL; and Group II (n = 25): Non-leukocytospermia - semen samples with a leukocyte count < 1 × 10(6)/mL. IMSI: Group I (n = 25): Leukocytospermia; and Group II (n = 25): Non-leukocytospermia.The endpoints included the rates of fertilisation, implantation, clinical pregnancy, miscarriage, ongoing pregnancy and live birth. Student's t-tests, Mann-Whitney tests and Chi-square tests were performed, and P < 0.05 was considered significant. RESULTS: The data from the ICSI groups showed that leukocytospermia did not have a negative influence on the rates of fertilisation (Group I: 57.9+/-30.2%, Group II: 61.9+/-27.7%; P = 0.74), implantation (Group I: 12.3%; Group II: 13.5%; P = 0.93), clinical pregnancy (Group I: 24%; Group II: 24%; P = 1.0), miscarriage (Group I: 0, Group II: 0), ongoing pregnancy (Group I: 24%; Group II: 24%; P = 1.0), or live births (Group I: 24%; Group II: 24%; P = 1.0). Similarly, the data from the IMSI groups also showed that the leukocytospermia did not have a negative influence on the rates of fertilisation (Group I: 67.6+/-24.6%, Group II: 59.5+/-28.1%; P = 0.36), implantation (Group I: 17.5%; Group II: 16.7%; P = 0.90), clinical pregnancy (Group I: 28%; Group II: 24%; P = 1.0), miscarriage (Group I: 14.3%; Group II: 0; P = 0.33), ongoing pregnancy (Group I: 24%; Group II: 24%; P = 1.0), or live births (Group I: 24%, 6/25; Group II: 24%, 6/25; P = 1.0). CONCLUSIONS: The results indicate that the leukocytospermia may not have a negative effect on the outcomes of ICSI or IMSI cycles. Nevertheless, it seems that it is necessary to more precisely determine the effects, if any, of seminal leukocytes on fertilisation and implantation processes. Such efforts will help to establish a more reliable leukocyte threshold, which could eventually demonstrate whether there is a negative influence on the ART procedures.

GnRH agonist versus GnRH antagonist in assisted reproduction cycles: oocyte morphology.

BACKGROUND: The selection of developmentally competent human gametes may increase the efficiency of assisted reproduction. Spermatozoa and oocytes are usually assessed according to morphological criteria. Oocyte morphology can be affected by the age, genetic characteristics, and factors related to controlled ovarian stimulation. However, there is a lack of evidence in the literature concerning the effect of gonadotropin-releasing hormone (GnRH) analogues, either agonists or antagonists, on oocyte morphology. The aim of this randomized study was to investigate whether the prevalence of oocyte dysmorphism is influenced by the type of pituitary suppression used in ovarian stimulation. METHODS: A total of 64 patients in the first intracytoplasmic sperm injection (ICSI) cycle were prospectively randomized to receive treatment with either a GnRH agonist with a long-term protocol (n: 32) or a GnRH antagonist with a multi-dose protocol (n: 32). Before being subjected to ICSI, the oocytes at metaphase II from both groups were morphologically analyzed under an inverted light microscope at 400x magnification. The oocytes were classified as follows: normal or with cytoplasmic dysmorphism, extracytoplasmic dysmorphism, or both. The number of dysmorphic oocytes per total number of oocytes was analyzed. RESULTS: Out of a total of 681 oocytes, 189 (27.8%) were morphologically normal, 220 (32.3%) showed cytoplasmic dysmorphism, 124 (18.2%) showed extracytoplasmic alterations, and 148 (21.7%) exhibited both types of dysmorphism. No significant difference in oocyte dysmorphism was observed between the agonist- and antagonist-treated groups (P>0.05). Analysis for each dysmorphism revealed that the most common conditions were alterations in polar body shape (31.3%) and the presence of diffuse cytoplasmic granulations (22.8%), refractile bodies (18.5%) and central cytoplasmic granulations (13.6%). There was no significant difference among individual oocyte dysmorphisms in the agonist- and antagonist-treated groups (P>0.05). CONCLUSIONS: Our randomized data indicate that in terms of the quality of oocyte morphology, there is no difference between the antagonist multi-dose protocol and the long-term agonist protocol. If a GnRH analogue used for pituitary suppression in IVF cycles influences the prevalence of oocyte dysmorphisms, there does not appear to be a difference between the use of an agonist as opposed to an antagonist.