Pregnancy potential and perinatal outcomes of embryos cryopreserved twice: a case-control study.

RESEARCH QUESTION: What are the pregnancy and perinatal outcomes of twice-cryopreserved embryos compared with embryos cryopreserved once? DESIGN: Retrospective register-based case-control study. The case group consisted of transfers of twice-cryopreserved embryos (n = 89), and the control group of transfers of embryos cryopreserved once (n = 304). Matching criteria were embryonic age at transfer and female age category of less than 35 years or 35 and greater. RESULTS: The survival rate of twice-cryopreserved embryos was 92.2%, and 93.7% of the planned frozen embryo transfers (FET) could be completed. FET was performed with cleavage-stage embryos in 17 cases and 68 controls and with blastocysts in 72 cases and 238 controls. The rates of live birth (27.0% versus 31.9%, adjusted odds ratio [OR] 0.70, 95% CI 0.40-1.22, P = 0.21), clinical pregnancy (31.5% versus 36.8%, adjusted OR 0.71, 95% CI 0.42-1.21, P = 0.21) and miscarriage (4.5% versus 3.9%, adjusted OR 1.10, 95% CI 0.33-3.60, P = 0.88) in the case and the control groups were comparable. No difference was seen in the preterm delivery rate (cases 4.2% versus controls 10.3%, P = 0.69). Twenty-five children were born in the case group and 100 in the control group. No difference in birthweight was detected between the groups and there were no large for gestational age fetuses or congenital malformations in the case group. CONCLUSIONS: Uncompromised live birth rates and neonatal outcomes may be expected after the transfer of twice-cryopreserved embryos. To avoid embryo wastage and transfer of multiple embryos, good quality surplus embryos from FET cycles may be cryopreserved again by vitrification.

A Mayer-Rokitansky-Kuster-Hauser patient with leiomyoma and dysplasia of neovagina: a case report.

BACKGROUND: Most patients with congenital uterus and vaginal aplasia (i.e., Mayer-Rokitansky-Kuster-Hauser [MRKH] syndrome) have rudimentary pelvic uterine structures that contain smooth muscle. Although leiomyomas and dysplasia of vaginal mucosa are relatively common in the general population, they are rare in MRKH patients. Data on the vulnerability of neovaginas to HPV-associated dysplasia are limited. CASE PRESENTATION: A rare case of an MRKH patient with two gynaecological conditions detected during long-term gynaecological follow-up is presented. At the age of 21, the patient was treated for HPV-associated neovaginal dysplasia. At the age of 47, a pelvic leiomyoma was detected with transvaginal ultrasound and confirmed with magnetic resonance imaging. CONCLUSION: A Pap smear or human papillomavirus testing is indicated in sexually active MRKH women. Uterine rudiments contain smooth muscle, which facilitates the development of oestrogen-dependent diseases, such as leiomyomas and adenomyosis. Although magnetic resonance imaging is recommended in cases of a pelvic mass, easily attainable and cost-efficient transvaginal ultrasound offers high diagnostic accuracy in patients with a surgically created neovagina and is suitable for the patients' follow-up. Guidelines for the gynaecological follow-up of MRKH patients are warranted.

Multinucleation in Day Two Embryos Is Not Associated with Multinucleation in Sibling Embryos After Freezing and Thawing.

BACKGROUND: Multinucleated embryos exhibit impaired implantation potential, but whether the presence of multinucleated embryos in an embryo cohort reflects the quality of the entire cohort is controversial. No data exists on multinucleation rate among frozen-thawed embryos. METHODS: De novo multinucleation and the number of multinucleated embryos on day two of embryo culture before freezing (D2) (n=415), at thawing (D2t) (n=320) and after an overnight culture after thawing (D3t) (n=265) was recorded. Associations between multinucleation before and after cryopreservation, female age and ovarian sensitivity to hormonal stimulation were assessed. RESULTS: The occurrence of at least one multinucleated embryo per embryo cohort was 62.4% on D2, 16.3% on D2t and 31.7% on D3t. The presence of multinucleated embryos prior to freezing was not associated with de novo multinucleation during post-thaw culture (p=0.845). On D2, multinucleation was high in young women, irrespective of the number of collected oocytes (p=0.702). In older age groups, multinucleation was highest if >17 oocytes were obtained (p<0.001) and the odds for multinucleation was the lowest if the consumption of recombinant follicle-stimulating hormone was >238 IU/oocyte (In the age group of 30-35 years OR 0.25 [0.13-0.47], and the age group of 36-40 years OR 0.35 [0.20-0.63]. CONCLUSION: Multinucleation is commonly seen in embryos and good-quality day two embryo cohorts before freezing. The presence of multinucleated embryos prior to freezing does not illustrate multinucleation in sibling embryos after thawing. Embryo multinucleation is associated with factors related to good prognosis in assisted reproduction treatments.

Vaginal cuff dehiscence is observed in a higher rate after total laparoscopic hysterectomy compared with other types of hysterectomy.

INTRODUCTION: Recently, it has been suggested that the occurrence of posthysterectomy vaginal cuff dehiscence has increased. Consequently, we evaluated the incidence of vaginal cuff dehiscence after different types of hysterectomies. Our hypothesis is that vaginal cuff dehiscence is more often associated with total laparoscopic hysterectomy (TLH) than other types of uterine removal. MATERIAL AND METHODS: A total of 13 645 hysterectomies from 1992 to 2015 were evaluated in the Turku University Hospital district, Finland. The primary outcome was occurrence of vaginal dehiscence after different types of hysterectomy. The hysterectomy and postoperative vaginal dehiscence trends were analyzed as the secondary outcome. In a subanalysis of dehiscence cases, women's characteristics and perioperative vaginal cuff opening and closure techniques were compared between conventional hysterectomies (vaginal, abdominal, and laparoscopic with vaginal closure) and TLH. RESULTS: Altogether, 22 cases of vaginal cuff dehiscence were included. Most cases (n = 15) occurred after TLH (n = 1104), resulting in an incidence of 1.27%. After conventional laparoscopic hysterectomy with vaginal closure (n = 2853), vaginal (n = 4150), and abdominal (n = 5538) hysterectomies, the incidence rates were 0.11%, 0.05%, and 0.02%, respectively. Compared to abdominal hysterectomy, which was associated with the lowest incidence rate, vaginal dehiscence after TLH had an odds ratio (OR) 71.1 (9.34-541.38, P < 0.001). In the subanalysis of possible underlying factors, the technique of opening of the vaginal cuff with or without electrocoagulation, duration of operation, and occurrence of postoperative infection or hematoma prior to VCD were observed differences between TLH and conventional hysterectomies. CONCLUSIONS: Compared with other types of hysterectomies, vaginal dehiscence was observed at the highest rate after TLH. Studies are needed to define if vaginal opening technique contributes to the risk of dehiscence.

Mid-luteal phase gonadotropin-releasing hormone agonist support in frozen-thawed embryo transfers during artificial cycles: A prospective interventional pilot study.

OBJECTIVE: To assess the effect of an additional single mid-luteal dose of gonadotropin-releasing hormone agonist (GnRHa) on pregnancy and perinatal outcomes in hormonally substituted frozen embryo transfer (FET) cycles. STUDY DESIGN: A prospective interventional pilot study. Women scheduled for FET were randomly selected to receive standard hormonal replacement therapy (HRT) for endometrial preparation or HRT with a single additional subcutaneous dose of 0.1mg triptorelin at the time of implantation. If FET was not followed by a pregnancy, women with surplus embryos were scheduled for a single second attempt in a crossover setting. Altogether, 144 FET cycles were analyzed. The carryover effect was tested using a logistic regression model. Logistic regression analysis for binary variables was applied with generalized estimation equation extension to account for dependence among repeated treatments. RESULTS: The live birth rate (LBR) was 9.8 percentage points higher and the miscarriage rate 14.7 percentage points lower in the intervention group (n=72) than in the control group (n=72), but the differences did not reach statistical significance. Implantation and clinical pregnancy rates were comparable between the groups. No congenital malformations or differences in the median birth weight of newborns were detected. CONCLUSIONS: Observable but statistically insignificant difference in LBR and miscarriage rate favoring luteal phase GnRHa support was detected. Further, no malformations or effect on fetal growth were observed. Larger studies are needed to confirm the results of this pilot study.

Pregnancy and perinatal outcomes after transfer of binucleated or multinucleated frozen-thawed embryos: a case-control study.

Blastomere multinucleation in human embryos is a common phenomenon, but data on its effect on pregnancy outcome and the health of newborns are scarce. In this case-control study, we assessed pregnancy and perinatal outcomes from 136 binucleated and multinucleated frozen-thawed embryo transfer cycles against a control group of 136 non-binucleated and multinucleated frozen embryo transfer cycles. Clinical pregnancy and live birth rates were lower among the case group (29.4% versus 44.1%, P = 0.012; 22.1% versus 36.0%, P = 0.011, respectively), but perinatal outcomes (gestational week at delivery, birth weight, placental weight and occurrence of congenital anomalies) were similar. Live birth rates among patients receiving embryos with multinucleation compared with binucleation was not significantly different (24.7% versus 13.2%). Consequently, frozen-thawed cleavage-stage embryos with bi- or multinucleation have lower than normal but still acceptable implantation potential and ability to produce healthy pregnancies and newborns. The study is limited by its retrospective nature. Time-lapse monitoring would be a more sensitive method of detecting multinucleation. Controls and cases were matched only by age at the time of oocyte retrieval, and other characteristics were only interpreted statistically. Although larger than previously reported, the number of cases is limited.

Ovarian tissue cryopreservation and transplantation among alternatives for fertility preservation in the Nordic countries - compilation of 20 years of multicenter experience.

INTRODUCTION: The aim of this study is to report the current status of ovarian tissue cryopreservation among alternatives for fertility preservation in the Nordic countries. MATERIAL AND METHODS: A questionnaire was sent to 14 Nordic academic reproductive centers with established fertility preservation programs. It covered fertility preservation cases performed up to December 2014, standard procedures for ovarian tissue cryopreservation and oocyte cryopreservation and reproductive outcomes following ovarian tissue transplantation. RESULTS: Among the Nordic countries, Denmark and Norway practice ovarian tissue cryopreservation as a clinical treatment (822 and 164 cases, respectively) and their programs are centralized. In Sweden (457 cases), ovarian tissue cryopreservation is practiced at five of six centers and in Finland at all five centers (145 cases). Nearly all considered ovarian tissue cryopreservation to be experimental. In Iceland, embryo cryopreservation is the only option for fertility preservation. Most centers use slow-freezing methods for ovarian tissue cryopreservation. Most patients selected for ovarian tissue cryopreservation were newly diagnosed with cancer and the tissue was predominantly retrieved laparoscopically by unilateral oophorectomy. Only minor complications were reported. In total, 46 women have undergone ovarian tissue transplantation aiming at recovering fertility, 17 healthy children have been born and several additional pregnancies are currently ongoing. Whenever patients' clinical condition is permissive, oocyte cryopreservation after hormonal stimulation is preferred for fertility preservation. Between 2012 and 2014, a smaller proportion of females have undergone fertility preservation in the Nordic centers, in comparison to males (1:3). CONCLUSIONS: Overall, ovarian tissue cryopreservation was reported to be safe. Slow freezing methods are still preferred. Promising results of recovery of fertility have been reported in Nordic countries that have initiated ovarian tissue transplantation procedures.

Effect of mid-luteal phase GnRH agonist on frozen-thawed embryo transfers during natural menstrual cycles: a randomised clinical pilot study.

This prospective randomised crossover study evaluated the effect of mid-luteal single-dose gonadotropin-releasing hormone agonist (triptoreline) on pregnancy outcomes in natural-cycle frozen embryo transfers (FETs). Ninety-eight women were randomised to receive either standard luteal support with vaginal micronised progesterone or an additional single dose of 0.1 mg triptoreline at the time of implantation. The intervention group was composed of 65 FET cycles and the control group of 62 cycles. In the intervention group, there were more positive pregnancy tests, clinical pregnancies and live births, but the differences did not reach statistical significance. The mean beta human chorionic gonadotropin (ß-hCG) concentration of singleton pregnancies was significantly lower in the intervention group compared to the control group (p = 0.048). No difference was detected in the median birth weight of the newborns.

[Premature ovarian insufficiency--a threat to a woman's health?]. / Munasarjojen toiminnan ennenaikainen hiipuminen--uhka naisen terveydelle?

Premature ovarian insufficiency (POI) is characterized by cessation of menstruation and elevated follicle stimulating hormone levels before the age of 40. Patients may have hypoestrogenic symptoms such as hot flushes. Most cases are idiopathic but the underlying mechanisms can be genetic, autoimmune-based or iatrogenic. Long-term deprivation of estrogen has serious implications for cardiovascular health and bone density. Early impaired fertility and infertility may be the main concerns for the patients. Hormone replacement therapy until the normal age of menopause is recommended, even though the scientific evidence is inadequate. The only proven method of achieving pregnancy in these patients is by ovum donation.

A case of conjoined twins after a transfer of a multinuclear embryo.

A pregnancy with conjoined twins was observed after transfer of a multinuclear embryo. As nuclear mechanisms have a role in cellular differentiation, association between multinucleation and fetal malformations is possible. Follow-up studies on children born after transfer of embryos with bi/multinuclear blastomeres are needed.

TBX6, LHX1 and copy number variations in the complex genetics of Müllerian aplasia.

BACKGROUND: Müllerian aplasia (MA) is a congenital disorder of the female reproductive tract with absence of uterus and vagina with paramount impact on a woman's life. Despite intense research, no major genes have been found to explain the complex genetic etiology. METHODS AND RESULTS: We have used several genetic methods to study 112 patients with MA. aCGH identified CNVs in 8/50 patients (16%), including 16p11.2 and 17q12 deletions previously associated with MA. Subsequently, another four patients were shown to carry the ~0.53 Mb deletion in 16p11.2. More importantly, sequencing of TBX6, residing within 16p11.2, revealed two patients carrying a splice site mutation. Two previously reported TBX6 variants in exon 4 and 6 were shown to have a significantly higher frequency in patients (8% and 5%, respectively) than in controls (2% each). We also sequenced LHX1 and found three apparently pathogenic missense variants in 5/112 patients. Altogether, we identified either CNVs or variations in TBX6 or LHX1 in 30/112 (26.8%) MA patients. CNVs were found in 12/112 (10.7%), patients, novel variants in TBX6 or LHX1 in 7/112 (6.3%), and rare variants in TBX6 in 15/112 (13.4%) patients. Furthermore, four of our patients (4/112, 3.6%) were shown to carry variants in both TBX6 and LHX1 or a CNV in combination with TBX6 variants lending support to the complex genetic etiology of MA. CONCLUSIONS: We have identified TBX6 as a new gene associated with MA. Our results also support the relevance of LHX1 and CNVs in the development of this congenital malformation.

[Reproductive health after cancer treatment--contraception, planning and monitoring of pregnancy]. / Lisääntymisterveys hoidetun syövän jälkeen --raskauden ehkäisyä, suunnittelua ja seurantaa.

Infertility is common after cancer treatments, but pregnancies of those treated for cancer usually proceed well. Pretreatment counseling by a fertility doctor improves posttreatment quality of life. The most important issues to be considered in pregnancy planning and monitoring include cytotoxic drug induced organ-specific insufficiencies and radiotherapy targeted at the thoracic region, whole body, or at the uterus during childhood. Hypothyroidism is the most common hormonal complication and is also significant with respect to fertility and gravidity.

Evaluation of SHOX copy number variations in patients with Müllerian aplasia.

BACKGROUND: Müllerian aplasia (MA) characterized by congenital loss of functional uterus and vagina is one of the most difficult disorders of female reproductive health. Despite of growing interest in this research field, the cause of the disorder for the majority of patients is still unknown. A recent report of partial SHOX duplications in five patients with MA has motivated us to further evaluate their role in the disorder. Therefore we have studied SHOX copy number variations (CNVs) in a cohort of 101 Finnish patients with MA and in 115 healthy controls. METHODS: We used multiplex ligation-dependent probe amplification (MLPA) to study SHOX CNVs. RESULTS: All patients showed normal amplification of SHOX. Several aberrations, duplications and deletions, were found downstream of the gene in five patients and seven controls, but these were all copy number polymorphisms. CONCLUSIONS: Our study in an extensive cohort of patients with MA does not support a role for SHOX CNVs in the aetiology of the disorder. Further studies in the field are important for both patients looking for answers as well as for the scientific community for better understanding the regulation of the female reproductive duct development.

Altered expression of genes involved in the production and degradation of endometrial extracellular matrix in patients with unexplained infertility and recurrent miscarriages.

During the secretory phase of the menstrual cycle, the composition of extracellular matrix (ECM) in endometrium changes to favour implantation. In the present study, we have analysed whether some cases of unexplained infertility and recurrent abortions could be explained by abnormal production or turnover of endometrial ECM. Comparison of mRNA levels of a panel of collagens, matrix metalloproteinases (MMP), tissue inhibitors of metalloproteinases (TIMP) and cathepsins in the samples revealed higher levels of type I collagen, MMP-2 and cathepsin H and decreased levels of TIMP-3 mRNA in mid-secretory endometrium of patients with unexplained infertility and/or recurrent miscarriages when compared with normal mid-secretory endometrium. Furthermore, changes were also seen in the levels of type I collagen and TIMP-3 mRNA between the proliferative and mid-secretory phases of normal endometrium. The results suggest an altered ECM turnover in the endometrium of patients with fertility disorders prior to implantation.