The need for longitudinal data on the value of fertility treatment for infertile patients' quality of life: A review and pilot study.

Infertility threatens the life goal of parenthood and, hence, quality of life (QoL) of (wo)men, but the fertility clinic trajectory might be burdensome. This review of longitudinal studies and pilot longitudinal study examines the impact of the pre-in vitro fertilization (IVF) fertility clinic trajectory on patient-reported outcome measures (PROMs) for emotional well-being, including QoL. A publication found that the diagnostic workup decreases men's infertility-specific distress while publications disagree whether it decreases (wo)men's anxious and depressive reactions. Intrauterine insemination (IUI) was found to increase (wo)men's depressive reactions. Publications on infertility-specific, health-related, and overall QoL were missing. The pilot indicated that (wo)men's overall QoL is not affected by the diagnostic workup but is decreased by the time of the third IUI. Longitudinal studies on the impact of starting the fertility clinic trajectory on PROMs are needed as they are essential for patient-centered clinical decision-making and patient-centered policy-level decision-making.

The impact of legally restricted embryo transfer and reimbursement policy on cumulative delivery rate after treatment with assisted reproduction technology.

STUDY QUESTION: What is the impact of the Belgian legislation (1 July 2003), coupling reimbursement of six assisted reproduction technology (ART) cycles per patient to restricted embryo transfer policy, on cumulative delivery rate (CDR) per patient? SUMMARY ANSWER: The introduction of Belgian legislation in ART had no negative impact on the CDR per patient based on realistic estimates within six cycles or 36 months. WHAT IS KNOWN ALREADY: The introduction of Belgian legislation limiting the number of embryos for transfer resulted in a reduction of the multiple pregnancy rate (MPR) per cycle by 50%. STUDY DESIGN, SIZE, DURATION: A retrospective cohort study with a study group after implementation of the new ART legislation (July 2003 to June 2006) and the control group, before legislation (July 1999 to June 2002). PARTICIPANTS/MATERIALS, SETTING, METHODS: CDR was compared in an academic tertiary setting between a study group after legislation (n = 795 patients, 1927 fresh and 383 frozen-thawed embryo transfer (FET) cycles) and a control group before legislation (n = 463 patients, 876 fresh and 185 FET cycles) within six cycles or 36 months, delivery or discontinuation of treatment. The CDR was estimated using life table analysis considering pessimistic, optimistic and realistic scenarios and compared after adjustment for confounding variables. In the realistic scenario we included information on embryo quality to define the prognosis of each patient discontinuing treatment. MAIN RESULTS AND THE ROLE OF CHANCE: In the realistic scenario, CDR within 36 months was comparable (all ages, P = 0.221) in study group (60.8%) and control group (65.6%), as well as in different age groups (<36 years, P = 0.242; 36-39 years, P = 0.851; 40-42 years, P = 0.840). In the realistic scenario applied to six cycles, we found lower CDRs in the study group than in the control group within the two first cycles (all ages, P = 0.009; <36 years, P = 0.007) but no difference in CDRs between the two groups within the four subsequent cycles (all ages P = 0.232; <36 years, P = 0.198). The CDR within six cycles was 60 and 65.3% for study group and control group, respectively, for all ages, and 65.8 and 70.4%, respectively, in the subgroup younger than 36 years. In women ≥36 years, CDR within six cycles was comparable in both groups (36-39 years, 43% in study versus 44.4% in control group, P = 0.730; 40-42 years, 21% in study versus 23% in control group, P = 0.786). LIMITATIONS, REASONS FOR CAUTION: A retrospective cohort study design was the only way to study the impact of legislation on CDR. Owing to the retrospective nature of this analysis over a long period of time, our data are potentially influenced by improvements in techniques and therefore improved success rates in ART over time. WIDER IMPLICATIONS OF THE FINDINGS: This 'Belgian model' can now be considered for application worldwide in countries with the aim to reduce the main ART side effect (high MPR) and its associated costs without a negative effect on the main intended effect (high CDR). STUDY FUNDING/COMPETING INTEREST(S): The authors have no conflict of interest to declare. No funding was obtained for this study.

The effect of modified quarter laser-assisted zona thinning on the implantation rate per embryo in frozen/vitrified-thawed/warmed embryo transfer cycles: a prospective randomized controlled trial.

BACKGROUND: Freezing/vitrifying and thawing/warming of embryos may impair the successful hatching process of the embryo out of its zona pellucida (ZP) and its following implantation into the uterus. Theoretically, assisted hatching (AH) may facilitate the hatching process and subsequently increase implantation rates (IRs). METHODS: In this prospective randomized controlled trial (RCT), the hypothesis was tested that the IR per embryo transferred is higher after transfer (ET) of frozen/vitrified-thawed/warmed embryos with thinned ZP after AH by modified quarter laser-assisted zona thinning (mQLAZT) when compared with ET of frozen/vitrified-thawed/warmed embryos without mQLAZT. Patients with frozen/vitrified embryos were randomized at the time of thawing/warming to a study group (with mQLAZT) or a control group (without mQLAZT). After thawing/warming, embryos were kept in culture for 24h, and mQLAZT was performed prior to ET. RESULTS: A total of 647 thawing cycles were randomized to either the mQLAZT group (n = 324) or the control group (n = 323). Reproductive outcome data were available for 302 cycles in the mQLAZT group and 317 cycles in the control group. Transfer could be performed in 73.5% and in 71.9% of the thawing/warming cycles in the mQLAZT group and the control group (P = 0.78), respectively. No significant differences were observed between the mQLAZT group and the control group for the IR [13.3%; 15.6%; rate ratio 0.85; 95% confidence interval (CI), 0.596-1.224], the ongoing IR (10.5 and 13.5%, P = 0.25) and the live birth rate [10.5%;13.3%; rate ratio 0.79; (95% CI), 0.530-1.189] per embryo transferred. CONCLUSIONS: In this RCT, mQLAZT did not improve the IR per embryo transferred in frozen/vitrified-thawed/warmed embryo transfer cycles. ClinicalTrials.govID NCT00593775.

Endometriosis and subfertility treatment: a review.

The aim of this article is to present a review on the influence of endometriosis on assisted reproductive techniques (ART), as well as on the influence of ART on endometriosis. Based on recent literature, this article will try to answer the following questions: 1) Does endometriosis change the success rate of ovulation induction (OI), intrauterine insemination (IUI) and in vitro fertilisation (IVF) and does previous chirurgical treatment of endometriosis change the success rate of OI, IUI and IVF? 2) Do ART alter the course of the disease? In order to answer these questions, we based ourselves on the following recent guidelines and reviews by reknown experts on endometriosis: the ESHRE Guideline for the Diagnosis and Treatment of Endometriosis, The Practice Committee of the American Society for Reproductive Medicine: Endometriosis and Fertility; a recent review paper on the relationship between endometriosis and subfertility and a recent meta-analysis on the relationship between endometriosis and ART. This review was then completed using more recent papers, published on PubMed as well as background articles, important references and own research papers presented at international meetings. The pregnancy rate after OI, IUI and IVF is decreased in women with endometriosis when compared to controls. The effect of previous surgery for endometriosis is unclear, due to great lack of standardised studies using well defined operation techniques and patient groups. The effect of ART on the spontaneous evolution and recurrence rate of endometriosis has hardly been studied. The presence of endometriosis has a negative effect on the pregnancy rate after ART. It is unclear if surgical treatment prior to ART may increase the pregnancy rate after ART. It is also unclear if ART is a risk factor for recurrence/progression of endometriosis.

Low and high grade mucoepidermoid carcinomas of the breast.

Mucoepidermoid carcinoma is a very rare primary tumour of the breast. Until now only 17 cases have been described in the literature. Generally these malignancies have a good prognosis, especially if well differentiated. We report a case of low-grade which recurred as high-grade after 32 months. She also developed a poorly differentiated adenocarcinoma in the other breast 12 years after her initial treatment. At present the patient is well without any sign of disease for 156 months. A literature review of this rare entity is presented.

Effects of cell concentration on viability and metabolic activity during cryopreservation.

Increasing the cell concentration during the cryopreservation of red blood cells (RBC) increased hemolysis. Similarly, increasing the cell concentration during the cryopreservation of hepatocytes reduced both the viability of the cells as assessed by trypan blue exclusion and the metabolic activity of the trypan blue-excluding cells. In both cell types, significant damage appeared at cell concentration levels exceeding 60%. With tightly packed RBC, hemolysis reached 63%, while for hepatocytes after thawing and dilution, trypan blue viability was reduced to 41% of that of the cells initially isolated. The viability of cryopreserved hepatocytes, estimated by trypan blue exclusion, was considerably reduced following incubation for 1 h at 37 degrees C and the extent of this reduction was also a function of cell concentration during freezing and thawing. The trypan blue viability of hepatocytes that were tightly packed during cryopreservation and then incubated at a concentration of 5 x 10(6) viable cells/ml fell dramatically to only 12.5%. The protein-synthesizing activity and the membrane transport activity of these cells, expressed in terms of cells that excluded trypan blue immediately following thawing and removal of the cryoprotectant, were reduced to 38.7 and 33.5%, respectively, of the activity in cells that were packed at 10% cell concentration. The fall in metabolic activity may have been due to complete loss of activity in some of the cells or reduced activity in most or all of the cells or any combination of these factors. It is concluded that there may be many mechanisms involved, but the most important factor is probably stresses produced by unphysiological cell-cell contacts occurring during the freeze-thaw cycle.

Cryopreservation of isolated rat hepatocytes: effects of iron-mediated oxidative stress of metabolic activity.

In an attempt to quantitatively evaluate the destructive effects of free radicals on metabolism, freshly prepared and cryopreserved isolated rat hepatocytes were exposed to and incubated with Fe2+ compounds, reputedly inducing oxygen-derived free radicals (OFR) capable of attacking the lipid structures of cellular membranes. Malondialdehyde (MDA) formation was interpreted as an expression of free radical interaction with polyunsaturated lipids, and in vitro incubations were carried out during the period of constant MDA formation. Protein synthesizing activity was evaluated by incubating control hepatocytes and cells previously exposed to 100 microM of Fe2+, to 100 microM of Fe2+, and 100 microM of desferrioxamine and to 100 microM of desferrioxamine alone with 0.1 microCi of L-[U-14C]isoleucine and in the presence of these compounds. Membrane transport activity was similarly evaluated by following the cellular uptake of alpha-amino-[1-14C]isobutyric acid. Protein-synthesizing activity of freshly prepared and cryopreserved hepatocytes was not affected by Fe2+ treatment, nor by the additions of the iron chelator desferrioxamine. Amino acid transport, however, was inhibited by 100 microM of Fe2+, but was effectively neutralized by the simultaneous addition of 100 microM of desferrioxamine. Cryopreserved hepatocytes equally presented a significantly inhibited amino acid transport activity over the incubation period. The results suggest that the metabolic depression measured in thawed hepatocytes does not result to any large extent from iron-catalysed OFR effects. When OFR production was deliberately induced, the most significant early change was seen in transmembrane amino acid uptake in both fresh and cryopreserved cells.

Heterotopic ovarian pregnancy after clomiphene ovulation induction.

Heterotopic pregnancy is a life threatening condition which seems to occur more frequently than previously estimated. We report a case of combined ovarian and intrauterine pregnancy after clomiphene treatment. Diagnosis was delayed because clinical presentation was atypical and ultrasound was falsely reassuring. The neonate was healthy but presented with a single umbilical artery. When an ectopic gestation is suspected after induction of ovulation or assisted reproductive technologies the presence of an intrauterine pregnancy can no longer be considered reassuring and an heterotopic pregnancy has to be ruled out.

Metabolic activity of freshly prepared and cryopreserved hepatocytes in monolayer culture.

The successful use of isolated hepatocytes for transplantation will, no doubt, require cryopreservation of the cells. However, cryopreservation results in the loss of viability of isolated hepatocytes. In this study a method is described that allows recovery of viable hepatocytes after cryopreservation. Freshly prepared and cryopreserved hepatocytes (1.8 M Me2SO in Euro-Collins solution) were suspended in Dulbecco's culture medium and allowed to form monolayers in Primaria T-25 culture flasks. Viable hepatocytes produced monolayers after 3 h of incubation and viable cultures could be maintained for up to 7 days as judged by trypan blue exclusion. Metabolic viability was measured by incorporation of radiolabeled isoleucine into proteins. Maximal protein synthetic capabilities in freshly prepared hepatocytes was obtained 24 h after culturing. Cryopreserved hepatocytes showed a decrease in protein synthetic capabilities after 24 h culturing. However, longer times of culture resulted in regenerating the capacity of these cryopreserved cells to carry out protein synthesis to levels similar to those of freshly prepared and cultured cells. Thus, incubation of monolayer cultures of cryopreserved hepatocytes for at least 48 h provides a means for reversing the injury caused by freeze-thaw stress and the regeneration of initial viability. This technique may provide a method that is suited for the use of cryopreserved hepatocytes for clinical transplantation.

The effects of cryopreservation on protein synthesis and membrane transport in isolated rat liver mitochondria.

Protein synthesizing activity and membrane transport were examined in fresh and cryopreserved isolated rat liver mitochondria. In the presence of 0.6, 1.2, and 1.8 M final concentrations of dimethyl sulfoxide (Me2SO), both metabolic parameters were considerably inhibited in the fresh samples and even more inhibited in the cryopreserved specimens. However, simple exposure to this penetrating cryoprotectant, followed by its subsequent removal by washing, did not seem to affect significantly the examined functions. When different freeze-thaw regimes were investigated, it was observed that optimal recovery of protein synthesis and membrane transport functions were obtained when fast freezing took place in the absence of Me2SO.