The live birth rate of vitrified oocyte accumulation for managing diminished ovarian reserve: a retrospective cohort study.

BACKGROUND: Vitrified M-II oocyte accumulation for later simultaneous insemination has been used for managing POR. Our study aimed to determine whether vitrified oocyte accumulation strategy improves live birth rate (LBR) for managing diminished ovarian reserve (DOR). METHODS: A retrospective study included 440 women with DOR fulfilling Poseidon classification groups 3 and 4, defined as the presence of serum anti-Müllerian hormone (AMH) hormone level < 1.2 ng/ml or antral follicle count (AFC) < 5, from January 1, 2014, to December 31, 2019, in a single department. Patients underwent accumulation of vitrified oocytes (DOR-Accu) and embryo transfer (ET) or controlled ovarian stimulation (COS) using fresh oocytes (DOR-fresh) and ET. Primary outcomes were LBR per ET and cumulative LBR (CLBR) per intention to treat (ITT). Secondary outcomes were clinical pregnancy rate (CPR) and miscarriage rate (MR). RESULTS: Two hundred eleven patients underwent simultaneous insemination of vitrified oocyte accumulation and ET in the DOR-Accu group (maternal age: 39.29 ± 4.23 y, AMH: 0.54 ± 0.35 ng/ml), and 229 patients underwent COS and ET in the DOR-fresh group (maternal age: 38.07 ± 3.77 y, AMH: 0.72 ± 0.32 ng/ml). CPR in the DOR-Accu group was similar in the DOR-fresh group (27.5% vs. 31.0%, p = 0.418). However, MR was statistically higher (41.4% vs. 14.1%, p = 0.001), while LBR per ET was statistically lower (15.2% vs. 26.2%, p < 0.001) in the DOR-Accu group. There is no difference in CLBR per ITT between groups (20.4% vs. 27.5%, p = 0.081). The secondary analysis categorized clinical outcomes into four groups regarding patients' age. CPR, LBR per ET, and CLBR did not improve in the DOR-Accu group. In the group of 31 patients, accumulated vitrified metaphase II (M-II) oocytes reached a total number of ≥ 15, and CPR improved among the DOR-Accu group (48.4% vs. 31.0%, p = 0.054); however, higher MR (40.0% vs. 14.1%, p = 0.03) resulted in similar LBR per ET (29.0% vs. 26.2%, p = 0.738). CONCLUSIONS: Vitrified oocyte accumulation for managing DOR did not improve LBR. Higher MR resulted in lower LBR in the DOR-Accu group. Therefore, the vitrified oocyte accumulation strategy for managing DOR is not clinically practical. TRIAL REGISTRATION: The study protocol was retrospectively registered and was approved by Institutional Review Board of Mackay Memorial Hospital (21MMHIS219e) on August 26, 2021.

Correlation between Sperm Micro Ribonucleic Acid-34b and -34c Levels and Clinical Outcomes of Intracytoplasmic Sperm Injection in Men with Male Factor Infertility.

Few studies have examined the correlation between sperm miRNA levels and clinical outcomes of intracytoplasmic sperm injection (ICSI). In this study, we aimed to assess the correlation of sperm miR-34b, miR-34c, miR-122, and miR-429 levels with ICSI outcomes in men with teratozoospermia and asthenozoospermia. TaqMan microRNA quantitative polymerase chain reaction was used to evaluate the relative expression of miRNAs in sperm. The relative miRNA levels quantified using a comparative method found that the four miRNAs were not associated with fertilization rate and early embryo development. However, revels of miR-34b and miR-34c in teratozoospermia sperm of the live birth group were significantly higher than those in the non-live birth group. Receiver operating characteristic curve analysis revealed that the optimal cut-off delta cycle threshold values of miR-34b and miR-34c were 8.630 and 7.883, respectively. Statistical analysis found that the levels of miR-34b and the miR-34c in teratozoospermic and asthenozoospermic sperm above the thresholds were not associated with the fertilization rate and the high-quality embryo rate above 50%; however, they were more likely to exhibit higher implantation, pregnancy, and live birth rates. miR-34b and miR-34c were significantly associated with ICSI clinical outcomes in male factor infertility, especially teratozoospermia. Further validation is required before it becomes a clinically valid reference indicator.

A mouse seminal vesicle-secreted lysozyme c-like protein modulates sperm capacitation.

Lysozyme (LYZ) c-like proteins are primarily present in the testis and epididymis of male reproductive tissues. Here, we report a novel member of the c-type LYZ family, the seminal vesicle-secreted LYZ c-like protein (SVLLP). Three forms of SVLLP were purified from mouse seminal vesicle secretions and characterized as glycoproteins with the same protein core but different N-linked glycans. SVLLP is structurally similar to c-type LYZ proteins. Only one of the 20 invariant residues was altered in the consensus sequence of c-type LYZs; however, the changed residue (N53S) is one of two essential catalytic residues. LYZ activity assays demonstrated that the three glycoforms of SVLLP lacked enzyme activity. SVLLP is primarily expressed in seminal vesicles. Immunohistochemistry revealed that it occurs in the luminal fluid and mucosal epithelium of the seminal vesicles. Testosterone is not the primary regulator for its expression in the seminal vesicle. SVLLP binds to sperm and suppresses bovine serum albumin-induced sperm capacitation, inhibits the acrosome reaction, and blocks sperm-oocyte interactions in vitro, suggesting that SVLLP is a sperm capacitation inhibitor.

Intrauterine adhesion prevention with Malecot catheter after hysteroscopic myomectomy: A novel approach.

OBJECTIVE: Intrauterine adhesion after hysteroscopic myomectomy contributes to infertility, recurrent miscarriages, menstrual irregularities, and hinders pregnancy outcomes. The aim of this study was to apply the indwelling Malecot catheter in prevention of intrauterine adhesion after hysteroscopic myomectomy and to further evaluate the effectiveness of this approach with reported live birth rates in infertile patients who underwent subsequent infertility treatment. MATERIALS AND METHODS: Seventeen patients with FIGO Classification System PALM-COIEN Type 0 or 1 submucous myoma that received hysteroscopic myomectomy were recruited in this retrospective analysis. Post-operative insertion of the Malecot catheter via the aid of the uterine sound was performed and the catheter was left in place for seven days. RESULTS: The mean duration of TTP (time to pregnancy) was 15.6 months after hysteroscopy. Within three years after the operation, 10 out of 17 infertility patients achieved ongoing pregnancy over 12 weeks. Ongoing pregnancy rate was 58.8% (10/17). Eight patients achieved live birth (seven singletons, one twin pregnancy) with mean gestational age of 38 weeks. Live birth rate was 47.1% (8/17). CONCLUSION: The Malecot catheter is an inexpensive, easy-to-operate, and effective physical barrier method for preventing IUA in infertile patients undergoing hysteroscopic myomectomy with high live birth rate and no obvious visible post-operative adhesions.

Dual trigger with gonadotropin releasing hormone agonist and human chorionic gonadotropin significantly improves live birth rate for women with diminished ovarian reserve.

BACKGROUND: Diminished ovarian reserve (DOR) remains one of the greatest obstacles affecting the chance of a successful live birth after fertility treatment. The present study was set to investigate whether using a "dual trigger" consisted of human chorionic gonadotropin (hCG) plus gonadotropin releasing hormone agonist (GnRH-a) for final oocyte maturation could improve the IVF cycle outcomes for patients with diminished ovarian reserve. METHODS: A total of 427 completed GnRH-antagonist downregulated IVF cycles with fresh embryo transfer (ET) were included in this retrospective analysis. DOR was defined as antral follicle count ≤5 and serum anti-Müllerian hormone level ≤ 1.1 ng/mL. The control group (n = 130) used a 6500 IU of recombinant hCG for trigger, and the study group (n = 297) used 0.2 mg of triptorelin plus 6500 IU of recombinant hCG for trigger. RESULTS: The dual-trigger group had significantly higher oocyte fertilization rate (73.1% vs. 58.6%), clinical pregnancy rate (33.0% vs. 20.7%) and live birth rate (26.9% vs. 14.5%) when compared to the hCG trigger group. In addition, the abortion rate (17.4% vs. 37.0%) and embryo transfer cancellation rate (6.1% vs. 15.4%) were both significantly lower in the dual trigger group. The primary outcome measure was the live birth rate per oocyte retrieval cycle. Secondary outcome measures were embryo transfer cancellation rate, clinical pregnancy rate, implantation rate, chemical pregnancy rate and abortion rate per oocyte retrieval cycle. CONCLUSIONS: Dual triggering the final oocyte maturation with GnRH-a and standard dose of hCG can significantly improve the live birth rate, clinical pregnancy rate, and fertilization rate in women with diminished ovarian reserve undergoing GnRH antagonist down-regulated IVF-ICSI cycles.

Early blastulation of day 4 embryo correlates with the increased euploid rate of preimplantation genetic screening cycles.

OBJECTIVE: It is known that embryos with faster growing potential, especially in blastocyst development, correlate with the increased euploid rate. Our study investigated the preimplantation genetic screening cycle to analyze the correlation between early blastulation (EB) on day 4 embryo and the euploid rate. MATERIALS AND METHODS: This is a retrospective study examining 273 biopsied blastocysts after preimplantation genetic screening obtained from 54 patients from March 2013 to March 2017. Of the 273 biopsied embryos, 81 had early blastulation on day 4 and were classified as the EB (+) group, while the other 192 had no early blastulation and were classified as the EB (-) group. Euploid rates were compared between the two groups. A total of 34 single euploid embryos were transferred, with 14 from the EB (+) group and 20 from the EB (-) group. Clinical pregnancy was compared between the groups. RESULTS: There is a statistically significant increase in the euploid rate in the EB (+) group (49.4% vs. 34.4%, p = 0.02). The clinical pregnancy rate was also increased in the single euploid embryo transfer group with early blastulation, but did not reach statistical significance (71.4% vs. 50.0%, p = 0.211). CONCLUSIONS: Early blastulation of day 4 embryo correlates significantly with the euploid rate. Early blastulation of day 4 embryo may serve as a potential aid for embryo selection for transfer in preimplantation genetic screening cycles.

Early blastulation (EB) of day 4 embryo is predictive of outcomes in single embryo transfer (SET) cycles.

OBJECTIVE: The aim of this study was to assess whether the early blastulation (EB) of day 4 embryo is a useful predictor for outcomes in fresh elective single embryo transfer (eSET) cycles. MATERIALS AND METHODS: We retrospectively enrolled patients undergoing fresh SET cycles in our hospital from April 2014 to September 2016 and met with the following criteria: 1) age <38 years, 2) first IVF/ICSI cycle, 3) at least two blastocysts with morphological grading better than or equal to 4BB. RESULTS: A total of 81 patients were included. Of whom, 55 patients (68%) had undergone eSET with embryos that had early blastulation on day 4 while the other 26 patients had had no EB. Early blastulation has shown a higher rate of good blastocyst (84.3% vs. 60.5%, p < 0.0001). The clinical pregnancy rate of EB group was significantly higher than that of non-EB group (56.4% vs. 27.0%, p = 0.013). There is also a tendency in EB group to have a lower abortion rate (3.23% vs. 28.6%, p = 0.081). CONCLUSIONS: EB on day 4 is a useful predictor of the quality of the following embryos (i.e. day 5 embryo). It is a simple tool in selecting the best embryo to get a higher pregnancy rate in fresh eSET cycles. TRIAL REGISTRATION: This study was supplementally registered by the MacKay Memorial Hospital Institutional Review Board on April 18, 2017 (registration No. 17MMHIS039e).

Serine Protease Inhibitor SERPINE2 Reversibly Modulates Murine Sperm Capacitation.

SERPINE2 (serpin peptidase inhibitor, clade E, member 2), predominantly expressed in the seminal vesicle, can inhibit murine sperm capacitation, suggesting its role as a sperm decapacitation factor (DF). A characteristic of DF is its ability to reverse the capacitation process. Here, we investigated whether SERPINE2 can reversibly modulate sperm capacitation. Immunocytochemical staining revealed that SERPINE2 was bound onto both capacitated and uncapacitated sperm. It reversed the increase in BSA-induced sperm protein tyrosine phosphorylation levels. The effective dose and incubation time were found to be >0.1 mg/mL and >60 min, respectively. Calcium ion levels in the capacitated sperm were reduced to a level similar to that in uncapacitated sperm after 90 min of incubation with SERPINE2. In addition, the acrosome reaction of capacitated sperm was inhibited after 90 min of incubation with SERPINE2. Oviductal sperm was readily induced to undergo the acrosome reaction using the A23187 ionophore; however, the acrosome reaction was significantly reduced after incubation with SERPINE2 for 60 and 120 min. These findings suggested that SERPINE2 prevented as well as reversed sperm capacitation in vitro. It also prevented the acrosome reaction in in vivo-capacitated sperm isolated from the oviduct. Thus, SERPINE2 could reversibly modulate murine sperm capacitation.

Day 4 good morula embryo transfer provided compatible live birth rate with day 5 blastocyst embryo in fresh IVF/ET cycles.

OBJECTIVE: Embryo transfers during cleavage stage (day 2 or day 3) and blastocyst stages (day 5 or day 6) are common in current daily practice in fresh IVF/ET cycles. Data regarding transferring day 4 embryos, morula/compact stage, is still restricted and the grading system is also inconsistent, as between IVF clinics. This study provided a new detailed classification system for morula/compact stage embryos and compared successes rates between day 4 and day 5 ET. MATERIALS AND METHODS: This was a retrospective study. A review of medical records from January 1st, 2013, to December 31st 2015, performed for all conventional insemination and ICSI cycles with a GnRH-antagonist protocol at the Infertility Division of MacKay Memorial Hospital in Taipei City, Taiwan. RESULTS: There were 427 cycles included in our study, 107 in study group (day 4 MET) and 320 in control group (day 5 BET). Pregnancy rates and live birth rate were compatible, as between morula embryo transfer (MET) and blastocyst embryo transfer (BET). The implantation rate (36.3% vs. 39.6%, respectively, p = 0.500), clinical pregnancy rate (49.5% vs. 51.9%, respectively, p = 0.737), and live birth rate (42.1% vs. 45.6%, respectively, p = 0.574) were statistically insignificant between groups. The term birth rate was statistically higher in the MET group than in the BET group (95.7% vs. 79.5%, respectively, p = 0.006). When the clinical outcomes between day 4 good MET and day 5 good BET were compared, the results were compatible. The implantation rate (48.8% vs. 41.1%, respectively, p = 0.335), clinical pregnancy rate (55.0% vs. 53.2%, respectively, p = 0.867), and live birth rate (47.5% vs. 47.1%, respectively, p = 1.000) showed no significant difference. The term birth rate was also higher in day 4 good MET group than in day 5 good BET group (100% vs. 78.3%, respectively, p = 0.025). CONCLUSION: In this study, we performed day 4 MET avoid BET on Sunday. The grading system we provided was more detailed for embryo selection and it was easier to remember. Our data showed that morula embryo transfer might be a flexible, easier and applicable method for embryo transfer in daily routine.

Expression of cystatin C in the female reproductive tract and its effect on human sperm capacitation.

BACKGROUND: Cystatin C (CST3), a cysteine protease inhibitor in seminal plasma, is expressed in animal uteri. However, its expression in the human female reproductive tract and its effect on human sperm capacitation are unclear. METHODS: The cellular localization of CST3 was observed using immunohistochemistry. The binding of CST3 to sperm was examined using immunocytochemistry. Sperm motility parameters were analyzed using computer-assisted sperm analysis. Sperm capacitation was evaluated by analyzing cholesterol content, protein tyrosine phosphorylation levels, and the acrosome reaction. RESULTS: Immunohistochemical staining demonstrated that CST3 is prominently expressed in the female reproductive tract, including the epithelial lining and cervix and endometrium fluids, particularly at times near ovulation. It can bind to human sperm on the post-acrosomal head region and the mid and principal piece of the tail. CST3 enhances sperm motility and inhibits the signal initiating sperm capacitation, i.e., efflux of cholesterol from the sperm plasma membrane and a late sperm capacitation event, i.e., the increase in the sperm protein tyrosine phosphorylation. The suppressive trend on sperm acrosome reaction further supports CST3's ability to inhibit sperm capacitation. CONCLUSIONS: These findings suggest that cervical CST3 may prevent precocious capacitation and acrosome reaction, thus preserving sperm fertilizing ability before it reaches the fallopian tube. Additionally, CST3 may help sperm enter the upper reproductive tract by enhancing sperm motility.

Simultaneous cul-de-sac and tubal pregnancy following in vitro fertilization.

OBJECTIVE: The aim of this study is to share a valuable experience of heterotopic pregnancy following in vitro fertilization. CASE REPORT: A 37-year-old, gravida 3, para 2 (cesarean section 2 times), woman underwent in vitro fertilization with three embryos transferred. On Day 23 after the embryo transfer, right tubal pregnancy with a 0.7-cm gestational sac was found by ultrasound, and her serum ß-human chorionic gonadotropin level was 81,388 mIU/mL. She underwent a laparotomy with right salpingectomy. On Day 43 after the embryo transfer, intermittent abdominal pains developed. A live fetus with a crown-rump length of 2.0 cm was found in the cul-de-sac. Under the diagnosis of abdominal pregnancy, she was admitted for sona-guided KCl and methotrexate injections. She received four units of packed red blood cells due to a drop in hemoglobin level from 12.5 g/dL to 8.6 g/dL. The patient recovered well, and the serum ß-human chorionic gonadotropin declined to <10 mIU/mL. CONCLUSION: Various forms of ectopic pregnancy should be kept in mind in early pregnancy following in vitro fertilization.

VEGF and FGF2 Improve Revascularization, Survival, and Oocyte Quality of Cryopreserved, Subcutaneously-Transplanted Mouse Ovarian Tissues.

This study was conducted to investigate the effect of the vascular endothelial growth factor (VEGF) and fibroblast growth factor 2 (FGF2) on revascularization, survival, and oocyte quality of cryopreserved, subcutaneously-transplanted mouse ovarian tissue. Autologous subcutaneous transplantation of vitrified-thawed mouse ovarian tissues treated with (experimental group) or without (control group) VEGF and FGF2 was performed. After transplantation to the inguinal region for two or three weeks, graft survival, angiogenesis, follicle development, and oocyte quality were examined after gonadotropin administration. VEGF coupled with FGF2 (VEGF/FGF2) promoted revascularization and significantly increased the survival rate of subcutaneously-transplanted cryopreserved ovarian tissues compared with untreated controls. The two growth factors did not show long-term effects on the ovarian grafts. In contrast to the untreated ovarian grafts, active folliculogenesis was revealed as the number of follicles at various stages and of mature oocytes in antral follicles after gonadotropin administration were remarkably higher in the VEGF/FGF2-treated groups. Although the fertilization rate was similar between the VEGF/FGF2 and control groups, the oocyte quality was much better in the VEGF/FGF2-treated grafts as demonstrated by the higher ratio of blastocyst development. Introducing angiogenic factors, such as VEGF and FGF2, may be a promising strategy to improve revascularization, survival, and oocyte quality of cryopreserved, subcutaneously-transplanted mouse ovarian tissue.

Outcomes of anti-Müllerian hormone-tailored ovarian stimulation protocols in in vitro fertilization/intracytoplasmic sperm injection cycles in women of advanced age.

OBJECTIVE: We aimed to compare the outcomes of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatments in women of advanced age (>40 years) using anti-Müllerian hormone (AMH)-tailored ovarian stimulation protocols versus conventional protocols based on antral follicle count (AFC). MATERIALS AND METHODS: We retrospectively reviewed 210 women who underwent IVF/ICSI cycles: 116 women underwent stimulation protocols that were tailored to their AMH levels, whereas 94 women received treatment using conventional stimulation protocols based on AFC as the ovarian reserve marker. RESULTS: The following parameters were significantly higher in the AMH-tailored group than in the conventional group: initial and total doses (IU) of recombinant follicle-stimulating hormone (rFSH) used for stimulation (514.2 ± 137.9 vs. 452.3 ± 135.3, p = 0.001; 4713.8 ± 1618.8 vs. 4047.2 ± 1366.0, p = 0.007, respectively), ovum pick-up rate (OPU; 88.8% vs. 75.5%, p = 0.016), serum estradiol (E2) level on the day of human chorionic gonadotropin (hCG) administration (1818.5 ± 1422.4 vs. 1394.0 ± 929.0 pg/mL, p = 0.028), number of oocytes retrieved (7.4 ± 5.1 vs. 5.5 ± 3.4, p = 0.007), number of embryos per case (4.2 ± 3.2 vs. 3.3 ± 2.5, p = 0.048), clinical pregnancy rates (22.4% vs. 8.5%, p = 0.008), implantation rates (13.1% vs. 3.9%, p = 0.001), and live birth rates per cycle (15.5% vs. 6.4%, p = 0.049). CONCLUSION: Individualized controlled ovarian stimulation (COS) protocols tailored to patients' AMH levels may improve the pregnancy rate, implantation rate, and live birth rate in women of advanced age undergoing IVF/ICSI compared with those receiving conventional stimulation protocols.

Correlation of cumulus gene expression of GJA1, PRSS35, PTX3, and SERPINE2 with oocyte maturation, fertilization, and embryo development.

BACKGROUND: GJA1 and PTX3 were proposed as gene markers for oocyte and embryo developmental competence, while SERPINE2 was reported to be associated with pregnancy outcome. PRSS35, which is exclusively expressed in the ovary, may be correlated with oocyte competence. This study was conducted to evaluate the correlation of cumulus GJA1, PRSS35, PTX3, and SERPINE2 gene expression levels with oocyte maturation, fertilization, and early embryo development. METHODS: In total, 308 cumulus cell samples separated from individual cumulus-oocyte complex were obtained from 40 patients undergoing the intracytoplasmic sperm injection treatment procedure. Gene expression levels (mRNA levels) in cumulus cells were assessed using quantitative real-time polymerase chain reaction. RESULTS: Gene expression levels of GJA1 and SERPINE2 in cumulus cells surrounding mature oocytes were significantly lower than those in cumulus cells enclosing immature oocytes. PRSS35 mRNA levels in cumulus cells of fertilized oocytes were significantly higher than those in cumulus cells of unfertilized oocytes. GJA1 and SERPINE2 seemed to express higher mRNA levels, while PRSS35 showed lower expression in cumulus cells of oocytes that developed into embryos with good morphology; however, the expression levels of all three genes and PTX3 showed no significant differences between embryos with good or poor morphology. CONCLUSIONS: GJA1 and SERPINE2 represent potential gene markers associated with oocyte maturation. PRSS35 may be correlated with oocyte fertilization potential. However, GJA1, PRSS35, PTX3, and SERPINE2 may not be considered as marker genes for predicting embryo morphology.

Embryonic early-cleavage rate is decreased with aging in GnRH agonist but not inantagonist protocols.

PURPOSE: The aim of this study was to evaluate the correlation between embryonic early-cleavage status and the age of patients receiving either a GnRH agonist long protocol or a GnRH antagonist protocol. METHODS: This retrospective study included 534 patients undergoing a fresh cycle of oocyte retrieval and day-3 embryo transfer. Of the 534 patients treated, 331 received a GnRH agonist long stimulation protocol (GnRH agonist group) for ovarian stimulation and 203 patients received a GnRH antagonist protocol (GnRH antagonist group). RESULTS: By logistic regression analysis, the rate of embryonic early-cleavage was significantly decreased with increasing age of women in the agonist (P < 0.001) but not in antagonist groups (P = 0.61). Based on the results of this study, maternal age is a critical factor for embryonic early-cleavage in agonist protocol but not in antagonist protocol. The results also showed that early-cleavage embryos were of better quality and resulted in a higher pregnancy rate than late-cleavage embryos in the GnRH agonist group. However, embryo quality and pregnancy rate was not significantly different between early and late cleavage embryos in the GnRH antagonist group. CONCLUSIONS: We conclude that embryonic early-cleavage status is negatively correlated with aging in women receiving GnRH agonist long down-regulation but not in GnRH antagonist protocols. We also conclude that early cleavage of the zygote is not a reliable predictor for pregnancy potential using the GnRH antagonist protocol.

Treatment of infertile women with unilateral tubal occlusion by intrauterine insemination and ovarian stimulation.

OBJECTIVE: The aim of this study was to evaluate the value of intrauterine insemination (IUI) combined with ovarian stimulation in women with unilateral tubal occlusion detected on hysterosalpingography (HSG). MATERIALS AND METHODS: A total of 703 patients undergoing IUI and controlled ovarian hyperstimulation were enrolled in this study. The study group consisted of 133 patients treated for unilateral tubal occlusion diagnosed by HSG during 2005-2011. The control group consisted of 570 patients with unexplained infertility treated during the same period. In all cases of the retrospective study, menstrual cycles were regular, basal serum follicle-stimulating hormone levels and sperm parameters were normal. RESULTS: There were no significant differences in pregnancy rate per cycle between the study (17.3%) and control groups (18.9%). The pregnancy rate was higher in patients with proximal tubal occlusion (21.7%) compared with mid-distal tubal occlusion (12.5%) or unexplained infertility (18.9%), but the difference was not statistically significant. CONCLUSIONS: Infertile patients with only unilateral proximal tubal occlusion detected on HSG can be treated initially by IUI combined with ovarian stimulation. The cycle outcomes in patients with proximal tubal occlusion are similar to patients with unexplained infertility. However, the stimulated IUI might not be a good choice for patients with unilateral mid-distal tubal occlusion because of a lower success rate, although further evidence is needed.

Dual trigger with combination of gonadotropin-releasing hormone agonist and human chorionic gonadotropin significantly improves the live-birth rate for normal responders in GnRH-antagonist cycles.

OBJECTIVE: To investigate whether dual triggering of final oocyte maturation with a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG) can improve the live-birth rate for normal responders in GnRH-antagonist in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) cycles. DESIGN: Retrospective cohort study. SETTING: Infertility unit of a university-affiliated medical center. PATIENT(S): Normal responders to controlled ovarian hyperstimulation who were undergoing IVF-ICSI with a GnRH antagonist protocol. INTERVENTION(S): Standard dosage of hCG trigger (6,500 IU of recombinant hCG) versus dual trigger (0.2 mg of triptorelin and 6,500 IU of recombinant hCG). MAIN OUTCOME MEASURE(S): Live-birth, clinical pregnancy, and implantation rates per cycle. RESULT(S): A total of 376 patients with 378 completed cycles with embryo transfer were enrolled (hCG trigger/control group: n = 187; dual trigger/study group: n = 191). The dual trigger group demonstrated statistically significantly higher implantation (29.6% vs. 18.4%), clinical pregnancy (50.7% vs. 40.1%), and live-birth (41.3% vs. 30.4%) rates as compared with the hCG trigger group. There was no statistically significant difference in terms of patient demographics, cycle parameters, or embryo quality. CONCLUSION(S): Dual trigger of final oocyte maturation with a GnRH-agonist and a standard dosage of hCG in normal responders statistically significantly improves implantation, clinical pregnancy, and live-birth rates in GnRH-antagonist IVF cycles.

Involvement of the serine protease inhibitor, SERPINE2, and the urokinase plasminogen activator in cumulus expansion and oocyte maturation.

The serpin peptidase inhibitor, clade E, member 2 (SERPINE2) inhibits urokinase-type plasminogen activator (PLAU) and tissue-type plasminogen activator. Higher SERPINE2 expression levels were detected in cumulus cells of human immature oocytes than in those of mature oocytes. The objective of this study was to evaluate whether high SERPINE2 levels in cumulus cells are associated with oocyte immaturity. Using the mouse cumulus-oocyte complex as an experimental model, the effects of elimination and overexpression of SERPINE2 in cumulus cells on cumulus expansion and oocyte maturation were assayed by in vitro maturation. Serpine2 and PLAU transcripts were the most highly expressed serpins and plasminogen activators, respectively. Their expression was coordinately regulated in cumulus cells during gonadotropin-induced oocyte maturation. Silencing of Serpine2 expression using small interfering RNAs or blockage of SERPINE2 protein using a specific antibody had no effect on oocyte maturation. However, overexpression of Serpine2 or exogenous supplementation with high levels of SERPINE2 impaired cumulus expansion and oocyte maturation, probably by decreasing hyaluronan synthase 2 (Has2) and versican (Vcan) mRNA expression. Amiloride, a specific PLAU inhibitor, also suppressed these processes. PLAU supplementation of the oocyte in vitro maturation medium caused earlier and more extensive expansion of cumulus cells and oocyte maturation that may be mediated by increased Has2 mRNA expression. However, these effects were neutralized by coincubation with SERPINE2 or amiloride and PLAU. In conclusion, SERPINE2 and PLAU are involved in cumulus expansion and oocyte maturation. High SERPINE2 levels impair these processes, probably by decreasing cumulus matrix gene expression as well as reducing cumulus hyaluronan contents and inhibiting PLAU activity. These findings may explain why cumulus cells surrounding immature human oocytes express high SERPINE2 levels.

Mechanisms underlying the inhibition of murine sperm capacitation by the seminal protein, SPINKL.

SPINKL, a serine protease inhibitor kazal-type-like protein initially found in mouse seminal vesicle secretions, possesses structurally conserved six-cysteine residues of the kazal-type serine protease inhibitor family. However, it has no inhibitory activity against serine proteases. Previously, it was found to have the ability to suppress murine sperm capacitation in vitro. Herein, we investigated the mechanisms underlying the suppressive effect of SPINKL on sperm capacitation. Three in vitro capacitation-enhancing agents, including bovine serum albumin (BSA), methyl-beta-cyclodextrin (MBCD), and dibutyryl cyclic AMP (dbcAMP), coupled with 3-isobutyl-1-methylxanthine (IBMX), were used to evaluate the influence of SPINKL on capacitation signaling. Preincubation of sperm with SPINKL suppressed BSA- and MBCD-induced sperm capacitation by blocking three upstream signals of capacitation that is the cholesterol efflux from sperm plasma membranes, extracellular calcium ion influx into sperm, and increases in intracellular cAMP. Moreover, SPINKL also inhibited downstream signal transduction of capacitation since it suppressed dbcAMP/IBMX and N(6) -phenyl cAMP (6-Phe-cAMP)-activated cAMP-dependent protein kinase-associated protein tyrosine phosphorylation. Such inhibition is probably mediated by attenuation of SRC tyrosine kinase activity. Furthermore, SPINKL could not reverse capacitation once sperm had been capacitated by capacitation-enhancing agents or capacitated in vivo in the oviduct. SPINKL bound to sperm existed in the uterus but had disappeared from sperm in the oviduct during the sperm's transit through the female reproductive tract. Therefore, SPINKL may serve as an uncapacitation factor in the uterus to prevent sperm from precocious capacitation and the subsequent acrosome reaction and thus preserve the fertilization ability of sperm.

Comparison of the clinical outcomes between fresh blastocyst and vitrified-thawed blastocyst transfer.

OBJECTIVE: To compare the clinical outcomes between fresh and vitrified-thawed day 5 blastocyst transfers. DESIGN: Retrospective case control study. SETTING: Tertiary referral center. PATIENT(S): Patients 38 years of age or less who underwent IVF/ICSI cycles with fresh or frozen-thawed blastocysts transferred from June 1, 2009 to November 30, 2011 INTERVENTION(S): Vitrification and thawing of day 5 blastocysts using the Cryotop method. (Kitazato BioPharma Co., Ltd., Fuji city, Shizuoka, Japan) MAIN OUTCOME MEASURE(S): Clinical pregnancy rate, implantation rate, ongoing pregnancy rate, and multiple pregnancy rates. RESULTS: Of the 118 cycles in the fresh transfer group, 234 blastocysts were transferred. The clinical pregnancy rate was 66.1 % and implantation rate was 50.9 %. The ongoing pregnancy rate was 56.8 % and the rates for singleton and twin pregnancies were 53.7 % and 44.8 %. Of the 59 cycles in the vitrified-thawed group, 111 blastocysts were transferred. The clinical pregnancy rate was 59.3 % and implantation rate was 43.2 %. The ongoing pregnancy rate was 47.5 % and the rates for singleton and twin pregnancies were 60.7 % and 39.3 %. The clinical pregnancy rate, implantation rate and ongoing pregnancy rate did not differ significantly between the two groups. CONCLUSIONS: The implantation rates were not significantly different between the fresh and the vitrified-thawed groups. Thus, single embryo transfer may be considered in fresh cycles to decrease multiple pregnancy rates. The surplus embryos should be vitrified for the frozen embryo transfer to improve the cumulative pregnancy rate.