A prospective study on the long-term outcome of prepubertal and pubertal boys undergoing testicular biopsy for fertility preservation prior to hematologic stem cell transplantation.

BACKGROUND: Few studies have reported the long-term outcomes of prepubertal and pubertal boys undergoing testicular biopsy for fertility preservation (FP). PROCEDURE: This prospective longitudinal study examined 21 boys (aged 1.5-14.5 years) who underwent testicular biopsy for FP prior to allogeneic (n = 20) or autologous (n = 1) hematological stem cell transplantation (HSCT) between 2003 and 2010. During counseling, pubertal boys were encouraged to produce a sperm sample by masturbation , while prepubertal boys were presented with surgical testicular tissue retrieval as an option for experimental FP. Clinical outcomes included postoperative complications, pubertal development, and sex-hormone levels. Survivors approaching adulthood were encouraged to provide semen samples. RESULTS: Twenty boys, including 14 in prepuberty and six in early puberty (Tanner stage 2-3), underwent open testicular biopsies. Two pubertal biopsies contained mature sperms, which were cryopreserved. Testicular tissue was vitrified in the remaining 18 cases. One pubertal boy (Tanner stage 4) underwent percutaneous testicular sperm aspiration and sperms obtained were cryopreserved. Postoperative complications (hematoma or infection) were rare. Overall, 14 boys survived >5 years (mean follow-up after HSCT, 7.2 years) and 11 showed advanced puberty. Semen samples were provided by five boys and obtained sperm were cryopreserved from two. Individuals at adulthood had normal testosterone levels but subnormal testicular size, high follicle stimulating hormone, and low inhibin B and anti-Müllerian hormone levels. CONCLUSION: No long-term risks were detected during continuous clinical follow-up. Experimental testicular biopsies for FP were well accepted by the patients and families, despite the absence of methods to use prepubertal tissue for fertility treatment.

Fertility preservation in girls with turner syndrome: prognostic signs of the presence of ovarian follicles.

CONTEXT: Many girls with Turner syndrome have follicles in their ovaries at adolescence. OBJECTIVE: Our objective was to study which girls might benefit from ovarian tissue freezing for fertility preservation. DESIGN: Clinical and laboratory parameters and ovarian follicle counts were analyzed among girls referred by 25 pediatric endocrinologists. SUBJECTS AND SETTING: Fifty-seven girls with Turner syndrome, aged 8-19.8 yr, were studied at a university hospital. INTERVENTIONS: Ovarian tissue was biopsied laparoscopically, studied for the presence of follicles, and cryopreserved. Blood samples were drawn for hormone measurements. MAIN OUTCOME MEASURES: Presence of follicles in the biopsied tissue related to age, signs of spontaneous puberty, karyotype, and serum concentrations of gonadotropins and anti-Müllerian hormone were assessed. RESULTS: Ovarian biopsy was feasible in 47 of the 57 girls. In 15 of the 57 girls (26%), there were follicles in the tissue piece analyzed histologically. Six of seven girls (86%) with mosaicism, six of 22 (27%) with structural chromosomal abnormalities, and three of 28 with karyotype 45X (10.7%) had follicles. Eight of the 13 girls (62%) with spontaneous menarche had follicles, and 11 of the 19 girls (58%) who had signs of spontaneous puberty had follicles. The age group 12-16 yr had the highest proportion of girls with follicles. Normal FSH and anti-Müllerian hormone concentrations for age and pubertal stage were more frequent in girls with follicles. CONCLUSIONS: Signs of spontaneous puberty, mosaicism, and normal hormone concentrations were positive and statistically significant but not exclusive prognostic factors as regards finding follicles.

Evaluating Emdogain and healing of replanted teeth using an intra-individual experimental-control study design.

The purpose of the present investigation was to use an intra-individual experimental-control study design to explore if application of Emdogain prior to re-plantation after a dry extra-alveolar period of 60 min would promote a favorable healing of the periodontal ligament cells. Ten patients, for whom already decisions had been taken to extract two maxillary premolars because of crowding, participated in the study. The teeth were extracted and endodontic treatment was performed extra orally. The experimental tooth and its alveolar socket were covered with Emdogain prior to replantation. The contra lateral tooth served as a control and was replanted without any prior treatment. The teeth were stabilized with a retainer for 3-7 days and the patients were followed up every third week. After 13 weeks, the teeth were finally extracted and prepared for histological examination. Radiographs were taken before the study period, at day 29 and prior to the final extraction. The results were in favor of Emdogain, but the overall difference between the Emdogain-treated tooth and its control was rather small, and it seemed questionable if the registered differences could be of any obvious practical clinical importance. Histologically, all the teeth showed some degree of pathology after such a long dry extra-oral time and the outcome seemed to be more correlated to the individual than to the treatment. Given more favorable conditions regarding storage medium and/or extra-oral time, Emdogain might still be of value for an uncomplicated healing after replantation.

Methods of cryopreservation of testicular tissue with viable spermatogonia in pre-pubertal boys undergoing gonadotoxic cancer treatment.

BACKGROUND: Banking of testicular tissue from pre-pubertal boys before gonadotoxic treatment is a crucial step in fertility preservation. We wanted to find optimal methods for cryopreservation of testicular tissue from pre-pubertal boys, modifying techniques developed for fetal and adult human testicular tissue cryopreservation. METHODS: Testicular tissue was collected from five pre-pubertal boys undergoing gonadotoxic treatment in a clinical programme. Two freezing protocols, originally developed for fetal and adult human testicular tissue, were applied for pre-pubertal testicular tissue cryopreservation. In both methods, 5% dimethyl sulphoxide (DMSO) was used as a cryoprotectant. The integrity of the tissue was investigated in non-frozen tissue cultured for 24 h and in cryopreserved-thawed tissue, using two different programmes. We also analysed frozen-thawed samples cultured for 24 h in comparison with untreated fresh fixed control tissue. Immunohistochemical analysis using anti-MAGE-A4, vimentin and CD34 monoclonal antibodies was performed in order to visualize and characterize the cryodamage of the different testicular cells and compartments. The structure of the tissue was evaluated using light microscopy. Qualitative control analysis was performed using transmission electron microscopy. RESULTS: No clear structural changes were observed in the fresh, fresh cultured and cryopreserved testicular tissue after using the protocol developed for adult testicular tissue. The programme earlier successfully used for human fetal testicular tissue cryopreservation caused more tissue damage. CONCLUSIONS: Pre-pubertal testicular tissue from boys facing gonadotoxic treatment survives cryopreservation, can be cryobanked and hopefully used for fertility preservation. Slow programmed freezing with DMSO as a cryoprotectant is efficient in maintaining the spermatogonia, Sertoli cells and stromal compartment during freezing, thawing and tissue culture.

Is fetal growth impaired after in vitro fertilization?

BACKGROUND: The objective was to study fetal growth parameters in in vitro fertilization (IVF) pregnancies and to investigate the relationship between fetal growth and maternal blood pressure. METHODS: We examined 64 women, pregnant after in vitro fertilization, with repeated ultrasound examinations measuring biparietal diameter, femur length, abdominal diameter and fetal weight at 24, 30, and 36 weeks of gestation. We calculated deviations in percent from expected values in regards to biparietal diameter, femur length, abdominal diameter, and fetal weight. Blood pressure was measured every second week. RESULTS: Biparietal diameter in the study group was significantly smaller at 24 (-3.3%, 95%CI -4.4 to -2.2) and 30 (-1.4%; 95%CI -2.5% to -0.3) weeks. Femur length differed significantly on all three occasions, at 24 (-6.3%; 95%CI -7.7 to -5.1), 30 (-6.6%; 95%CI -8.0 to -5.3), and 36 (-3.9%; 95%CI; -5.0 to -2.8) weeks. Abdominal diameter demonstrated a significant deviation at 24 weeks (-1.6%; 95%CI -2.8 to -0.4). Fetal weight did not reach significant deviations at any gestational age. There was no correlation between deviation of the individual growth parameters or estimated fetal weight and elevated blood pressure. CONCLUSION: The growth pattern of in vitro fertilization pregnancies does not seem to differ from spontaneously conceived pregnancies to any appreciable extent. In the present material, no relationship between fetal growth and maternal blood pressure could be observed. We could not show that an impaired fetal growth predates the development of hypertension.

[In vitro oocyte maturation for safer treatment of infertility. The risk of ovarian overstimulation syndrome is minimized]. / In vitro-mognad av ägg ger säkrare fertilitetsbehandling. Risken för ovariellt överstimuleringssyndrom minimeras.

Ovarian hyperstimulation syndrome is a well known side effect of hormone stimulation in assisted reproduction. New treatments using minimal amounts of gonadotropins or no hormone supplementation may reduce this risk. In-vitro maturation (IVM) is a treatment where final oocyte maturation is achieved in the laboratory. Results have been acceptable and this method may provide a low-risk and cost-effective alternative to traditional IVF. IVM would thus avoid the high amounts of exogenous gonadotropins required for controlled ovarian hyperstimulation. Currently, only a few teams internationally are pursuing research in this field of human reproduction. IVM is a promising treatment alternative and can be recommended especially for patients at risk of developing ovarian hyperstimulation syndrome.

Embryo transfer is equally effective at cleavage stage and blastocyst stage: a randomized prospective study.

OBJECTIVE: To compare the implantation and pregnancy rates after cleavage stage embryo transfer (ET) with transfer of blastocyst-stage (days 5-6) embryos. STUDY DESIGN: Prospective randomized trial at an assisted reproduction unit in a university hospital. Women with six or more follicles at the last ultrasound scan before oocyte aspiration were randomized for transfer of a maximum of two embryos after 2-3 days (n = 80) or after 5-6 days (n = 64) of culture. Embryo quality, implantation and pregnancy rates were evaluated. Statistical significance was tested with the Chi-square test and Fisher's exact test. RESULT(S): No significant difference was observed in implantation rates (21.1% versus 20.9%, respectively) and clinical pregnancy rates (36.7% versus 32.5% respectively) after blastocyst and cleavage stage transfers for the two groups. The pregnancy rate among subjects who had at least one good quality embryo transferred was 37.5% per day 2-3 ET and 60% per day 5-6 ET. CONCLUSION(S): The overall implantation and pregnancy rates after embryo transfer at cleavage stage and at blastocyst stage transfer were not statistically different. Women who had at least one good quality blastocyst (n = 25) had a high pregnancy rate (60% per ET). Blastocyst transfer is a good alternative for couples with many good quality embryos on day 2 after insemination.

Recombinant LH is equally effective as recombinant hCG in promoting oocyte maturation in a clinical in-vitro maturation programme: a randomized study.

BACKGROUND: Fertilization treatment using oocytes matured in vitro from pre-ovulatory follicles has many potential applications. It minimizes the risk of severe ovarian hyperstimulation and is an alternative for women with polycystic ovary syndrome who may have problems regarding stimulation for IVF. In-vitro maturation (IVM) may prove important for subjects needing fertility preservation, and also provides information about the final stages of oocyte maturation. METHODS: From a randomized study of 73 women in an IVF programme, 36 subjects with 228 oocytes were allocated for oocyte maturation in culture medium with recombinant hCG, and 37 subjects with 256 oocytes for maturation with recombinant LH. The primary outcome was the rate of nuclear maturation of oocytes to metaphase II. During the same period, 32 women outside the study underwent 38 individually tailored IVM treatments. RESULTS: The oocyte maturation rate was 54.8% with hCG and 55.9% with LH; fertilization and cleavage rates were not significantly different. Three pregnancies were achieved in the hCG group and one in the LH group. Seven pregnancies (22.6% per embryo transfer) were achieved in the parallel group. CONCLUSIONS: Recombinant hCG or LH are equally effective in promoting oocyte maturation in a clinical IVM programme.

Embryo transfer by midwife or gynecologist: a prospective randomized study.

BACKGROUND: Embryo transfer (ET) in assisted reproduction treatments has traditionally been performed by gynecologists in the Nordic countries. As gynecologists often have a busy schedule, midwives and nurses have become increasingly important in performing the treatment, providing subject information, ultrasound monitoring and assistance at ET. As part of the continuous development of our IVF treatment we have carried out a prospective randomized pilot study where either a midwife or a gynecologist has performed ET. The aim of this study was to see if a skilled IVF midwife could perform ET with similar results to a gynecologist. METHODS: On the day of oocyte aspiration the subjects were randomized, by means of closed envelopes, for ET to be performed either by a midwife or a gynecologist. A total of 102 subjects were included in the study, 51 for ET by a skilled midwife and 51 by a gynecologist. There were no differences in the groups in respect to ET routine and catheters used. RESULTS: No significant differences were observed in subject characteristics as regards age, method of pituitary down-regulation or proportion of IVF/ICSI cycles. Similar clinical pregnancy rates between ETs performed by midwives vs. gynecologists, 31% vs. 29%, respectively, were seen. Subject experience as judged by a questionnaire also showed high acceptance of ET by a midwife. CONCLUSION: The results show that it is a feasible option to allow midwives to carry out ETs.

Follicles are found in the ovaries of adolescent girls with Turner's syndrome.

Infertility caused by ovarian failure is a characteristic feature in Turner's syndrome. Spontaneous pregnancies are seen in 2-5% of these women, and up to 30% have at least some pubertal development, indicating the presence of follicles in their ovaries in adolescence. It has not been clear at which age the follicles disappear. We analyzed the numbers and densities of follicles in ovarian cortical tissue from nine adolescent girls with Turner's syndrome who came to our clinics after having been informed about the study, with an aim to preserve ovarian tissue for possible infertility treatment later in life. A quarter to one whole ovary was laparoscopically removed for the procedure. Follicles were seen in the biopsy tissue in eight of nine subjects from whom ovarian tissue was laparoscopically obtained, the highest numbers being seen in the youngest girls and in those with mosaicism. In one 17-yr-old girl, no ovarian tissue was found. Follicle density was correlated with serum levels of FSH; individuals with the lowest FSH levels had the highest follicle density. One to 190 follicles were counted in the approximately 0.1-2.0 mm(3) of tissue analyzed, giving a density of 1.5-499 follicles/mm(3) of ovarian cortical tissue. Girls up to the age of 17 had primordial follicles in their ovaries. Three girls, two aged 15 yr and one aged 19, had only secondary follicles, with many being atretic. Our finding that adolescent girls with Turner's syndrome still have follicles in their ovarian cortical tissue raises the possibility of future fertility through cryopreservation of ovarian tissue. However, before such procedures can be recommended for clinical management, it is essential that future studies be performed to determine whether the oocytes retrieved from girls with Turner's syndrome have a normal chromosomal complement.