The emperor still looks naked.

Preimplantation genetic screening for aneuploidy continues to excite disagreement, discussion and confusion in the field of reproductive medicine. This commentary provides a contribution to the ongoing debate.

Implementation of a multicomponent intervention to optimise patient safety through improved oxygen prescription in a rural hospital.

OBJECTIVE: To rationalise oxygen procedures in adult medical and surgical inpatients with a view to improving patient safety. DESIGN: Prospective pre- and post-intervention audit. SETTING: Manning Hospital, a rural referral hospital in Taree NSW. PARTICIPANTS: Pre-intervention: 82 patients aged 72.7 ± 14.7 years. Post-intervention: 77 patients aged 73.6 ± 12.4 years. INTERVENTION: A multicomponent intervention composed of implementation of a local hospital oxygen policy, introduction of a specific oxygen prescription chart and targeted staff education. MAIN OUTCOME MEASURES: Satisfactory oxygen prescription, monitoring and titration. RESULTS: Only 2/82 (2.4%) patients had satisfactory oxygen prescription specifying target saturation, device and initial flow rate before the intervention compared with 26/77 (34%) patients post-intervention (χ(2) = 56.88, df = 5, P < 0.0001). Percentage of patients with conditions predisposing to hypercapnic respiratory failure who were overtreated with oxygen dropped from 9/19 (47%) to 4/22 (18%) following the study intervention (χ(2) = 4.011, df = 1, P = 0.04). Oxygen therapy monitoring was satisfactory during the audit period, but oxygen titration was unsatisfactory and did not significantly improve following the intervention. CONCLUSIONS: A multicomponent intervention can achieve a significantly increased rate of satisfactory oxygen prescriptions specifying target saturation, including in those who are at risk of hypercapnic respiratory failure.

Selecting the 'best' embryos: prospects for improvement.

This review considers why and how embryos are selected for transfer and with what consequences. It concludes that: (i) current selection methods are inadequate or at least inadequately subjected to evidential scrutiny; (ii) decisions about number of embryos should be based not solely on input (numbers transferred) but on the likelihood of the transfer resulting in multiple pregnancies - out turn; and (iii) what is needed are better methods not just for selecting better embryos, but also for selecting responsible clinicians who collude less with their patients' demands but advise them more responsibly.

Evidence-based medicine and the role of the private sector in assisted reproduction: a response to Dr Fishel's commentary 'Evidenced-based medicine and the role of the National Health Service in assisted reproduction'.

We respond to Dr Fishel's commentary on evidenced-based medicine in assisted reproduction and the role of the UK's National Health Service. We agree that proper randomised clinical trials are not easy to set up or execute. Recruitment is also challenging but requires that all personnel involved in the study, clinicians, embryologists and nurses, agree with its aims and buy in to the need for an answer. Those who believe fervently in the method under scrutiny prior to the availability of robust evidence are likely to undermine the success of any trial. New technologies are not necessarily better technologies. Neither is the supposed 'logic' of a treatment nor anecdotal clinical experience a substitute for evidence properly gained and fairly demonstrated. Dr Fishel would agree that the first obligation of healthcare professionals, whether they are in the public or private sector, is not to do harm to their patients. Adopting new interventions without rigorous assessment of the potential for harm flies in the face of this basic principle.

Derivation and feeder-free propagation of human embryonic stem cells under xeno-free conditions.

BACKGROUND AIMS: Human embryonic stem (hES) cells hold great potential for cell therapy and regenerative medicine because of their pluripotency and capacity for self-renewal. The conditions used to derive and culture hES cells vary between and within laboratories depending on the desired use of the cells. Until recently, stem cell culture has been carried out using feeder cells, and culture media, that contain animal products. Recent advances in technology have opened up the possibility of both xeno-free and feeder-free culture of stem cells, essential conditions for the use of stem cells for clinical purposes. To date, however, there has been limited success in achieving this aim. METHODS, RESULTS AND CONCLUSIONS: Protocols were developed for the successful derivation of two normal and three specific mutation-carrying (SMC) (Huntington's disease and myotonic dystrophy 1) genomically stable hES cell lines, and their adaptation to feeder-free culture, all under xeno-free conditions.

A new stoma for an older person-An association with quality of life and physical function: A systematic review.

BACKGROUND: Older people are more likely to have a stoma postabdominal surgery than younger people. Few studies have examined the effect of a stoma on older people. The aim of this review was to explore the effect of a stoma on functional independence of an older person. We explored secondary outcomes of poststoma formation length of hospital stay, quality of life and factors affecting stroma independence. METHODS: An exploratory systematic review was developed by our multidisciplinary group including an expert patient, colorectal surgeon, stoma nurse, physiotherapist, geriatrician, and methodologist. Four databases were searched including studies with participants 60 years old or older, who had undergone abdominal surgery for any pathology resulting in an abdominal stoma. RESULTS: We identified 857 studies, of which we included 25 in the final review incorporating 6972 participants (average age 67.4 years). There was a strong association between presence of stoma and (1) worse physical function (standardized MD = 0.7; 95% CI 0.21-1.19; I2  = 95) and (2) worse quality of life (standardized MD = 1.61; 95% CI 0.5-2.72, I2  = 98). The same effect was seen in fecal ostomy and urinary diversion. Few studies measured stoma independence and only one examined factors affecting this. No studies examined length of stay. CONCLUSIONS: Stoma have a negative association with the physical function and quality of life of older people. Future studies should focus on identifying modifiable factors that may affect physical function, quality of life, and stoma independence.

Influence of BMI on risk of miscarriage after single blastocyst transfer.

BACKGROUND: Debate exists regarding the effect of raised BMI on the outcome of pregnancies after assisted reproduction technology. We assessed the effect of BMI on the risk of miscarriage in women conceiving following single blastocyst transfer (SBT) after controlling for confounding factors. METHODS: Fresh and cryo-thawed cycles of SBT that resulted in a pregnancy between January 2006 and March 2010 were included. Patients with BMI < 18.5 kg/m(2) or older than 40 years were excluded. Patients were grouped according to their BMI at the start of treatment cycle. The main outcome measure was the miscarriage rate before 23 weeks gestation. Confounding variables examined included female age, duration and cause of infertility, previous miscarriage, smoking status and quality of blastocyst replaced. RESULTS: A total of 413 women conceived following SBT in fresh (n = 325) or cryo-thawed (n = 88) IVF cycles, of whom 244 had a normal BMI (18.5-24.9) and 169 had a raised BMI of ≥ 25. Overall, 27% (113/413) of women miscarried before 23 weeks gestation. Women with a BMI of ≥ 25 had more than double the risk of miscarriage compared with women who had normal BMI [38 versus 20%, odds ratio (OR): 2.4, 95% confidence interval (CI) 1.6-3.8, P < 0.001, respectively]. After adjusting for confounding variables, having a BMI of ≥ 25 significantly increased the risk of clinical miscarriage before 23 weeks gestation in both fresh (adjusted OR = 2.7, 95% CI 1.5-4.9, P = 0.001) and cryo-thawed IVF cycles (OR = 6.8, 95% CI 1.5-31.1, P = 0.012). CONCLUSIONS: Raised BMI is independently associated with higher miscarriage rate after IVF treatment.

Reducing multiple pregnancies after assisted reproduction treatment: Québec says 'Yes, we can!'.

Multiple pregnancy (MP) is widely recognized as the single biggest risk to children born as a result of assisted reproduction treatment. There is an emerging trend in Europe and Canada to promote single-embryo transfer (SET). In this issue, Gleicher argues that twin pregnancies should not be seen as an unfavourable outcome of assisted reproduction treatment. He argues that SET policies 'make no sense' since they will aggravate already unsatisfactory population growth in some countries. He also argues that governmental intervention to impose SET policies, despite proving successful in reducing MP, are inappropriate. The overwhelming evidence in the literature indicates that his opinion is not supported by credible data. Views should be based on solid data rather than personal judgement. Governmental interventions to reduce twin pregnancies, as demonstrated previously in Belgium and now in Québec, have been successful. The risks of twin pregnancies are real and borne by women and children, not their doctors. Doctors managing infertile couples are no longer entitled to take risks with the health of the next generation.

The influence of delayed blastocyst formation on the outcome of frozen-thawed blastocyst transfer: a systematic review and meta-analysis.

BACKGROUND: There are conflicting results on whether the rate of blastocyst development before freezing influences the outcome of frozen-thawed blastocyst transfers. METHODS: We conducted a systematic review and meta-analysis of controlled studies to compare pregnancy outcomes following transfer of thawed blastocysts that were frozen either on Day 5 or Day 6 following fertilization in vitro. Searches were conducted on MEDLINE, EMBASE, Cochrane Library and Web of Science. Study selection and data extraction were conducted independently by two reviewers. The Newcastle-Ottawa Quality Assessment Scale was used for quality assessment. RESULTS: We identified 15 controlled studies comprising 2502 frozen-thawed transfers involving blastocysts that were either frozen on Day 5 or Day 6. Meta-analysis of these studies showed significantly higher clinical pregnancy rate [relative risk (RR) = 1.14, 95% confidence interval (CI): 1.03-1.26, P = 0.01] and ongoing pregnancy/live birth rate (RR = 1.15, 95% CI: 1.01-1.30, P = 0.03) with Day 5 compared with Day 6 frozen-thawed blastocyst transfers. Sensitivity analysis of those studies where blastocysts frozen on Day 5 or Day 6 were at the same stage of development showed no significant difference in the clinical pregnancy rate (RR = 1.07, 95% CI: 0.87-1.33, P = 0.51) and ongoing pregnancy/live birth rate (RR = 1.08, 95% CI: 0.92-1.27, P = 0.36). CONCLUSION: Slower developing blastocysts cryopreserved on Day 6 but at the same stage of development as those developing to the blastocyst stage on Day 5 have similar clinical pregnancy and ongoing pregnancy/live birth rates following frozen-thawed blastocyst transfers.

Preimplantation genetic haplotyping: 127 diagnostic cycles demonstrating a robust, efficient alternative to direct mutation testing on single cells.

Preimplantation genetic diagnosis using whole genome amplification and a haplotyping approach (PGH) was first described in 2006 and suggested as an efficient alternative to single-cell PCR for monogenic disorders. DNA from single cells was amplified using multiple displacement amplification; the resulting products were then tested using disease-specific PCR multiplexes applied under standard laboratory conditions to determine the haplotypes in the embryo. This study reports on a total of 127 completed biopsy cycles for 101 couples at risk of: autosomal recessive disease (71 cycles, 53 couples including one germ-line mosaic carrier), autosomal dominant disease (31 cycles, 26 couples including one germ-line mosaic carrier), X-linked recessive disease (18 cycles, 16 couples including one germ-line mosaic carrier), X-linked dominant disease (six cycles, five couples) and a double inheritance of both autosomal and X-linked recessive diseases (one cycle, one couple). Of these, 107 cycles reached embryo transfer. Overall success rates were: fetal heart beat-positive pregnancies (FHB+)/biopsy cycle=28%; FHB+/embryo transfer=34%; FHB+/couple=36%; 26 babies born, 13 ongoing pregnancies. These data demonstrate that PGH provides a robust, efficient and successful alternative to single-cell PCR for monogenic diseases.

Reduction of the multiple pregnancy rate in a preimplantation genetic diagnosis programme after introduction of single blastocyst transfer and cryopreservation of blastocysts biopsied on day 3.

BACKGROUND: An elective single-embryo transfer (SET) policy has not been applied to preimplantation genetic diagnosis (PGD) for inherited genetic disorders because of concerns regarding post-thaw survival of biopsied embryos. Our objective was to evaluate the survival and pregnancy potential of embryos biopsied for PGD at the cleavage stage and cryopreserved at the blastocyst stage and its contribution to the overall success of an elective SET policy in a PGD programme. METHODS: From January 2006, all couples who had two or more transferable PGD blastocysts biopsied on Day 3 of culture were offered single-blastocyst transfer (SBT) and cryopreservation of surplus blastocyst(s) using a slow-freezing technique. We compared the outcome of 32 cryo-thawed PGD cycles with that of 191 cryo-thawed conventional in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles performed between January 2006 and July 2008. We also compared the outcome of all fresh PGD cycles performed before and after January 2006. RESULTS: The cryo-thawed blastocyst survival rate was similar between the PGD and IVF/ICSI groups (87% versus 88%, P = 0.94). There was no significant difference in the implantation and clinical pregnancy rates between the two groups (35% versus 29%, P = 0.45 and 34% versus 36%, P = 0.77, respectively). During the same period, the multiple pregnancy rate in the fresh PGD programme dropped from 36% to 10% (OR = 0.20, 95% CI 0.08-0.48, P < 0.001) with no reduction in pregnancy rates. CONCLUSIONS: The survival and implantation potential of biopsied PGD embryos cryopreserved at the blastocyst stage is comparable to that of non-biopsied IVF/ICSI cryopreserved blastocysts. Elective SBT and cryopreservation of surplus blastocysts for later use should extend to include PGD for inherited genetic disorders.

Infertility information on the World Wide Web: a cross-sectional survey of quality of infertility information on the internet in the UK.

BACKGROUND: The internet is a frequently used source of information for infertile couples. Previous studies suggested that the quality of health information on the internet is poor. The aim of this study was to assess the quality of websites providing information on infertility and its management in the UK. Differences between website types and affiliations were assessed. METHODS: A Google search for the keyword 'infertility' was performed and 107 relevant websites were identified and categorized by type. Websites were assessed for credibility, accuracy and ease of navigation using predefined criteria. RESULTS: The total scores for all types of websites were low, particularly in the accuracy category. Websites affiliated to the UK National Health Service (NHS) scored higher than those affiliated to private fertility clinics and other clinics providing non-conventional fertility treatment. Specifically, NHS websites were more likely to report success rates (92.9% versus 60% and 0%, P < or = 0.05) and display information about their sources of funding (85.7% versus 15% and 14.8%, P < or = 0.0001). CONCLUSIONS: Internet resources available to infertile patients are variable. Differences in the quality of infertility information exist between the different types of websites.

A three-arm randomised controlled trial comparing Gonadotrophin Releasing Hormone (GnRH) agonist long regimen versus GnRH agonist short regimen versus GnRH antagonist regimen in women with a history of poor ovarian response undergoing in vitro fertilisation (IVF) treatment: Poor responders intervention trial (PRINT).

BACKGROUND: Poor response to ovarian stimulation with exogenous gonadotrophins occurs in 9-24% of women undergoing in vitro fertilisation (IVF) treatment, which represents an estimated 4000-10,000 women per year in the UK. Poor responders often have their treatment cycle cancelled because of expected poor outcome.One treatment strategy that may influence outcome is the choice of pituitary suppression regimen prior to the initiation of ovarian stimulation. The three commonly used pituitary suppression regimens in IVF treatment are:(1) the GnRH agonist long regimen,(2) the GnRH agonist short regimen and(3) the GnRH antagonist regimen.A systematic review of randomised controlled trials of these pituitary suppression regimens has shown the evidence to be either inconclusive or inconsistent. We therefore designed a three arm randomised trial to evaluate the effectiveness of these regimens in women who had poor ovarian response in a previous IVF treatment cycle. METHODS/DESIGN: Consenting, eligible women will be randomised to one of the three regimens using an internet-based trial management programme that ensures allocation concealment and employs block randomisation and minimisation for prognostic variables. The primary outcome is the number of oocytes retrieved. Other outcomes include total dose of follicle stimulating hormone (FSH) used for ovarian stimulation, mature oocytes retrieved, embryos available for transfer, implantation rate and clinical pregnancy rate.The sample size for this trial has been estimated as 102 participants with 34 participants in each of the three arms. Appropriate interim analysis will be conducted by a Data Monitoring and Ethics Committee (DMEC), and the final analysis will be by intention to treat. TRIAL REGISTRATION: ISRCTN27044628.

Assisted reproductive technologies to prevent human mitochondrial disease transmission.

Mitochondria are essential cytoplasmic organelles that generate energy (ATP) by oxidative phosphorylation and mediate key cellular processes such as apoptosis. They are maternally inherited and in humans contain a 16,569-base-pair circular genome (mtDNA) encoding 37 genes required for oxidative phosphorylation. Mutations in mtDNA cause a range of pathologies, commonly affecting energy-demanding tissues such as muscle and brain. Because mitochondrial diseases are incurable, attention has focused on limiting the inheritance of pathogenic mtDNA by mitochondrial replacement therapy (MRT). MRT aims to avoid pathogenic mtDNA transmission between generations by maternal spindle transfer, pronuclear transfer or polar body transfer: all involve the transfer of nuclear DNA from an egg or zygote containing defective mitochondria to a corresponding egg or zygote with normal mitochondria. Here we review recent developments in animal and human models of MRT and the underlying biology. These have led to potential clinical applications; we identify challenges to their technical refinement.

IVF results: optimize not maximize.

The desire to improve in vitro fertilization (IVF) results has led clinicians to replace more than 1 embryo in the uterus. As a result, multiple births have increased over the last 2 decades to epidemic proportions, exposing the field of assisted conception to justified criticism. This review aims to ensure that physicians involved in the field of fertility treatment are aware of the risks and complications related to multiple pregnancies, and to explore possible strategies such as blastocyst culture, preimplantation genetic screening, and embryo cryopreservation, which can help to control and reverse the tide of multiple pregnancies without reducing the good success rate that modern IVF treatment enjoys. A brief overview of the respective UK legislative system is also presented.

Preimplantation genetic diagnosis--an overview.

Since the early 1990s, preimplantation genetic diagnosis (PGD) has been expanding in scope and applications. Selection of female embryos to avoid X-linked disease was carried out first by polymerase chain reaction, then by fluorescence in situ hybridization (FISH), and an ever-increasing number of tests for monogenic diseases have been developed. Couples with chromosome rearrangements such as Robertsonian and reciprocal translocations form a large referral group for most PGD centers and present a special challenge, due to the large number of genetically unbalanced embryos generated by meiotic segregation. Early protocols used blastomeres biopsied from cleavage-stage embryos; testing of first and second polar bodies is now a routine alternative, and blastocyst biopsy can also be used. More recently, the technology has been harnessed to provide PGD-AS, or aneuploidy screening. FISH probes specific for chromosomes commonly found to be aneuploid in early pregnancy loss are used to test blastomeres for aneuploidy, with the aim of replacing euploid embryos and increasing pregnancy rates in groups of women who have poor IVF success rates. More recent application of PGD to areas such as HLA typing and social sex selection have stoked public controversy and concern, while provoking interesting ethical debates and keeping PGD firmly in the public eye.

Strategies and outcomes of the first 100 cycles of preimplantation genetic diagnosis at the Guy's and St. Thomas' Center.

OBJECTIVE: To establish strategies for the implementation of a successful preimplantation genetic diagnosis (PGD) service. DESIGN: Retrospective review of data from a single center. SETTING: A United Kingdom National Health Service hospital. PATIENT(S): Patients (60 couples) were referred for PGD from UK genetic centers. INTERVENTION(S): We followed the protocol of ovarian stimulation, oocyte retrieval, fertilization, single cell biopsy on day 3, and embryo transfer on day 4. Pregnancies unaffected by the familial genetic condition. RESULT(S): A total of 60 couples was treated for 20 different conditions. Early cycles using nonsequential embryo culture media were less successful (13% pregnancy rate/embryo transfer) than later cycles using sequential media (33.5%). Ninety-four percent of embryos (n = 473) had a single cell removed at biopsy. The overall pregnancy rate was 24% per cycle started, 29% per egg collection, 38% per transfer, and 40% per couple treated. In one cycle, an affected pregnancy followed PGD for spinal muscular atrophy (SMA). CONCLUSION(S): The use of sequential media and single cell biopsy results in a successful PGD program with encouraging pregnancy rates.

Effect of blastomere loss on the outcome of frozen embryo replacement cycles.

OBJECTIVE: To assess the impact of survival of cryopreservation and thawing with all blastomeres intact on the outcome of frozen embryo replacement (FER) cycles. DESIGN: Prospective observational study. SETTING: University-affiliated tertiary referral assisted conception unit. PATIENT(S): The number of intact blastomeres before cryopreservation and after thawing was prospectively recorded in 1,687 cleavage-stage embryos thawed in 377 FER cycles. The cycles were categorized into two groups: group A (n = 184) included cycles in which all embryos transferred survived the cryopreservation and thawing process with all their original blastomeres intact; group B (n = 193) included cycles in which embryos transferred included at least one partially damaged embryo that has lost up to 50% of its original blastomere number. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Pregnancy and embryo implantation rates. RESULT(S): Groups A and B were comparable with respect to mean age at cryopreservation, mean number of oocytes retrieved and fertilized normally in the fresh cycle, and mean age at frozen transfer. No significant difference was found between the two groups with regard to mean number of frozen and thawed embryos per cycle and mean endometrial thickness reached before P supplementation. More embryos were transferred per cycle in group B than group A (2.4 +/- 0.6 vs. 2.1 +/- 0.6, respectively). However, the pregnancy and clinical pregnancy rates per cycle were significantly higher in group A than in group B (39.1% and 28.3% vs. 22.8% and 13.5%, respectively). The implantation rate was also higher in group A than in group B (17.3% vs. 8.1%, respectively). CONCLUSION(S): FER cycles in which all embryos transferred remained fully intact at thawing achieve a better outcome than those with at least one partially damaged embryo.

Long gonadotropin-releasing hormone agonist versus short agonist versus antagonist regimens in poor responders undergoing in vitro fertilization: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of the long GnRH agonist vs. the short GnRH agonist vs. the GnRH antagonist regimens in poor responders undergoing IVF. DESIGN: Randomized controlled trial. SETTING: Tertiary referral fertility units. PATIENT(S): Women with previous poor ovarian response undergoing IVF. INTERVENTION(S): One hundred eleven women were randomized to the long GnRH agonist, short agonist, and antagonist regimens. MAIN OUTCOME MEASURE(S): The primary outcome was the number of oocytes retrieved. Secondary outcome measures were gonadotropin consumption, duration of stimulation, cycle cancellation rate, mature oocytes retrieved, fertilization rate, cycles reaching ET, and clinical and ongoing pregnancy rates. RESULT(S): Number of oocytes retrieved was significantly higher with long GnRH agonist compared with the short agonist regimen (4.42 ± 3.06 vs. 2.71 ± 1.60), while there was no significant difference between long agonist and antagonist regimens (4.42 ± 3.06 vs. 3.30 ± 2.91). Duration of stimulation and total gonadotropin dose were significantly higher with long agonist compared with short agonist and antagonist regimens. The ongoing pregnancy rate was 8.1% with long and short agonist regimens and 16.2% with the antagonist regimen. CONCLUSION(S): Long GnRH agonist and antagonist regimens offer a suitable choice for poor responders, whereas the short agonist regimen may be less effective because of fewer eggs retrieved.