Mate-pair genome sequencing reveals structural variants for idiopathic male infertility.

Currently, routine genetic investigation for male infertility includes karyotyping analysis and PCR for Y chromosomal microdeletions to provide prognostic information such as sperm retrieval success rate. However, over 85% of male infertility remain idiopathic. We assessed 101 male patients with primary infertility in a retrospective cohort analysis who have previously received negative results from standard-of-care tests. Mate-pair genome sequencing (large-insert size library), an alternative long-DNA sequencing method, was performed to detect clinically significant structural variants (SVs) and copy-number neutral absence of heterozygosity (AOH). Candidate SVs were filtered against our in-house cohort of 1077 fertile men. Genes disrupted by potentially clinically significant variants were correlated with single-cell gene expression profiles of human fetal and postnatal testicular developmental lineages and adult germ cells. Follow-up studies were conducted for each patient with clinically relevant finding(s). Molecular diagnoses were made in 11.1% (7/63) of patients with non-obstructive azoospermia and 13.2% (5/38) of patients with severe oligozoospermia. Among them, 12 clinically significant SVs were identified in 12 cases, including five known syndromes, one inversion, and six SVs with direct disruption of genes by intragenic rearrangements or complex insertions. Importantly, a genetic defect related to intracytoplasmic sperm injection (ICSI) failure was identified in a patient with non-obstructive azoospermia, illustrating the additional value of an etiologic diagnosis in addition to determining sperm retrieval rate. Our study reveals a landscape of various genomic variants in 101 males with idiopathic infertility, not only advancing understanding of the underlying mechanisms of male infertility, but also impacting clinical management.

Ovarian HBV replication following ovulation induction in female hepatitis B carriers undergoing IVF treatment: A prospective observational study.

Hepatitis B virus (HBV) can be found in ovarian tissues. This study compared HBV DNA levels in follicular fluid collected during oocyte retrieval with paired serum samples in HBV carriers after ovarian stimulation during IVF treatment for infertility. Sixty-four HBV carrier women referred to the Assisted Reproductive Units of two Hong Kong hospitals were recruited. At oocyte retrieval, the follicular fluid aspirated from the first follicle was collected for study. In 22 women, the first follicular fluid sample from both ovaries was similarly collected and studied. These women were also tested for liver function test and HBeAg. In 28 (43.8%) women, HBV DNA was detected in follicular fluid and the level correlated with serum levels (Spearman's correlation P < .001). There was concordant detection of HBV DNA in both ovaries, and the levels were significantly correlated (Spearman's correlation P = .029). In 40% of women with FF HBV DNA, the follicular fluid:serum ratio was >1.0, suggesting stimulation of HBV replication. These women also had significantly different liver function test results. Increased HBV replication exists in 40% of women with HBV DNA detected in follicular undergoing ovarian stimulation during IVF treatment.

Efficacy, feasibility and patient acceptability of ultrasound-guided manual vacuum aspiration for treating early pregnancy loss.

BACKGROUND: Ultrasound-guided manual vacuum aspiration (USG-MVA) is an effective but underutilised alternative to medical or surgical evacuation of the uterus following first trimester miscarriage. AIMS: To evaluate the efficacy, feasibility and patient acceptability of USG-MVA for treating early pregnancy loss. MATERIAL AND METHODS: We invited patients with early pregnancy losses to participate in this prospective cohort study. We reviewed the medical records of the participants and their visual analogue pain score during MVA. Primary outcomes were efficacy, feasibility and patient acceptability of USG-MVA. Secondary outcomes included the success rate of culture of chorionic villi for chromosomal analysis and complications from the USG-MVA procedure. RESULTS: We included a consecutive series of 35 women who underwent the USG-MVA procedure. The efficacy of USG-MVA in achieving complete evacuation was 97.1%. The procedure was well tolerated and the mean procedure-related pain score was 6.25 out of 10 (SD 1.55). Overall, all patients were satisfied with the procedure. The successful culture rate of chromosomal analysis was 94.3%. There were no major complications. CONCLUSION: USG-MVA is an effective treatment for the management of early pregnancy loss in an out-patient setting. It is an alternative to surgical evacuation under general anaesthesia, particularly for women desiring chromosomal analysis of products of conception. Further studies are required to investigate its health-related and economic benefits in hospital service provision.

The effect of endometrial scratch on natural-cycle cryopreserved embryo transfer outcomes: a randomized controlled study.

The benefit of endometrial scratch (ES) prior to embryo transfer is controversial. Systemic analysis has confirmed its potential benefit, especially in women with repeated IVF failures, yet most studies have focused on fresh embryo transfer, and its effect on vitrified-warmed embryo transfer (FET) cycles is yet to be explored. We hereby present our prospective, double-blind, randomized controlled study on the evaluation of the implantation and pregnancy rate after ES prior to natural-cycle FET. A total of 299 patients underwent natural-cycle FET and were randomized to receive ES (n = 115) or endocervical manipulation as control (n = 114) prior to FET cycle, and a total of 196 patients had embryo transfer (93 patients in each group). Our study showed no significant difference in the implantation and pregnancy rate, as well as the clinical and ongoing pregnancy or live birth rates between the two groups. It appears that ES does not have any beneficial effect on an unselected group of women undergoing FET in natural cycles. Further studies on its effect in women with recurrent implantation failure after IVF are warranted.

The changing pattern of uterine contractions before and after fresh embryo transfer and its relation to clinical outcome.

In this prospective cohort study of 286 women undergoing fresh embryo transfer after IVF, uterine contraction frequency and direction were measured before (-5 min), 5 min after (+5 min) and 60 min after (+60 min) embryo transfer. Mean ± SD uterine contraction frequency at -5 min was 1.8 ± 1.1 contractions per min, increasing significantly (P < 0.05) to 2.0 ± 1.1 at +5 min, and returning back to baseline 1.8 ± 1.1 at +60 min. At -5 min, the proportion of women the with retrograde, antegrade, indeterminate direction and absent contractions were 33%, 44%, 17% and 6%; at +5 min, 40%, 42%, 13% and 5%, and at +60 min, 42%, 38%, 14% and 6%. No significant change was observed in the proportion of direction at these three time points. Logistic regression analysis showed live birth rate was significantly reduced in older women (P = 0.035) and in those with higher uterine contraction frequency at +5 min (P = 0.006). Frequency of uterine contraction immediately after embryo transfer (+5 min) seemed to be a significant predictor of IVF outcome and may help to identify women who could benefit from the use of muscle relaxant therapy to improve outcome.

A prospective randomized controlled trial of 3D versus 2D ultrasound-guided embryo transfer in women undergoing ART treatment.

STUDY QUESTION: Does three-dimensional (3D) versus two-dimensional (2D) ultrasound (US) guidance during embryo transfer (ET) increase the ongoing pregnancy rate in women undergoing ART treatment. SUMMARY ANSWER: There is no significant difference in the ongoing pregnancy rate of women undergoing 3D versus 2D US-guided ET. WHAT IS KNOWN ALREADY: Studies have suggested that 3D US may confer additional benefits compared with 2D US during ET, although this has not been tested within the context of an RCT. STUDY DESIGN, SIZE, DURATION: This was a single-blind, single centre prospective RCT performed between April 2015 and April 2016. A total of 481 recruited women were randomised into either a 3D or 2D US-guided ET group. PARTICIPANTS/MATERIALS, SETTING, METHOD: Women younger than 42 years in whom the endometrial cavity could be adequately visualised by US underwent ET in a university ART unit following a standard treatment protocol. All US examinations were performed by a single operator. In both 3D and 2D US groups, the inner catheter tip was aimed at the centre of the uterine cavity. The primary outcome measure was ongoing pregnancy rate, defined as the presence of at least one foetus with heart pulsation at 8 weeks of gestation. MAIN RESULTS AND THE ROLE OF CHANCE: There was no significant difference in the ongoing pregnancy rate between the 3D and 2D US groups (35.4% versus 37.1%, P = 0.70; rate ratio 0.96, 95% confidence interval 0.75-1.21). There were also no significant differences in terms of positive hCG rate, biochemical pregnancy rate, implantation rate, clinical pregnancy rate, miscarriage rate, ectopic pregnancy rate and multiple pregnancy rate. LIMITATIONS, REASONS FOR CAUTION: This study recruited unselected women undergoing routine ET and was therefore not sufficiently powered to assess differences in subsets of women. WIDER IMPLICATIONS OF THE FINDINGS: Although 3D US may be a modern method for demonstrating the ET procedure, it should not be currently recommended as a strategy to improve clinical outcomes in women undergoing ART treatment. STUDY FUNDING/COMPETING INTERESTS: This study was funded by the Health and Medical Research Fund of Hong Kong. The authors have no conflicts of interest to disclose. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02413697. TRIAL REGISTRATION DATE: 4 April 2015. DATE OF FIRST PATIENT'S ENROLMENT: 20 April 2015.

Assessment of the embryo flash position and migration with 3D ultrasound within 60 min of embryo transfer.

STUDY QUESTION: Does the air bubble (embryo flash) position and migration as visualized with 3D ultrasound (US) within 60 min of embryo transfer correlate with clinical outcome following fresh ART transfer cycles? SUMMARY ANSWER: The location of the embryo flash and the direction of its movement at 60 min, but not at 1 or 5 min after transfer, are associated with clinical pregnancy. WHAT IS KNOWN ALREADY: Studies assessing the relation between the pregnancy rate and the position of the catheter tip and/or the position of the air bubbles following embryo transfer show conflicting results to date. STUDY DESIGN, SIZE AND DURATION: This was a prospective cohort study including 277 infertile women undergoing ART between July 2011 and August 2013. PARTICIPANTS/MATERIALS, SETTING AND METHODS: Good prognosis patients undergoing fresh ART cycles within a single tertiary University unit were assessed by 3D US at 1, 5 and 60 min after embryo transfer. The distance of the embryo flash from the fundus was measured at these time points, along with the direction of the embryo flash movement within 60 min of transfer. MAIN RESULTS AND THE ROLE OF CHANCE: Within 60 min of embryo transfer, 76.4% (198/259) of the embryo flashes migrated towards the fundus, 12.4% (32/259) migrated towards the cervix and 11.2% (29/259) remained static. There was no significant association between the embryo position or movement and the pregnancy rate at 1 and 5 min. At 60 min, however, the pregnancy and implantation rates among subjects with embryo flashes located <15 mm from the fundus was significantly higher than those with embryo flashes located >15 mm from the fundus (46.5 and 32.8% versus 25.8 and 18.2%, respectively; P < 0.05). The pregnancy and implantation rates when the embryo flash was seen moving towards the cervix (25.0 and 15.0%) was significantly lower (P < 0.05 and P < 0.01, respectively) compared with those remaining static (55.2 and 37.7%) or moving towards the fundus (45.5 and 32.8%). LIMITATIONS AND REASONS FOR CAUTION: Although the air bubbles seen at the time of embryo transfer are thought to represent the position of the embryo, they are in fact a surrogate marker of the embryo itself, as this cannot be directly visualized by US. WIDER IMPLICATIONS OF THE FINDINGS: Following embryo transfer the majority, but not all, embryo flashes undergo significant migration towards the fundus. The location of the embryo flash and the direction of its movement at 60 min, but not at 1 or 5 min after transfer, is associated with clinical outcome. These findings may challenge the traditional notion that the exact position of the embryo flash immediately following embryo transfer is related to clinical outcome. STUDY FUNDING/COMPETING INTERESTS: The authors have no relevant funding or conflicts of interest to disclose.