An economic analysis of preimplantation genetic testing for aneuploidy by polar body biopsy in advanced maternal age.

OBJECTIVE: What are the cost per live birth and the incremental cost of preventing a miscarriage with preimplantation genetic testing for aneuploidy (PGT-A) by polar body biopsy and array-based comprehensive genome hybridisation (aCGH) versus regular IVF/ICSI without PGT-A for infertility treatment in women 36-40 years of age? DESIGN: Decision tree model. POPULATION: A randomised clinical trial on PGT-A (ESTEEM study). METHODS: Two treatment strategies were compared: one cycle of IVF/ICSI with or without PGT-A. Costs and effects were analysed with this model for four different cost scenarios: high-, higher medium, lower medium and low-cost. Base case, sensitivity, threshold, and probabilistic sensitivity analyses were used to examine the cost-effectiveness implications of PGT-A. RESULTS: PGT-A increased the cost per live birth by approximately 15% in the high-cost scenario to approximately 285% in the low-cost scenario. Threshold analysis revealed that PGT-A would need to be associated with an absolute increase in pregnancy rate by 6% to >39% or, alternatively, would need to be US$2,969 (high-cost scenario) to US$4,888 (low-cost scenario) cheaper. The incremental cost to prevent one miscarriage by PGT-A using the base case assumptions was calculated to be US$34,427 (high-cost scenario) to US$51,146 (low-cost scenario). A probabilistic sensitivity analysis showed cost-effectiveness for PGT-A from 1.9% (high-cost scenario) to 0.0% (low-cost scenario) of calculated samples. CONCLUSIONS: While avoiding unnecessary embryo transfers and miscarriages are important goals, patients and doctors need to be aware of the high-cost implications of applying PGT-A using aCGH on polar bodies. TWEETABLE ABSTRACT: PGT-A by polar body biopsy and comprehensive genome hybridisation increases cost per live birth and requires high financial spending per miscarriage averted.

Expression of mRNA and protein of IL-18 and its receptor in human follicular granulosa cells.

PURPOSE: There is no information available about the IL-18 receptor in ovarian follicles, so the present study attempts to demonstrate the expression of IL-18 and its receptor in human granulosa cells (GCs). METHODS: To evaluate the concentration of IL-18 in serum and follicular fluid (FF), we collected serum and FF from 102 women undergoing oocyte retrieval. Also, to detect expression of IL-18 and its receptor by luteinized GCs, these cells were pooled six times from a total of twenty individual patients with 5-16 follicles each. The IL-18 concentration was determined by ELISA and the expression of IL-18 and its receptor by immunocytochemistry and reverse transcription polymerase chain reaction. RESULTS: Our results showed that the median IL-18 concentration in serum, 159.27 pg/ml (IQR 121.41-210.1), was significantly higher than in FF, 142.1 pg/ml (IQR 95.7-176.5), p < 0.001. Moreover, we found that IL-18 and its receptor are expressed by GCs. CONCLUSION: The presence of IL-18 in FF and the expression of IL-18 and its receptor by GCs suggest an important role for this cytokine in ovarian function.

Ovulation detection in saliva, is it possible.

BACKGROUND/AIMS: The new mini-microscope Geratherm® ovu control was evaluated for its recognition of saliva ferning in a collective of 47 patients taking part in an artificial reproductive technology program on the day of follicular puncture. METHODS: The ferning phenomenon was evaluated by patients and laboratory staff according to the criteria: no ferning, slight ferning and good ferning. RESULTS: Geratherm® ovu control showed a specificity of 78% and a sensitivity of 80% in relation to rising E2 levels under follicle-stimulating hormone/human chorionic gonadotrophin. A comparison of the evaluations of the saliva test carried out by patients and by laboratory staff resulted in a high and substantial agreement of 89.4% (κ). CONCLUSION: Evaluations performed by ovu control were similar to those achieved with a highly sophisticated inverted microscope.

ESHRE PGD consortium best practice guidelines for organization of a PGD centre for PGD/preimplantation genetic screening.

In 2005, the European Society for Human Reproduction and Embryology (ESHRE) PGD Consortium published a set of Guidelines for Best Practice PGD to give information, support and guidance to potential, existing and fledgling PGD programmes. Subsequent years have seen the introduction of new technologies as well as the evolution of current techniques. Additionally, in light of recent advice from ESHRE on how practice guidelines should be written/formulated, the Consortium believed it was timely to update the PGD guidelines. Rather than one document that covers all of PGD, the new guidelines are separated into four documents, including one relating to organization of the PGD centre and three relating to the methods used: DNA amplification, fluorescence in situ hybridization and biopsy/embryology. Here, we have updated the sections on organization of the PGD centre. One area that has continued to expand is Transport PGD, in which patients are treated at one IVF centre, whereas their gametes/embryos are tested elsewhere, at an independent PGD centre. Transport PGD/preimplantation genetic screening (PGS) has a unique set of challenges with respect to the nature of the sample and the rapid turn-around time required. PGS is currently controversial. Opinions of laboratory specialists and clinicians interested in PGD and PGS have been taken into account here. Current evidence suggests that PGS at cleavage stages is ineffective, but whether PGS at the blastocyst stage or on polar bodies might show improved delivery rates is still unclear. Thus, in this revision, PGS has been included. This document should assist everyone interested in PGD/PGS in developing the best laboratory and clinical practice possible.

Three singleton deliveries with healthy children from one couple after cryo-tESE and ICSI.

UNLABELLED: We report on a couple who delivered three healthy babies in three deliveries after cryo-TESE combined with ICSI. The male patient suffers from congenital bilateral absence of the vas deferens (CBAVD). METHODS: Three testicular sperm extraction (TESE) operations were performed in the male accompanied by six stimulated ICSI cycles in the female patient. Altogether, 59 oocytes were retrieved. Fifty-one oocytes (86%) were in metaphase II and 38 fertilized regularly (75%). Sixteen embryos, in the 3-6 cell stage, were transferred to the uterus. RESULTS: The first, fifth and sixth embryo transfers of fresh embryos led to intact intrauterine singleton pregnancies. The pregnancy and implantation rates with fresh embryos were 50% and 20%, respectively. CONCLUSIONS: TESE or microscopic epididymal sperm aspiration in patients with CBAVD in combination with a healthy female partner is likely to yield very good results in ICSI/ET. As azoospermia can be caused by cystic fibrosis and cystic fibrous transmembrane conductance regulator gene mutation range varies dramatically in patients of different ethnic groups.

Electro-rotation of mouse oocytes: single-cell measurements of zona-intact and zona-free cells and of the isolated zona pellucida.

Passive electrical properties of oocytes and of zonae pellucidae, and the mechanical coupling between them, can be elucidated by means of rotating-field-induced rotation. In low-conductivity media (25-100 microS/cm) rotation of mouse oocytes (with or without their zonae) requires fields in the 1-100 kHz frequency range. However, an isolated zona shows weak rotation in the opposite direction to that of a cell, and in response to much higher field frequencies (approx. 1 MHz). In zona-intact mouse oocytes, the rotation of cell and zona are not rigidly coupled: thus rotation of the cell can still be induced when the zona is held stationary. However, rotation of freely suspended zona-intact cells is much slower than that of zona-free cells and requires an optimum field frequency that is approximately 1.5 kHz higher. These observations show that the electrical properties of the oocyte that are measured by rotation are altered by the presence of the zona pellucida, even though no such influence has been detected using micro-electrodes. The data are consistent with the zona acting as a porous shell with a conductivity of 40 microS/cm (preliminary estimate made at a single medium conductivity of 26 microS/cm). Measurements on cells from which the zonae had been removed gave values for the membrane capacity and resistivity of 1.2-1.3 microF/cm2 and 400 omega.cm2, respectively. These values may reflect the presence of plasmalemma microvilli. The results strongly suggest that the technique may be useful for studies of cell maturation and for in vitro fertilization, because the cells may be further cultured after measurement.

High sensitive DNA typing approaches for the analysis of forensic evidence: comparison of nested variable number of tandem repeats (VNTR) amplification and a short tandem repeats (STR) polymorphism.

The approach of using nested primers for the APO B variable number of tandem repeats (VNTR) increases the sensitivity of the polymerase chain reaction (PCR) to single cell level. Different experiments and a comparison to the short tandem repeats (STR) system VWA were carried out, to determine the applicability of this method to forensic samples. Nested amplification of the Apo B VNTR was affected by a strong tendency towards preferential amplification of the shorter alleles. This phenomenon was observed for DNA quantities as low as 100 pg and impaired, depending on the allele length, the results for mixed samples. As expected, VWA polymorphism showed less preferential amplification. The high sensitivity of both PCR systems is accompanied by an increased susceptibility to contamination. Using artificially contaminated bloodstains, the bloodstain genotype, the contamination or both genotypes could be found on one piece of evidence. Here a single analysis can lead to an incorrect result. Therefore a strategy for obtaining reliable results should consist of multiple stain extractions and the amplification of different stepped dilutions of the DNA solution.

Accuracy of laparoscopic diagnosis of endometriosis.

BACKGROUND AND OBJECTIVE: Laparoscopy is the standard method to visually identify endometriotic lesions under magnification within and outside the minor pelvis. The aim of this study was to analyze the accuracy of laparoscopic visualization in diagnosing the various endometriotic sites as confirmed histologically. METHOD: Presumed endometriotic sites were observed in 164 patients operated on under the clinical suspicion of endometriosis. Targeted biopsies were performed for histologic corroboration, comparing the laparoscopic findings and diagnosis to the histological results. RESULT: The histological reports of the biopsies confirmed the presence of endometriosis in 138 patients (84.1%), but in 26 patients (15.9%), no evidence of endometriosis was observed. 100% of "red" lesions, 92% of "black" lesions, and 31% of "white" lesions turned out to be endometriosis. Of the 264 various suspected endometriotic sites observed, 142 (53.8%) were confirmed histologically. The most accurate diagnosis was in lesions on the parietal peritoneum of the pelvis, confirmed in 9/9 cases (100%); the ovarian fossa, confirmed in 8/12 cases (66.7%); and the uterosacral ligaments and posterior surface of the broad ligament, confirmed in 83/138 cases (60.1%). As for the other sites, the histologic confirmation rates in the ovarian surface, bowel serosa, and vesicouterine fold of the peritoneum were 48%, 40%, and 13%, respectively. CONCLUSION: Endometriosis has a multiple appearance, and the lesions may be confused with nonendometriotic lesions. It is clear that a nonhistology-based diagnosis may lead to unnecessary prolonged medical treatment and operations and may delay the proper treatment measures from being applied. Therefore, a meticulous histological confirmation should still be the first step in the laparoscopic diagnosis and treatment of suspected endometriosis.

Correlation of endoscopic interpretation of endometriosis with histological verification.

INTRODUCTION: In this study we correlate the laparoscopic findings of endometriosis with the histological confirmation of the disease over a period of two years. MATERIALS AND METHODS: One hundred and sixty-four laparoscopies performed at the Department of Gynecology & Obstetrics, University of Kiel, over a two-year period were reviewed for laparoscopic findings and histological confirmation of endometriosis. RESULTS: The majority of patients suspected of endometriosis at laparoscopy were confirmed by histological examination, i.e. 138 out of 164 patients (84.1%). CONCLUSION: Laparoscopy is the easiest diagnostic tool for the diagnosis of endometriosis which can be confirmed by histological examination.

Comparison of c-DNA microarray analysis of gene expression between eutopic endometrium and ectopic endometrium (endometriosis).

PROBLEM: As recent studies have suggested abnormalities in the regulation of specific genes in the development of endometriosis, we investigated differentially expressed genes in endometriosis compared to endometrium. METHOD OF STUDY: Gene expression profiles using the Atlas microarray were performed in endometriotic tissue and endometrium. Nine of the 13 genes of endometriotic tissue showed an up-regulation in relation to endometrium and four of the 13 genes a down-regulation. RESULTS: Of the 1176 genes on the Atlas Human 1,2 array, only 13 differentially expressed identical genes were detected after repeating the gene analysis three times. CONCLUSION: According to our c-DNA analysis some differentially expressed genes may be involved in the pathogenesis of endometriosis. An imbalance in the genes responsible for the reproductive process may lead to a decrease in embryo implantation in patients with endometriosis.

Is granulocyte colony-stimulating factor level predictive for human IVF outcome?

BACKGROUND: We investigated granulocyte colony-stimulating factor (G-CSF) in human reproduction. METHODS: From a total sample of 93 patients, we analysed in group 1 (n = 82) the level of G-CSF and estradiol (E(2)) in serum and follicular fluid (FF) on day of follicular puncture (FP). Furthermore, in response to ovarian stimulation, G-CSF levels in serum were compared between low (n = 11), moderate (n = 53) and high (n = 18) response patients. In group 2 (n = 23) serum for G-CSF assessment was collected throughout menstrual cycle until gestation. Group 3 (n = 11) patients with endometriosis were assessed for G-CSF in serum and FF on day of FP without further differentiation. RESULTS: G-CSF in FF was higher than in serum (P < 0.01). G-CSF in serum increased from low through moderate to high response (P < 0.001); pregnancy rates were 0, 24.5 and 33.5% respectively. G-CSF in serum increased throughout stimulation, reached a peak with ovulation induction (P = 0.01) and decreased until embryo transfer (P=0.001). G-CSF level only in pregnant patients (n = 11) increased from embryo transfer to implantation to gestation (P = 0.005). In endometriosis patients G-CSF in serum and FF was lower than in non-endometriosis patients (P < or = 0.03) and corresponded with low response patients. CONCLUSIONS: G-CSF is involved in follicle development and may be a predictor of IVF outcome.

ESHRE PGD Consortium 'Best practice guidelines for clinical preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS)'.

Among the many educational materials produced by the European Society of Human Reproduction and Embryology (ESHRE) are guidelines. ESHRE guidelines may be developed for many reasons but their intent is always to promote best quality practices in reproductive medicine. In an era in which preimplantation genetic diagnosis (PGD) has become a reality, we must strive to maintain its efficacy and credibility by offering the safest and most effective treatment available. The dominant motivators for the development of current comprehensive guidelines for best PGD practice were (i) the absence of guidelines and/or regulation for PGD in many countries and (ii) the observation that no consensus exists on many of the clinical and technical aspects of PGD. As a consequence, the ESHRE PGD Consortium undertook to draw up guidelines aimed at giving information, support and guidance to potential, fledgling and established PGD centres. The success of a PGD treatment cycle is the result of great attention to detail. We have strived to provide a similar level of detail in this document and hope that it will assist staff in achieving the best clinical outcome for their patients.

[Women with epilepsy planning pregnancy]. / Kinderwunsch und Schwangerschaft bei Frauen mit Epilepsie.

There are many important health issues for women with epilepsy, in particular for women of childbearing age. Recent surveys have shown that only a minority of such patients received information on important issues concerning pregnancy. Pre-pregnancy counselling should include information on interactions of antiepileptic drugs (AEDs) and oral contraceptives, risk of teratogenicity, use of folic acid, the importance of monotherapy with the lowest effective dosage of an AED, and the safety of breast feeding as well as other special aspects of epilepsy and pregnancy. Planned pregnancy and counselling before conception is crucial. With a multidisciplinary approach the majority of pregnancies will have a favourable outcome. The article addresses these issues and describes practical considerations for the counselling of women with epilepsy who are planning pregnancy.

Pelviscopic reversal of tubal sterilization with the one- to two-stitch technique.

STUDY OBJECTIVE: To describe 28 pelviscopic proximal reversals of tubal sterilization. DESIGN: Cohort study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Twenty-eight women. INTERVENTIONS: Twenty-two women underwent bilateral and six unilateral tubal end-to-end anastomosis through a catheter introduced through the working channel of a hysteroscope for a combined hysteroscopic-laparoscopic operation. MEASUREMENTS AND MAIN RESULTS: In the two-stitch technique the first stitch adapted the mesosalpinx and the second (4-0 or 6-0 material) to unite the tube muscularis. In some cases a third stitch was applied to either the muscularis or mesosalpinx. In all cases the wound was sealed with tissue col at the end of the procedure. Tubal patency was achieved in 95% of bilateral anastomoses and 100% of unilateral ones. Seventeen pregnancies (61%) were achieved within a minimum of 6 months and a maximum of 4 years. Fifteen patients (54%) had an intrauterine pregnancy with normal delivery and two (7%) had a tubal pregnancy. No abortions occurred. CONCLUSION: Laparoscopic end-to-end anastomosis is a suitable surgical alternative to tubal end-to-end anastomosis by laparotomy and has all the advantages of a laparoscopic procedure.

[400 cycles with assisted fertilization in severe teratozoospermia]. / 400 Zyklen mit assistierter Fertilisation bei starker Teratozoospermie.

From May 1991 to July 1993, assisted fertilisation by micromanipulation (PZD, SUZI and ICSI) was performed in 397 cycles with severe teratozoospermia. In the second series of 152 cycles with SUZI, the pregnancy rate per cycle was 5% (10% per transfer). In the third series, the method was changed from SUZI to ICSI.

[Delivery after subzonal sperm injection (SUZI) in extreme male subfertility]. / Geburt nach subzonaler Spermainjektion (SUZI) bei extremer männlicher Subfertilität.

For the therapy of severe forms of male sterility, we introduced all three methods of assisted fertilisation by micromanipulation in our hospital: partial zonal dissection (PZD), subzonal sperm injection (SUZI) and intracytoplasmatic sperm injection (ICSI). We report on our first pregnancy and birth.

Pregnancy following intracytoplasmic sperm injection of immotile spermatozoa selected by the hypo-osmotic swelling-test: a case report.

The success of intracytoplasmic sperm injection (ICSI) is poor when only immotile spermatozoa can be retrieved. In a couple with complete male asthenozoospermia the possible use of the hypo-osmotic swelling test to select spermatozoa for microinjection was examined. Following incubation in hypo-osmotic medium (Hypo 10, IVF Science, Göteborg, Sweden), 26% of immotile spermatozoa showed signs of sperm swelling (HOS-positive). After injection of HOS-positive spermatozoa, 5 out of 12 oocytes fertilized (41%) and after transfer of three embryos a healthy singleton pregnancy was achieved. In a previous ICSI cycle of this couple without preselection of spermatozoa by the HOS test, only 1 out of 10 oocytes fertilized. It is concluded that selection of spermatozoa by hypo-osmotic swelling-test prior to sperm microinjection seems to be a valuable tool to increase the fertilization rate in cases with complete asthenozoospermia.

Success of intracytoplasmic sperm injection in couples with male and/or female chromosome aberrations.

This paper reports on results of intracytoplasmic sperm injection (ICSI) in patients in whom constitutional or secondary chromosome aberrations were detected in the male and/or female partner. Out of 434 couples treated by ICSI (590 cycles), 16 couples (3.7%) were affected by constitutional chromosome aberrations and 96 (22.1%) by secondary chromosome aberrations. Constitutional chromosome aberrations were found in eight male and eight female patients. Couples with the aberration in the male showed significantly lower fertilization, implantation and pregnancy rates (P < 0.05). The occurrence of female constitutional chromosome aberrations led to lower fertilization rates but implantation and pregnancy rates were similar to a control group; however, a higher abortion rate was noted. In the group with secondary chromosome aberrations, 22 males and 59 females carried an abnormality and in 15 couples, both partners. Compared to the remaining (unaffected) 322 couples, fertilization and embryo transfer rates were reduced but implantation rates and pregnancy rates were not different. In all couples where an abortion occurred, mainly parental autosomal aberrations were involved (six out of eight). Our retrospective analysis shows that an unexpectedly high number of infertile couples in an ICSI programme are affected by chromosome aberrations, which in turn may explain the reduced fertilization rates observed in this subgroup of patients.