Reproductive biomedicine online最新文献

It is not uncommon that a published paper offers unintended insights, unnoticed by its authors. This was to a substantial degree the case with a recent publication addressing the effects of endometriosis on IVF. Using donor-recipient cycles as the study population to isolate recipient effects, the well-executed study demonstrated only mildly adverse outcome effects of endometriosis on IVF cycle outcomes, to a substantial degree laying to rest this still controversial issue. In the process, however, the study also raised some very interesting - but left undiscussed - insights into a host of other issues with considerable relevance to endometriosis and IVF practice in the USA and UK. These are the subject of this communication.

Research question: What are the effects of pipette- versus laser-assisted artificial blastocyst collapse (ABC) on the morphokinetics of warmed blastocyst re-expansion, and what is the potential effect on treatment outcomes?

Design: Surplus blastocysts were extracted from 203 patients. These were divided into three groups: study group A, artificial collapsed by the aspiration of blastocoel fluid with a pipette; study group B, trophectoderm opened with a laser pulse; control group, no manipulation before vitrification was performed. During the 5-year study period, 257 associated single-warm blastocyst transfers were scheduled. The start and duration of the re-expansion process before transfer were annotated. Pregnancy and live birth data were also collected for the transfers.

Results: The overall blastocyst survival rate was 96.9%, with no effect observed as a result of the two ABC methods. The re-expansion of blastocysts in study group B was initiated significantly sooner after warming (0.50 ± 0.37 h) than in group A (0.79 ± 0.56 h) or the control group (1.22 ± 1.00 h). The duration of the re-expansion process was significantly reduced in study groups A (P = 0.021) and B (P = 0.004) compared with the control group. The embryos of participants who achieved a live birth had a significantly (P < 0.001) faster start of re-expansion (0.60 ± 0.42 h) than the embryos in those who did not produce an ongoing pregnancy (1.05 ± 0.92 h).

Conclusions: Laser-treated blastocysts exhibited substantially shorter re-expansion times. Because faster re-expansion of the blastocyst is associated with positive treatment outcomes, the laser technique should be prioritized over the pipetting technique if ABC is considered.

Ovarian cortex cryopreservation is now a validated fertility preservation technique. Autotransplantation of this tissue allows restoration of ovarian hormone function in more than 90% of patients, and birth of at least one child in 30% of transplanted women. In the case of very highly gonadotoxic treatments, it is recommended that ovarian cortex be cryopreserved as first-line therapy to safeguard future fertility. However, the ovary left in place runs a very high risk of being significantly altered. This raises the question of harvesting both ovaries, looking to restore fertility as well as endocrine function. Indeed, hormone balance in these cancer survivors may be recovered naturally for their entire lifetime. Autotransplantation could also be performed to restore hormone function in women with no wish to have children, with the sole purpose of improving their quality of life. Ethical and legal challenges exist and are discussed in this paper, but they do not constitute an argument against it. Clinical trials investigating this strategy are clearly needed, but this approach truly offers women the chance of having both endocrine and reproductive functions restored and maintained throughout their entire life.

Research question: How safe and effective is transrectal oocyte retrieval (TROR) for fertility preservation in nulliparous virginal women?

Design: This was a retrospective single-centre study of 105 nulliparous women from five satellite centres of Fakih IVF, UAE, who underwent TROR for oocyte cryopreservation. Extensive bowel preparation and rectal cleansing was performed prior to oocyte retrieval. Patient characteristics, stimulation protocol, and procedure outcome and safety data were collected. Correlation analyses of the number of follicles and oocyte yield in relation to age and anti-Müllerian hormone (AMH) concentration, and the number of follicles in relation to oocyte yield were performed.

Results: This study evaluated 105 patients who underwent 152 cycles of ovarian stimulation and TROR. The most common indication was social fertility preservation. A significant positive correlation was found between the AMH concentration and number of oocytes (r = 0.83, P < 0.003). No intra-operative or postoperative complications were observed.

Conclusion: This study demonstrated that TROR is an alternative and clinically effective oocyte harvesting procedure in assisted reproductive technology, producing good results in terms of oocyte yield, with no complications and a good safety profile. Although transvaginal oocyte retrieval remains the gold-standard treatment, TROR is safe and effective for virginal women in whom transvaginal oocyte retrieval is not an option.

Research question: Do directed oocyte donors differ from non-directed identity-release oocyte donors regarding pre-donation motives and ambivalence, and post-donation satisfaction and openness?

Design: The study is part of the longitudinal Swedish Study on Gamete Donation where consecutive samples of identity-release gamete donors at seven Swedish University Hospitals were approached during a 3-year period (2005-2008). The participants of the current study were 16 women who donated oocytes to family members or friends (directed donation) and 123 women who donated to unknown recipients (non-directed donation). Survey data on motivation, ambivalence, post-donation satisfaction and openness were collected at five time points between acceptance as a donor and 14-17 years post-donation. Statistical group comparisons and longitudinal analyses were conducted.

Results: In contrast to non-directed donors, who reported general altruism as their main motivation, directed donors were primarily motivated by empathy with the recipients. Pre-donation ambivalence was present in a quarter of donors and did not differ between groups (P = 0.601). Post-donation satisfaction was similar between groups (P = 0.17) and stable over time (P = 0.37). One directed donor reported regretting her donation, and this was attributed to negative relations with the recipients. Donors from both groups were generally open about having donated, but some directed donors felt restricted by the recipients' wishes.

Conclusions: Despite being differently motivated, the current findings suggest that directed oocyte donors are comparable to non-directed oocyte donors in terms of pre-donation ambivalence and post-donation satisfaction and openness. The findings also highlight how directed donation may be associated with specific challenges, which emphasizes the need for pre- and post-donation counselling.

Research question: Does the shortened warming protocol impact the cell viability and outgrowth competence of human vitrified blastocysts warmed with or without fatty acids?

Design: In this study, 326 discarded vitrified human blastocysts donated for research by consenting couples were used. The blastocysts were randomly allocated to five groups depending on the warming solutions, protocols and recovery culture media: the control-conventional, control-shortened, FA-conventional, FA-shortened, and FA-shortened/recovery culture with fatty acid (FA-shortened/RF) groups. The blastocysts were warmed with or without fatty acids following the manufacturer's instruction (conventional method) or using the shortened method, in which blastocysts were immersed in a thawing solution for 1 min and then cultured in the recovery medium for 2 h. The embryo volume recovery, cell viability, intracytoplasmic lipid droplets and outgrowth competence were evaluated.

Results: The degree of blastocyst volume recovery was significantly higher after shortened warming than after conventional warming (P = 0.0130-0.0278). Cell membrane collapse was observed during the shortened warming. The blastocyst survival rate and expansion status after the recovery culture were comparable among the five groups. However, the proportion of necrotic cells was increased in the control-shortened, FA-shortened and FA-shortened/RF groups (P = 0.0160-0.0498). The adhesion rates were comparable among all the groups; however, the outgrowth area was significantly higher in the FA-conventional group than in the other groups at 96 h (P = 0.0026-0.0487).

Conclusions: The efficacy of the shortened warming protocol depends on the warming solutions used. The shortened protocol effectively improves the daily workflow; however, to prioritize clinical outcomes, each laboratory should thoroughly examine its impact before introducing it.

Research question: What is the level of understanding, and what are the attitudes and considerations regarding preconception carrier screening (PCS) among couples seeking IVF or intracytoplasmic sperm injection (ICSI)?

Design: A mixed-methods design was used. Nine interviews were conducted with couples or individual partners (n = 16) who had an initial consultation for IVF/ICSI in the 2 years preceding this study. A questionnaire was completed by 115 participants. No actual PCS was offered.

Results: All interviewed couples expressed a positive attitude towards PCS, and over half of the respondents stated that they would pursue or seriously consider pursuing PCS if possible. Some couples falsely believed that PCS could identify a cause for their fertility problems and increase their chance of conceiving. The desire to make an informed reproductive decision was the most important argument in favour of PCS. The primary argument against PCS was the apprehension of being confronted with reproductive dilemmas. The longer the delay to IVF/ICSI treatment required to perform PCS, the more couples would be inclined to decline screening. Participants indicated that they would prefer to receive information about PCS from a medical specialist at an early stage in their IVF/ICSI treatment.

Conclusion: Although attitudes towards PCS were generally positive, some concerns were raised about treatment delays and potential reproductive dilemmas, and some couples had misconceptions about the purpose of screening within the context of their IVF/ICSI treatment. These findings highlight the importance of tailoring information and counselling to the specific needs of couples seeking IVF/ICSI.

Research question: What number of retrieved oocytes is associated with the optimum chance of achieving a live birth for women undergoing ovarian stimulation with individualized follitropin delta?

Design: An individual patient data meta-analysis was performed on 1772 patients from five randomized controlled trials using individualized follitropin delta for ovarian stimulation with fixed daily dosing based on serum anti-Müllerian hormone (AMH) level and body weight. Live birth rate (LBR) and ovarian hyperstimulation syndrome (OHSS) were evaluated in relation to the number of oocytes retrieved. Predicted LBR was obtained using a logistic regression analysis with fractional polynomials. Subgroup analyses were performed based on number of oocytes retrieved, age and AMH level.

Results: The analysis included patients treated with follitropin delta who had at least one oocyte retrieved. The mean number of oocytes retrieved was 10.4, and overall LBR was 32.1%. Predicted LBR increased with the number of oocytes retrieved, reaching >34% for patients with 8-14 oocytes retrieved, and peaking at 34.9% for patients with 11 oocytes retrieved. LBR declined gradually beyond retrieval of 14 oocytes. LBR was 27.8%, 33.6% and 30.9% for patients with 1-7, 8-14, and ≥15 oocytes retrieved, respectively. LBR decreased with increasing age: 32.7%, 30.7% and 23.4% at <35, 35-37 and 38-42 years, respectively. The incidence of OHSS (any grade) was 2.1%, 5.2% and 17.0% for patients with 1-7, 8-14, and ≥15 oocytes retrieved, respectively.

Conclusions: After ovarian stimulation with individualized follitropin delta, LBR in fresh transfer cycles was highest for patients with 8-14 oocytes retrieved, and peaked in patients with 11 oocytes retrieved. The results support the appropriateness of the follitropin delta dosing algorithm.