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The Official Journal of the Middle East Fertility Society Abstracts of
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The Official Journal of the Middle East Fertility Society Abstracts of
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A comprehensive review on immunoinfertility:
relevant aspects to assisted conception
Raja Z. Karaki and Najwa A. Al-Mously
Fertility and Assisted Reproduction Unit, Al - Amal Maternity Hospital, and Department of Microbiology and Immunology,Faculty of Pharmacy, Al - Isra University, Amman – Jordan
ABSTRACT
Objective: To highlight the association between autoantibodies and infertility emphasizing their impact on assisted conception.
Design: A comprehensive review for more than 200 articles was carried out from which the most relevant were selected.
Results: Autoantibodies may play an important role in reproductive failure. Clinical studies suggest that infertile patients may suffer from subclinical autoimmune disease in addition to mechanical or other problems. In both males and females, antisperm antibodies (ASA) on the sperm surface and in cervical mucous may exert an adverse effect on sperm-cervical mucous interaction, fertilization and post fertilization events in IVF-ET. The presence of autoantibodies in females whether non-organ specific or organ-specific, can affect the reproductive process. Antiphospholipid antibodies (APA) have been the most strongly implicated in unexplained infertility, and correlated with repeated IVF-ET failure. Of the organ-specific autoantibodies, antiovarian and antithyroid may serve as possible markers of reproductive failure. Concerning the treatment of immunoinfertility, immunosuppressive therapy for ASA-associated infertility showed controversial results. IUI and standard IVF could be beneficial in cases with low to moderate amounts of ASA while with high titers, ICSI should be the primary choice. In APA-positive patients, the administration of heparin and aspirin significantly improves the viable pregnancy rate.
Conclusion: This review mainly recommends paying utmost attention to autoimmune factors as an important cause in unexplained infertility and failure of assisted reproduction. Autoantibodies profiles should therefore be required for each couple undergoing assisted conception with certain clinical conditions that raise the suspicion of having immunoinfertility. The question of how these patients can be treated remains not fully answered, this is partially solved in regard to assisted reproduction technologies in combination with medical therapy. Large-scale placebo-controlled trials are needed to evaluate the importance of such treatment.
Keywords: Immunoinfertility, IVF-ET failure, antisperm antibodies, treatment of immunoinfertility.
The role of intrauterine insemination
and in-vitro fertilization in idiopathic infertility
Amparo Ruiz and Antonio Pellicer
Instituto Valenciano de Infertilidad; department of Pediatrics, Obstetrics and Gynecology, Valencia University School of Medicine; and Hospital Universitato Dr. Peset, Valencia, Spain
ABSTRACT
Unexplained infertility represents 15% among infertile couples. To increase the chance of conception, intrauterine insemination (IUI) and in-vitro fertilization (IVF) are frequently used. This review analyzes the chances of conception with different approaches, in order to properly advice couples with no evident cause of infertility after complete work-up. The possibility of becoming spontaneously pregnant is 2% if no treatment is performed. IUI is an effective treatment, with 30-40% cumulative pregnancy rates. We usually offer 4 cycles of IUI with mild ovarian stimulation. IVF should be the next step. In this case, we can also learn about the etiology of infertility, specifically the possibility of fertilization failure and abnormal oocytes. Fertilization failure can be expected to be in the range of 11 to 20%, but can be easily overcome employing simultaneously intracytoplasmic sperm injection (ICSI). Once the oocytes have fertilized, the outcome of the replacement is about 37% pregnancy rate, similar to other causes of infertility. Abnormal oocytes can be found in 11.5% of the cycles, and can be also treated with ICSI, but these couples may develop into intractable problems that may finally need ovum donation.
Evaluating the ability of biological
substances for induction of acrosome reaction in normozoospermic samples
Seyed M. Kalantar, Elizabeth Lenton and Ian D. Cooke
Research & Clinical Center for Infertility, Yazd University of Medical Sciences, Yazd, Iran and Department of Obs. & Gyn. Jessop Hospital for Women, The University of Sheffield, Sheffield, UK
ABSTRACT
Objective: To compare different acrosome reaction inducing substances and to study the effect of different incubation times in human normospermic samples.
Design: Prospective study.
Intervention: Each sample was divided into 11 aliquots and after 3 hrs., 8 hrs. and overnight incubation in capacitation condition human recombinant ZP3 (rhuZP3), human follicular fluid(hFF), progesterone (P), calcium ionophore A23187, DMSO, fetal calf serum (FCS), hFF+FCS, A23187+FCS and control (EBBS+0.3%HSA) were added. The samples were then incubated for different periods followed by Hypo-osmotic swelling (HOS) medium. The acrosome was stained with monoclonal antibody 18.6 and acrosomal status examined by fluorescent microscopy.
Main outcome measures: Induction of acrosome reaction.
Results: The defect of a 3 hrs pre-treatment incubation using different ARISs indicates that only progesterone was able to significantly induce AR, 8% VS control 3%, p<0.05. When spermatozoa were capacitated for 8 hrs. induction of AR by P and hFF were significant at 23±3 and 14±4, respectively VS control 5±2, p>0.05. Follicular fluid and P significantly increased the AR after overnight capacitation incubation 16±3 and 26±2, respectively, VS 10±3 in the control to p <0.05. Although rhuZP3 and FCS also induced the AR, differences were less marked 14±4, 19±1, respectively rhuZP3 in combination with hFF (either before or after) gave values of 20±4 and 21±3, respectively, significantly different from hFF alone (16±3) and higher than rhuZP3 alone.
Conclusions: The acrosome reaction induced by biological stimuli such as progesterone is time-dependent with an optimum capacitation period of 8 hrs. whereas, the chemical stimuli are not time- dependent. It is of interest to perform more clinical research for further confirmation whether progesterone can be used for induction of acrosome reaction before intracytoplasmic sperm injection (ICSI).
Key words: Acrosome reaction, IVF, progesterone, sperm
Development of a hyperosmotic shrinkage
test to measure the functional integrity of the membrane of human round
spermatids retrieved from testes for use in ICSI
Panayiotis M. Zavos, Pavlos Aslanis, Constantinos N. Zarmakoupis,
Juan R. Correa and Panayota N. Zarmakoupis-Zavos
Andrology Institute of America; Kentucky Center for Reproductive Medicine and IVF, Lexington, Kentucky, USA; Greek-American Andrology Institute of Athens, Athens, Greece and Centro de Fertilidad Del Caribe, Rio Piedras, Puerto Rico
ABSTRACT
Objective: To develop methods for selection of viable round spermatids for use in ICSI.
Design: A prospective study.
Patients: Round spermatids (RS) were recovered from testes of eight azoospermic (non-obstructive) males via testicular biopsies.
Interventions: The quality of the round spermatids harvested from testes, was determined via a standardized hyperosmotic shrinkage test (HYOS-test) and a supra-vital stain to assess their membrane integrity.
Results: The results from the applied measurements pointed out that spermatids recovered via the traditional methods of testicular biopsy, exhibited significant deficiencies in their cell membrane profiles, as measured via the supra-vital stain and the HYOS-test. Only 13% showed intact membranes (live-dead) and even more importantly, only 7% showed any response to the HYOS- test. Exposure of RS to the HYOS-test resulted in volume reduction and subsequent crenation. The occurrence of this cellular membrane behavior, suggests that fluid transport from the cell was allowed in an attempt to reach osmotic equilibrium with the surrounding hyperosmotic medium.
Conclusions: The findings generated in this study suggest that spermatids (RS) when recovered via the traditional manner, undergo irreversible membrane damage which could have detrimental effects in the ability of those immature male gametes to be actively involved in complete fertilization and furthermore, in the proper development of the embryos during embryonic and fetal development. It is possible that those deficiencies noted in the current study could be due to the tearing of the cells during separation of the cells from the parenchymal testes and could offer an explanation of the extremely low rate of pregnancies established during ICSI using round spermatids.
Key words: Round spermatids, non-obstructive azoospermia, Hyperosmotic shrinkage test.
Laparoscopic ovarian electrocautery
improves ovarian response to gonadotropins in clomiphene citrate resistant
patients with polycystic ovary syndrome
Ehab M. Soliman, Abdelhamid M. Attia, Alaa N. Elebrashi, Ashraf
S. Younis & Mohamed E. Salit
The Obstetrics and Gynaecology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
ABSTRACT
Objectives: To review the results of laparoscopic ovarian electrocautery treatment in women with PCOS, and to compare their response to ovulation induction treatment before and after the procedure.
Design: Clinical prospective study.
Subjects: This study was conducted on 37 patients suffering from anovulatory infertility due to PCO and who failed to respond to clomiphene citrate or hMG/hCG treatment. All patients showed clinical, ultrasound and hormonal profiles with the diagnosis of polycystic ovarian disease.
Intervention: Laparoscopic drilling of both ovaries was performed using a unipolar electrode with 5 punctures maximally in each ovary. Serum LH, FSH, and testosterone levels were re-assessed one week after electrocautery. Patients were then followed up for the resumption of spontaneous menstruation and ovulation using vaginal ultrasound monitoring. Six months after electrocautery, women who resumed regular menstruation but failed to conceive and those who remained amenorrheic or oligomenorrheic were treated with hMG/hCG therapy.
Results: Spontaneous ovulatory cycles were resumed in 43.2% of cases. The cumulative pregnancy rate after the procedure was approximately 60%, whether spontaneous or after hMG/hCG stimulation. After the procedure, the ovarian response to hMG improved significantly and the percentage of ovulatory cycles increased to 74% as compared to 33% before ovarian cautery. There was a significant reduction in the number of ampoules used per day, daily effective dose and number of treatment days per cycle resulting in reduction of the cost. The pregnancy rate per treatment cycle was significantly higher (38%) after ovarian cautery as compared to 8.9% prior to ovarian cautery.
Conclusion: Infertile anovulatory women with PCOS and high basal LH levels become more responsive to gonadotropin therapy following ovarian drilling.
Key Words: PCO, polycystic ovary, anovulation, laparoscopic electrocautery, ovarian drilling
Bacterial infection of the reproductive
tract of infertile men in Iran
Mohammad A. Khalili, Mohammad R. Pourshafie, Mahnaz Saifi and
Mohammad B. Khalili
Research and Clinical Center for Infertility, Yazd University of Medical Sciences, Yazd, Iran; Department of Microbiology, Institute of Pasture, Tehran, Iran; and Department of Microbiology, Yazd University of Medical Sciences, Yazd, Iran
ABSTRACT
Objectives: To evaluate the presence of bacterial organisms in the ejaculates of infertile men; also to observe whether sperm preparation medium reduces seminal bacteria; and if so, which one.
Design: Prospective study.
Materials and Methods: The parameters of concentration, morphology, and progressive motility of spermatozoa were evaluated in 90 ejaculates. Each sample was divided equally into two portions. One portion was processed using the swim-up sperm separation method with Ham’s F10 medium. Both the pre and post-processing samples were cultured for aerobic and anaerobic bacteria along with Mycoplasma and Ureaplasma spp.
Results: A total of 57 samples (63.3%) and 21 samples (23.3%) were contaminated pre- and post- swim up, respectively. A total of 14 and 8 different bacterial species were detected in pre- and post-swim up samples, respectively. Staphylococcus saprophyticus and Escherichia coli were the most common bacteria in fresh ejaculates. In addition, the samples with Ureaplasma urealyticum, E. coli, or Mycoplasma hominis showed sperm with low progressive motility of 21.3±16.7, 23.9±20.8, 6.4±14.0, respectively.
Conclusion: Because bacterial infection was relatively high in infertile ejaculates, a full bacteriological examination followed by effective antibiotic treatment is strongly recommended. Furthermore, the role of different sperm preparation media in combating the seminal bacterial species needs to be investigated accordingly.
Keywords: Male infertility, microorganisms, semen.
Bilateral selective uterine artery
embolization in uterine myomatosis
Tansu Küçük, N. Kemal Duru, M. Cemal Yenen,
Rüstü Ergür and Recai Pabuçcu
Gülhane School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
ABSTRACT
Objective: To assess the efficacy of angiographic selective uterine artery embolization on uterine myomas.
Methods: Three women with myoma uteri 40, 40 and 50 years old respectively were included in this study. They were presented with menometrorrhagia and accompanying pelvic pain and anemia in some. Bilateral selective uterine artery embolization was performed with the technique described by Seldinger. Metallic coils in various diameters were used for obliteration. Uterine artery embolizations were performed successfully in all three patients. Patients were followed up to twelve months with ultrasonography measuring myoma diameters and uterine artery color Doppler studies.
Results: In two out of three, myomas shrunk significantly while not so significant in the remaining patients. Primarily inguinal and some pelvic pain was the only complication seen after embolization; non-steroid anti-inflammatory drugs were enough to resolve the pain. Although they were not seeking fertility, one of them conceived unintentionally in the fifth month of follow-up period. This suggests that bilateral uterine artery embolization wouldn't be deleterious on implantation of fertilized oocytes.
Conclusion: Large series are needed to compare with the other treatment choices and reach statistically significant results. Bilateral uterine artery embolization may be a new choice for infertile women with uterine myomas.
Keywords: Uterine myomatosis, conservative treatment, embolization
Vigorous prostatic massage to retrieve
spermatozoa for intracytoplasmic sperm injection in anejaculation: a case
series
Ibrahim Fahmy, Catharine Rhodes, Ahmed Kamal, Mahmoud Metwali,
Ragaa Mansour, Gamal Serour and Mohamed Aboulghar
The Egyptian IVF-ET Center, Maadi, Cairo, Egypt
ABSTRACT
Objective: To report our experience with simple, non-invasive method of vigorous prostatic massage to retrieve spermatozoa from patients with anejaculation.
Design: Prospective case series
Setting: The Egyptian IVF-ET Center.
Subjects: Nine patients with anejaculation. Four men had psychogenic anejaculation, four had diabetes and one had iatrogenic anejaculation due to anti-hypertensive medication. Ten cycles of intracytoplasmic sperm injection (ICSI) were performed.
Interventions: On the day of oocyte retrieval, vigorous prostatic massage was done. If examination of the expressed prostato-vesicular secretion revealed a sufficient number of motile spermatozoa, ICSI was performed. If adequate numbers of spermatozoa were not obtained, surgical retrieval of sperm was done for ICSI.
Main outcome measures: Sperm retrieval, fertilization and pregnancy rates.
Results: Prostatic massage was successful in retrieving sperm for ICSI in 6/10 cycles, with counts ranging from 1 to 50 x 10 6 /ml. The fertilization rate was 42%. Three pregnancies resulted; two ongoing twin gestations and one male infant, giving a pregnancy rate of 50% in the prostatic massage cycles. Testicular sperm extraction was done in the remaining four cycles, with sperm counts of 3 to 4 x 10 6 /ml. The fertilization rate was 67%, and one ongoing pregnancy resulted, giving a pregnancy rate of 25%.
Conclusion: Vigorous prostatic massage is an effective management option for spermatozoa retrieval for assisted conception in selected patients with anejaculation.
Key words: Anejaculation, ICSI, prostatic massage, spermatozoa retrieval
Department of Obstetrics and Gynecology, Assiut University Hospital, Assiut, Egypt
ABSTRACT
Objective: To evaluate the role of hysteroscopic tubal cannulation in the treatment of proximal tubal obstruction.
Setting: Department of obstetrics and gynecology, Assiut University Hospital, Assiut.
Design: A prospective study.
Materials and Methods: Fifty eight infertile women who have proximal tubal obstruction (unilateral or bilateral), diagnosed by hysterosalpingography (HSG). Twenty-one cases were excluded after a diagnostic laparoscopy due to the presence of distal or bipolar obstruction. Another 3 cases were excluded after a diagnostic hysteroscopy due to the inability to visualize the tubal ostia. Hysteroscopic tubal cannulation was performed for 34 cases using Novy Cornual cannulation set under laparoscopic control. Follow-up using HSG was done two months later to evaluate tubal patency.
Results: Hysteroscopic tubal cannulation was initially successful in 27 cases (26 fallopian tubes), giving a success rate of 71.9%. At follow-up 89% of the tubes remained patent.
Conclusion: Hysteroscopic tubal cannulation has a place in the treatment of PTO. It is less invasive and less expensive than tuboplasty. It could be done before resorting to assisted reproductive techniques.
Key words: Tubal cannulation, hysteroscopy, proximal tubal obstruction.
Comparative study of testicular sperm
retrieval between the open biopsy method and the needle aspiration technique
in azoospermic patients
Majed E. Atassi, Majed Takkla, Sambasivarao K, Iqbal Lohia, Dawoud
A. Yassa and Walid K. Idriss
Arab Fertility Center, Al-Diya Hospital, Homs, Syria and Arab Fertility Center, Khalid Idriss Hospital, Jeddah, Saudi Arabia
ABSTRACT
Objective: To compare testicular sperm retrieval between the open biopsy method and the needle aspiration technique in azoospermic patients of different pathological patterns, in relation to testicular volume and FSH level.
Design & Setting: Comparative prospective study in two fertility centers in two countries.
Patients: Two hundred and nine azoospermic patients.
Interventions: Uniform sampling of testis was made in all the patients of two sperm retrieval groups. Rapid needle movements under appropriate negative pressure implemented the aspiration technique.
Main outcome measures: Rate of sperm retrieval in normal spermatogenesis, hypospermatogenesis, maturation arrest, germ cell aplasia and unknown histology were the different patterns studied in relation to testicular volume and FSH level.
Results: The sperm retrieval was recorded highest in normal spermatogenic patients in both the groups of open biopsy (92.3%) and needle aspiration (95.83%). Regarding the hypospermatogenic patients, the sperm retrieval was 41.66% by open biopsy and was 32.35% by needle aspiration. The sperm retrievals by biopsy and aspiration were found lowest, in the patients of maturation arrest (40%, and 32.14%) and in germ cell aplasia (33.33%, and 30.76%). The retrieval rates of unknown histology group were recorded better than the three patterns of severe spermatogenic defects, but lower than the normal spermatogenic pattern as 62.5%, in biopsy and 69.23% in aspiration groups. However, the results were found comparable between the groups of two different procedures adopted. The average testicular volume (ml±SE) measured was significantly (p<0.001) low compared to normal in germ cell aplasia (8.99±6.26 and 9.26±4.33 ml) of biopsy and aspiration groups respectively. The average FSH level (IU/l±SE) was measured significantly higher in germ cell aplasia 20.96±5.23 (p<0.001) of needle aspiration and 22.18±4.98 (p<0.05) of biopsy groups.
Conclusions: The testicular sperm retrieval by the needle aspiration technique was comparable to that of the open biopsy method. A higher recovery rate in the normal spermatogenic patients was probably due to good status of spermatogenesis existing in these patients. Better results can be obtained by needle aspiration if the technique is properly implemented. Low testicular volume and high FSH levels did not influence much on the retrieval rate in non-obstructive azoospermia, and they are not strong predictors for sperm recovery.
Key words: Testicular sperm aspiration, testicular sperm extraction, male factor infertility, azoospermia
One stage intracytoplasmic
sperm injection and tubal transfer in male factor infertility patients
undergoing laparoscopic oocyte retrieval
M. Magdy El-Sheikh, Mostafa Hussein, Sally
Fouad and Rania EL-Sheikh
Al Salama Hospital IVF Unit, Jeddah Saudi Arabia
ABSTRACT
Objective: To evaluate the procedure of intracytoplasmic sperm injection and tubal transfer as a one-stage treatment in patients with male factors infertility undergoing laparoscopic oocyte retrieval.
Design: Retrospective analysis.
Setting: Tertiary assisted reproduction unit.
Patients: Eighteen patients with male factor infertility.
Intervention: Following laparoscopic oocyte retrieval, patients were treated with ICSI. In the presence of patent fallopian tubes a maximum number of 4 injected oocytes were replaced into the tubes at the end of the procedure.
Main outcome measure: Clinical pregnancy.
Results: Eighteen patients underwent the one stage ICSI and tubal transfer procedure. Twelve were classified as poor responders with four or less follicles. Six patients had the procedure performed in view of anticipated technical difficulties. Eight clinical pregnancies were achieved (44% per transfer) with five pregnancies in the poor responders group.
Conclusion: The transfer of injected mature oocytes to fallopian tubes in a single operative procedure could be employed for the treatment of male infertility.
Key words: Laparoscopic oocyte retrieval, ICSI, ZIFT, poor responders.
Human albumin administration for the
prevention of severe OHSS
Hesham Al-Inany, Mohamed Aboulghar and Johannes L.H. Evers
The Cochrane Menstrual Disorder and Subfertility Group Albumin reviewers
ABSTRACT
Objectives: To review the effectiveness of human albumin administration in the prevention of severe ovarian hyperstimulation syndrome.
Data collection and analysis: A diverse search strategy was employed, including a hand-search of core journals from 1966 to the present, bibliographies of relevant trials, MEDLINE database, abstracts from North American and European meetings and contact with authors of relevant papers. Trials under consideration were evaluated for methodological quality and appropriateness for inclusion without consideration of their results. Relevant data were extracted independently by two reviewers using the standardized data extraction sheet. Validity was assessed in terms of method of randomization, completeness of follow-up, presence or absence of crossover and co-intervention.
Data Synthesis: 2x2 tables were generated for all relevant outcomes. Odds ratios were calculated using the Peto modified Mantel-Haenszel technique.
Results: Meta-analysis of the three included trials demonstrated a significant reduction in severe ovarian hyperstimulation syndrome on the administration of human albumin (common odds ratio 0.1, 95% confidence interval 0.03 to 0.39). There was no evidence of an increase in the pregnancy rate (common odds ratio 1.69, 95% confidence interval 0.7 to 4.07)
Conclusions: This review shows a clear benefit from the administration of intravenous albumin around the time of oocyte retrieval in the prevention of severe OHSS in high risk cases. However, the results of this review can not be regarded as conclusive as they are based on only three small trials. Further trials are urgently needed.
Key words: Albumin, ovarian hyperstimulation syndrome, meta-analysis