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Weight loss may increase fecundity, but does it influence pregnancy risks?
S. Robinson
Section of Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
Maternal overweight and obesity are prevalent, 40% of women have a body mass index greater than 25 kg/m2 measured at their booking clinic. This weight is associated with major risks for the pregnant woman and her foetus. Overweight and obese women who are seeking fertility treatment need to be advised of these risks but also the chances of conception are greater should they lose weight. Fertility treatment, particularly that for polycystic ovary syndrome, is far more likely to be successful should a women lose weight. Firstly the effects of maternal obesity on the mother herself will be reviewed including hypertension (preeclampsia is found in 3.9% of lean women and 13.5% of women with a body mass index greater than 30 kg/m2), worsening diabetes mellitus and thromboembolic disease. Secondly there are issues for the foetus. The odds ratio of birth weight greater than the 90th centile is more than 2 fold in women with a body mass index greater than 30 kg/m2. The odds ratio for late fetal death increases significantly for both overweight and obese women. Thirdly the association between the maternal obesity and operative delivery rate are such that both emergency and elective caesarean sections are increased over 1.5 fold when BMI is greater than 30 kg/m2. An American study showed a 21% caesarean section rate for controls increasing to 33% in obese and 47% in morbidly obese women. The risk of long-term weight gain are also related to weight and weight gain in pregnancy. Obesity has major consequences on successful outcome of pregnancy. Therefore the obese woman is more likely to fall pregnant and more likely to have a successful outcome of pregnancy should she be able to lose weight before conception.
Risk analysis of obesity in assisted reproduction
S. Bhattacharya
Department of Obstetrics & Gynaecology, University of Aberdeen, UK
Increased body mass index (BMI) is known to affect reproductive performance. This presentation will explore risks associated with assisted reproduction in women with high BMI. An initial search of the literature on this subject revealed a number of observational studies. Interpretation of some of the results was difficult due to variations in the definition of obese/overweight populations, and lack of consistency as regards selection of outcome measures. The available evidence suggests that obesity compromises spontaneous pregnancy rates and outcome of conventional fertility treatment, such as ovulation induction. Weight loss in overweight women has been shown to be beneficial in terms of achieving higher pregnancy rates. The independent effect of obesity on the outcome of in-vitro fertilisation (IVF) is less clear and existing studies vary in their conclusions. An association with an increase in the dose and duration of gonadotrophin use, the risk of cycle cancellation and a decrease in the number of oocytes retrieved, have been reported in women undergoing assisted reproduction. Women with high BMI experience higher miscarriages rates and have a lower chance of live birth. They also face higher risks of perinatal and maternal morbidity. Weight loss should be encouraged in overweight women contemplating assisted reproduction. More prospective studies with clear entry criteria and uniform reporting of outcomes are needed.
Management of obese women in assisted Conception units: a UK survey
M. Zachariah
Centre for Reproductive Medicine, Derriford Hospital, Plymouth, UK
A national audit was performed to ascertain the management at infertility clinics of clinically obese patients. This was with particular reference to Body Mass Index (BMI) limits for specific treatments and general advice given to patients regarding obesity. A postal questionnaire was sent to all assisted conception units (ACUs) in the UK offering fertility treatment. The return rate was 86 of 100 (86%). There was a great deal of variation between different units in the practice standards of obese infertile women. This audit demonstrates the wide variation in current UK practice and highlights the need for the adoption of national guidelines for the management of obese infertile women.
Exercise and weight reduction
J. Gill
Institute of Biomedical and Life Sciences, University of Glasgow, UK
Evidence from cross-sectional population studies indicates that high levels of physical activity are associated with low levels of body fat.
A physically active lifestyle can help to attenuate age-related weight gain, but it is probably necessary to increase physical activity levels as we get older in order to maintain a constant body weight.
Increasing physical activity may have a greater effect in minimising age-related weight gain in heavier individuals who are particularly susceptible to weight gain.
While increasing physical activity can play a role in inducing weight loss, dietary restriction is also necessary to maximise initial body weight reduction.
However, physical activity plays an important role in helping long-term weight maintenance following initial weight loss.
The amount of physical activity needed to maintain a healthy body weight differs between individuals, but may be as high as 60 – 90 minutes of moderate activity (e.g. brisk walking) per day in those who are particularly susceptible to gaining weight.
How to engage with your obese client
S. Trueman
Shropshire & Mid Wales Fertility Centre, Royal Shrewsbury Hospital North, Shrewsbury, UK
How to use successful communication skills so that you do not alienate your obese client.
How to keep your client empowered to make changes.
How to use some aspects of the ‘motivational interview technique’, to assist with the defensive obese client.
Sue will present elements of case study material to show how emotionally complex the problem of weight loss may be for some clients.
Practicalities of weight reduction
J. Jenkins
Division of Obstetrics & Gynaecology, St Michaels Hospital, Southwell Street, Bristol, UK
The management of obesity and its sequelae, the fastest growing killers of the western world, now forms a large part of a GPs workload, but can any health-care worker be involved in supporting their patient in self-management and medical management and if so, what tools are available and what works?
How to set up a weight reduction programme and integrate it with ART
U. Acharya
South West Centre for Reproductive Medicine, Derriford Hospital, Plymouth, UK
Experience of a weight management clinic
How it was set up
What was undertaken
Results
Points that were successful
Points that did not work
Learning points
Strategies for weight management
Plenary 1: Recreational drugs and fertility
The endocannabinoid system in reproductive biology: looking at both sides of fertility
M. Maccarrone
Department of Biomedical Sciences, University of Teramo, Italy, and IRCCS Neurological Institute C. Mondino Foundation, Rome, Italy
Mammalian reproduction is a complicated process designed to diversify and strengthen the genetic complement of the offspring. An emerging concept in mammalian reproduction is the role of endocannabinoids, a group of endogenously produced lipid mediators, that bind to and activate cannabinoid receptors. Although adverse effects of cannabinoids on fertility have been implicated for years, the mechanisms by which they exert these effects were not clearly understood. With the identification of cannabinoid receptors, endocannabinoid ligands, their key synthetic and hydrolytic pathways, and the generation of mouse models missing cannabinoid receptors, a wealth of information on the significance of cannabinoid/endocannabinoid signaling in spermatogenesis, fertilization, preimplantation embryo development, implantation and postimplantation embryonic growth has been generated. This lecture will focus on various aspects of the endocannabinoid system in reproductive biology, covering both male and female fertility. It is hoped that a deeper insight would lead to potential clinical applications of the endocannabinoid signaling as a target for correcting infertility and improving reproductive health in humans.
The effects of alcohol in pregnancy and the subsequent child
M.L. Plant
Centre for Clinical and Health Services Research, University of the West of England, Bristol, UK
Over the past twenty years there has been a steady increase in heavy drinking and alcohol-related problems in women of childbearing age in the United Kingdom (UK). This is particularly true of women in the younger age range. Recent research suggests that teenage girls in the UK are now even more likely to drink in ‘binges’ than are their male counterparts. Heavy drink in pregnancy carries a risk for both mother and baby. Alcohol-related damage ranges from the severe end of the spectrum known as Fetal Alcohol Syndrome (FAS) to individual alcohol-related birth anomalies first described in the early 70's. This syndrome is still rarely diagnosed in the UK and other European countries, unlike North America. The features of what are now referred to as Fetal Alcohol Spectrum Disorders (FASD) will be described and the longer term harm to the affected child will be discussed. This presentation is a review of available evidence. Heavy drinking during pregnancy can cause severe, permanent damage to the child. The implications of this will be discussed.
Support of the drug-using mother and subsequent child
H. Caroll
Manchester Specialist Midwifery Service, Zion Community Resource Centre, Hulme, Manchester, UK
The session will include: How the Manchester Specialist Midwifery Service supports the drug-using mothers by providing an appropriate accessible and family focused service. This embraces all aspects of a vulnerable and socially excluded lifestyle whilst encouraging and enabling clients to think beyond their immediate needs.
Patrick steptoe memorial lecture
Food, fat and fertility
S. Franks
Imperial College Faculty of Medicine, University of London and St Mary's and Hammersmith Hospitals, London, UK
Nutrition has a major impact on reproductive function. Given the high energy-cost of pregnancy, it is not surprising that there is a close relationship between nutritional status and reproductive function. The effects of under-nutrition on ovarian function in women involve a clear-cut hypothalamic mechanism that is best illustrated by amenorrhoea associated with anorexia nervosa in which there are profound abnormalities in the pulsatile pattern of gonadotrophin secretion. The cytokine hormone, leptin, produced by adipocytes, may be an important mediator, ‘reporting’ nutritional status to the hypothalamus. The effects of ‘over-nutrition’ on reproductive function are less well understood but, in this case, direct ovarian actions of metabolic hormones are likely to be more influential than hypothalamic effects. Obesity is also associated with anovulation. Obesity per se may have an adverse effect but there is an important interaction of obesity and polycystic ovary syndrome (PCOS), the most common cause of anovulatory infertility. Weight gain in women with PCOS is characterized by a disproportionate decrease in insulin sensitivity and a reciprocal increase in serum insulin concentrations. Insulin appears to have an important role in human ovarian function. Insulin, in physiological doses, stimulates follicular steroidogenesis. Furthermore, insulin enhances the action of LH on steroidogenesis in a synergistic fashion so that, at concentrations which mimic the levels in women with PCOS, LH-induced oestradiol and progesterone production are enhanced 15 – 20 fold. We suggest that this interaction of insulin and LH is instrumental in the aetiology of anovulation in PCOS. In summary, negative energy balance is associated with impairment of the hypothalamic regulation of gonadotrophins whereas calorie excess is more likely to involve a direct effect on the ovary in which insulin is the key metabolic hormone. Thus both extremes of nutritional status have a negative impact on fertility.
Consent issues for nurses in the 21st century
Embryology update
A. Glew
The Essex Fertility Centre, Holly House Hospital, High Road, Buckhurst Hill, Essex, UK
The advancing face of embryology can be a daunting area when counselling patients for consenting to particular parts of their treatment plan. In recent years we have seen the rise and fall of assisted hatching, the increasing demands for moving towards single embryo transfer and still the debate continues as to whether blastocyst is the way forward. All these techniques will incur some form of decision making clouded by the interaction of both clinical judgement and patient choice This paper will discuss these issues and touch on some of the more recent and pending introductions likely to affect the way we counsel our patients.
21st century technology: PGD
M.E. Jamieson
Assisted Conception Service, Glasgow Royal Infirmary, Glasgow, UK
Preimplantation Genetic Diagnosis (PGD) was developed as an alternative to prenatal diagnosis. It is appropriate for a small number of patients who are at risk of passing on a serious genetic disease and allows diagnosis before embryos are replaced in the uterus and a pregnancy is established. The technique involves ovarian stimulation, IVF or ICSI and biopsy when either one or two cells are removed from the embryo. Two main types of tests are used, fluorescence in situ hybridisation (FISH) or techniques such as the polymerase chain reaction (PCR) which amplify a single gene. Despite PGD involving many of the same processes as IVF it is a genetic diagnosis and not a treatment for infertility so the patients and issues arising present a different challenge to the fertility clinic.
Obtaining consent for 21st century technology
H. Walton
National Service for Preimplantation Genetic Diagnosis, Glasgow Royal Infirmary, Glasgow, UK
Preimplantation Genetic Diagnosis (PGD) was originally developed for couples with an increased risk of having a child with a serious genetic disorder who do not wish to consider prenatal diagnosis with the possibility of having to terminate a pregnancy. The range of disorders has now been extended to include diseases with lower penetrance and HLA typing. Couples who require PGD have a long and complicated process to follow, since at every stage of their treatment there is a risk of cancellation. The nurse needs to explain not only the IVF or ICSI treatment process, but also all the stages involved in PGD. The couple will then be able to give informed consent to all the possibilities that can happen during treatment. Even when a pregnancy is achieved, pre-natal diagnosis with chorionic villus sampling (CVS) or amniocentesis must be considered, not only to confirm the PGD diagnosis but also in the context of any other risks e.g. maternal age.
Embryology and andrology
Where have we come from? Nonreproductive tissue banking in the UK
H. Gillan
NBS Tissue Services, Wakefield Tissue Bank, Pinderfields Hospital, Wakefield, UK
The regulatory framework within Tissue Banking has developed rapidly from what was described as a “cottage industry” of bone banks within hospital theatres to a sophisticated European Directive for Cells and Tissues within the space of 10 years. The drivers for this change came from within the industry but only the scandals at Alder Hey and Bristol have ensured that there is now legislation rather than voluntary schemes. Tissue Banking was inspected to the Code of Practice for Tissue Banking which is based on ISO 9001:2000 and GMP. This has recently been replaced by the European Directive for Cells and Tissues and the Human Tissue Act. Licences will be issued by the Human Tissue Authority who are the competent authority. The environment in which tissues are processed has been revolutionised over the past 15 years and we now process in Grade A safety cabinets with Grade B Clean Room backgrounds. Although this has increased the safety of tissue products it has also led to inspections similar to that of pharmaceuticals which can result in the over specifying of products which are retrieved in mortuary conditions and are therefore innately contaminated. This has led to much debate throughout tissue banking and this presentation will aim to explain how this has occurred and provide some insight into how regulation could affect reproductive tissue banking.
Where are we going? the EU directive and assisted reproduction
J. Dimond
Human Fertilisation and Embryology Authority, London, UK
By 7th April 2007 all clinics carrying out donation, procurement, testing, processing, preservation, storage and distribution of gametes and embryos must be licensed under the EU Tissue and Cells Directive. All relevant clinics will receive an HFEA inspection under the Directive between April 2007 and April 2009. In working to achieve this, the HFEA aims to minimise the additional regulatory burden wherever possible, subject to the constraints of the legal requirements. Measures include streamlining licensing and inspection under the Directive with the existing regulatory framework. Also by issuing clear outcome focussed standards upon which compliance will be based and which avoid prescription beyond the mandatory requirements of the Directive. The HFEA is combining the Standards and the Code of Practice to produce one standards document containing requirements of both the Directive and the HFE Act. Meanwhile, clinics are implementing quality management systems, and other new requirements set by the Directive, such as third party agreements and full traceability of data relating to quality and safety. The HFEA Assisted Conception Standards set the format for a quality system that applies to ART services. Implementation of the Directive will change the regulatory framework in that regulation now extends to services involving fresh gametes such as IUI. However, it is expected that the transposition regulations will mean that all clinics have to be inspected at least every two years, instead of annually. There is also a shift towards greater ongoing collaboration between the HFEA and professional bodies, in setting the standards that clinics are expected to meet. The Directive introduces complex issues and considerable work for the ART sector. However, in the long term it is hoped that patients will reap the benefits through the consistent high quality level of care that will result from the Directive's emphasis on quality, safety, and continual improvement.
How might we get there? Implementation of a near GMP facility in Sheffield
R. Cutting
Assisted Conception Unit, Centre for Reproductive Medicine and Fertility, The Jessop Wing, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
In order to comply with the forthcoming EU tissue banking directive and to reach standards suitable for ‘supernumerary’ embryos to be donated to the Centre for Stem Cell Biology, University of Sheffield, GMP laboratory, a program to upgrade our IVF laboratories commenced in January 2005. The complex process of IVF can not be slotted into simple process flow as with the manufacture of a pharmacy product. Weekly design meetings with the clean room contractor and validation consultant enabled solutions to be found with respect to the process of IVF and the possibility of working toward GMP without compromising patient treatment. The design stage included making decisions on the grade of air within the facility and change system to achieve this. Process flow was considered, with specific plans drawn for the movement of consumables, waste, samples, equipment and liquid nitrogen within the lab suite. A full monitoring system was designed and integrated in the facility. The build took 6 months to complete with full validation of facility and equipment during a two week shut down. Treatments recommenced in October 2005. The environment has lead to different working practices. For example, consumable storage is limited within the suite and consumables are managed in a consumable prep room. Maintaining the environment is more time and labour intensive. Currently, although we have grade B air supply to our facility we are wearing grade C clothing and paper notes are still used for witnessing. Even with this compromise we are able to maintain a grade A environment within our flow hood. More importantly stability in pregnancy rates was achieved during the build and our initial results show that it is possible to deliver a successful IVF service within a clean room environment.
Tubal disease and ART
Tubal disease: incidence, aetiology and classification
P. Wardle
Department of Obstetrics and Gynaecology, Southmead Hospital, Bristol, UK
Tubal damage is a common cause of infertility. It is identified in 15 – 20% of couples attending specialist fertility clinics and is responsible for 25 – 35% of female infertility. A variety of pathologies may lead to partial obstruction or complete occlusion of the fallopian tube with damage restricted to the proximal or distal segments, or involving multiple sites along the whole tube. Pelvic inflammatory disease (PID) is the commonest cause, responsible for more than 50% of tubal disease. It is always bilateral and usually involves multiple sites. The risk of tubal damage has been estimated at 11%, 23% and 54% after one, two, or three episodes of PID. Proximal tubal disease may also result from congenital malformations, endometriosis, salpingitis isthmica nodosa, polyps or intratubal debris. Apart from PID, distal tubal disease may be due to adhesions from previous peritonitis, previous surgery or endometriosis. There are a variety of methods for assessing tubal damage, including laparoscopy with dye hydrotubation, hysterosalpingography (HSG), sonohysterosalpingography and chlamydia serology. However, most classification systems are based on visual assessment at laparoscopy alone. By not taking account of other factors (such as chlamydia serology, past obstetric history or the appearance of the endosalpinx at HSG), these classification systems are unreliable guides for prognosis, for selection of patients for surgery, or for comparison of results between different clinics or with different techniques. Development of a comprehensive classification of tubal damage would be useful for research studies. However, the multifactorial nature of tubal disease would inevitably make this too complex for routine clinical practice. The best option for classification at present would be a simple model to differentiate those with a favourable prognosis from those with an unfavourable prognosis. The ‘Hull and Rutherford’ classification provides this, with an intermediate group where additional factors might then be used to decide whether surgery or IVF is appropriate.
Investigation of tubal status in the infertile couple
S. Papaioannou
Department of Obstetrics and Gynaecology, Heart of England Foundation NHS Trust, Birmingham Heartlands Hospital, Birmingham, UK
Tubal disease is a contributor to the presentation of 25 – 35% of infertile couples. The incidence of proximal tubal blockage (an important distinction) has been estimated at 10% to 25% of the total number of cases of women with tubal disease. The historical evolution of the multitude of tubal assessment tests that have been described is fascinating. From Rubin's test to the injection of radioactive material into the uterine cavity to contemporary alternatives like selective salpingography, salpingoscopy, falloposcopy and fertiloscopy, the quest for the perfect tubal assessment test has strived to improve on the safety, accuracy, reproducibility, effectiveness, predictive value and cost of each suggestion. The evidence base (or absence thereof) for each test in these categories is presented. The availability of this variety of tests is a witness to the shortcomings of each one of them. The NICE fertility guideline recommends hysterosalpingography as the default test for tubal patency. Laparoscopy and dye, still regarded as the ‘gold standard’ with which all other tests should be compared, is reserved for the investigation of infertile women with suspected co-morbidities. These time honoured techniques are not without their own shortcomings however. Hystero-Contrast-Sonography is also recommended as an alternative to hysterosalpingography. The evidence base for these tests, wider compared to the competitors, is presented. The Fallopian Tube, the cradle of fertilisation, with its unique anatomy, physiology and function is a lot more complicated a structure than a tube, that is a simple conduit of fluid. Our routine clinical practice of flushing fluids through the Fallopian Tube therefore reflects a basic patent or blocked, white or black description, which does not elaborate on the complexities of tubal function. The measurement of tubal perfusion pressures at selective salpingography and the technique of microsalpingoscopy or fertiloscopy are proposals for a more comprehensive, functional tubal assessment.
Ectopic pregnancy: medical treatment vs surgery with or without preservation of tube
Y. Cheong
School of Medicine and Biomedical Sciences, Academic Unit of Reproductive & Developmental Medicine, Jessop Wing, Sheffield, UK
The incidence of ectopic pregnancy is increasing, mainly due to the increased incidence of pelvic inflammatory disease. Tubal pregnancy can be managed by laparotomy, operative laparoscopy, medically and occasionally by observation alone. Management must be tailored to the clinical condition and future fertility requirements of the woman. In selected cases medical management can be as effective as laparoscopic salpingostomy/salpingectomy. There is no clear evidence that salpingotomy should be used in preference to salpingectomy; salpingostomy should be considered in the presence of contralateral tubal disease for fertility reasons. Conservative surgery results in slightly higher rates of intrauterine pregnancy and higher recurrent ectopic pregnancies.
Career prospects for the reproductive medicine specialist
J. Stewart
Newcastle Fertility Centre, International Centre for LIFE and Royal Victoria Infirmary, Newcastle upon Tyne, UK
The aim of this talk is to discuss the career prospects for Gynaecologists with an interest in reproductive medicine. There are openings for such doctors in the research setting, following a special interest and as a subspecialist both in the NHS and private sectors. I hope to address this subject in the context of training and accreditation, job opportunities, and the political climate all of which may affect the way our careers develop over the coming years.
Working as a subspecialist in reproductive medicine
M.C. Davies
Reproductive Medicine Unit, University College London Hospitals NHS Trust, London, UK
A subspecialist is usually defined as someone who spends at least half their working week in their field of expertise. Not all subspecialty trainees will take up subspecialist consultant posts. The job market in O&G has not provided enough posts for subspecialists, particularly in our field. The government's promise of increased IVF provision has not really been translated into extra consultant posts. Some trainees have gone straight into subspecialist posts, some to academic posts, a few to specialist practice in the private sector, and some to mixed NHS posts. Over time, jobs evolve and special interests develop. Referrals come in to consultants running a good service and inevitably your subspecialist practice will grow. Helping patients by utilising specialist knowledge and skills is the cornerstone of medical practice, and for most of us this brings the greatest personal reward. Subspecialists will often be solving problems that others cannot. Within the field of reproductive medicine, most subspecialists will have a particular interest – IVF, or menopause, or laparoscopic surgery – that dominates their clinical practice. Developing a regional or national service is usually strongly linked to research and a teaching hospital base. Even less ambitious consultants can maintain clinical research, with the academic component of subspecialty training as a basis. Business acumen is not tested at medical school but is remarkably useful, and not just in private practice. Finance and marketing count in the world of IVF contracting – and convoluted R&D applications. Training others was a Hippocratic duty, and directing a subspecialty programme is hugely enjoyable as well as being a good way to keep up to date. Running a department may extend into running the profession – subspecialists often appear in national committees, they lead the specialist societies, they are influential in the HFEA. One needs to get out of the hospital occasionally, and ski trips are compulsory.
Plenary 2: Delayed parenthood
Qualitative aspects of oocyte development and ageing
R.G. Gosden
Weill Medical College of Cornell University, New York City, USA
Selection of the embryo(s) with the highest implantation potential for transfer is a key goal for reducing the risks of multiple pregnancy and minimising the chances of pregnancy loss. For reasons that are still unclear, embryo quality judged by clinical and biological criteria is poorer on average in humans than laboratory animals and declines steeply with maternal age. Whilst aneuploidy, polyploidy and mosaicism are common, apparently diploid embryos also frequently fail to establish pregnancy. The oocyte is held to be more responsible than the sperm in view of the age factor and because it contributes the bulk of cytoplasm, including mitochondria for which there is theoretical and experimental evidence of involvement in embryonic loss and aneuploidy. For practical reasons, it is easier to assess embryo than oocyte quality, and three strategies are available:
Morphological observations show a higher rate of blastocyst development when (a) the first cleavage is 24 – 26 hours post insemination/ ICSI, (b) there is no multinucleation, and (c) <20% fragmentation at the 2-cell stage and no fragmentation before cleavage. Attainment of 8 cells by the morning of day 3 was associated with a higher blastocyst rate than either a slower or faster rate of development. We were unable to confirm a correlation between pronuclear distribution or alignment and day 5 development. Time-lapse videomicrography should help to clarify the value of morphological observations, though it is unsuitable for routine clinical monitoring.
Non-invasive monitoring of the culture medium offers an attractive strategy, and more research is needed to evaluate the main candidates, including carbohydrates, amino acids, reactive oxygen species and HLA-G.
Blastomere biopsy for aneuploidy screening is increasingly practised, but still has important technical shortcoming and it is desirable to avoid invasive methods if other, equally effective methods can be discovered.
Delayed parenthood
M.C. Davies
Reproductive Medicine Unit, University College London Hospitals NHS Trust, London, UK
The rate of pregnancies for women in their thirties has overtaken that for younger women for the first time. First births to the over-35s increase year on year. Behind these statistics is a hidden well of suffering for those couples who have left it too late. Although improved population health is associated with falling age at menarche, the age of menopause is unchanged. Fertility is usually lost 8 – 10 years before menopause. Our methods of assessing ovarian function have become more sophisticated but ovarian failure remains an untreatable condition. ART practitioners deal with the consequences daily. A woman's age is the best single predictor of success in IVF. NHS funding stops at age 40. Egg donation is the end of the road; it is unacceptable to many couples, and unaffordable to most. Britain's oldest mother went to Moscow and others go to Spain, Israel and the States. The outcome of late pregnancy is poorer. Miscarriage and ectopic pregnancy are more common. Fetal chromosomal anomalies rise. Gestational diabetes, hypertension, abruption and placenta praevia and pre-term delivery all increase. A small but definite rise in perinatal mortality attributable to delayed childbearing can be detected, even though the trend of late childbirth has been led by healthy women with higher income and education. It has also contributed significantly to the rising Caesarean section rate. The intention of this talk is not to blame women. The reasons for delayed parenthood are complex: availability of contraception, financial insecurity, career advancement, breakdown of relationships … these issues deserve further sociological research. Providing information on the medical consequences of delayed conception may help couples to plan their lives, to have children in the safest years from 20 to 35, and avoid the heartbreak of infertility and pregnancy loss.
Family environment and parent-child well-being in younger and older IVF mothers
J. Boivin
School of Psychology, Cardiff University, Cardiff, UK
Objective. IVF is increasingly used to by-pass age-related infertility in couples who try to conceive late in the reproductive life cycle of the woman. In the present study we investigate the impact of age by comparing family environment, parental and child well-being in younger and older women using IVF.
Methods. Participants were parents whose first child was conceived using IVF. The children were aged five to nine years. Women were categorised into age groups according to age at first delivery with the Younger group being <32 years (n = 98) and the Older group being >38 years (n = 77). Mothers and/or fathers completed a questionnaire about demographic (e.g. age, education, income) and medical (e.g. labour and gestational complications) characteristics as well as family environment (e.g. warmth, hostility), parental well-being (e.g. depression, aggression) and child well-being (e.g. concentration, anxiety). All items were drawn from well-validated questionnaires with good psychometric properties. Fertility clinics posted the questionnaire to families who returned completed questionnaires in the stamped pre-addressed envelopes provided.
Results. As expected, age parameters were significantly different (p < 0.001) between the Younger (M = 30.1, SD = 1.6, range 25 – 32 years) and Older age group (M = 40.5, SD = 3.3, range 38 – 54 years) (t(173) = 27.56, p < 0.001). Older women had been married for longer (t(158) = 5.31, p < 0.001), were more likely to have a university degree (c2(1) = 7.01, p < 0.001) and had a higher family income (c2(3) = 12.26, p < 0.05) than did younger women. Older women were more likely to have had oocyte or embryo donation than younger women (c2(3) = 20.45, p < 0.001), who were more likely to have used their own gametes. Older women were more likely to have had bleeding during the pregnancy (c2(1) = 9.34, p < 0.002), to have had a planned caesarean (c2(1) = 7.34, p < 0.007) and to have breastfed (c2(1) = 3.21, p < 0.10) than younger women. The latter were more likely to have twins than older women (c2(1) = 4.62, p < 0.05). In terms of family environment, older women were more positive about their interactions with their child (t(173) = 1.96, p < 0.05) than younger women, but couples in these families were not as warm (e.g., expression of affection, support, appreciation) toward each other than couples where the mother was younger at first pregnancy. Specifically, women in the Older group expressed less warmth toward their partner (t(161) = 1.64, p = 0.10) and perceived their partner to be less warm toward them (t(162) = 2.97, p < 0.003) than did women in the Younger group. Fathers in the Older group expressed less warmth toward their child (t(128) = 1.85, p = 0.10), toward their partner (t(124) = 3.19, p < 0.002), and perceived their partner to be less warm toward them (t(124) = 2.78, p < 0.006) than did fathers in the Younger group. Child well-being measures showed that fathers in the Older group perceived their child as being less attentive and more impulsive and overactive (t(125) = 2.09, p < 0.039) than did fathers in the Younger group. Parental wellbeing measures showed that Older mothers reported more depressive symptoms (t(172) = 2.42, p < 0.016) than did mothers in the Younger group. Multivariate discriminant analysis examining these variables as a group while controlling for years married was significant (c2(13) = 60.76, p < 0.001) and showed that high maternal depression and lack of paternal warmth in the marital relationship were the key factors discriminating between Younger and Older groups. Group centroids on this discriminating dimension showed that Older women scored significantly more poorly (centroid = .915) on this dimension than did Younger women (centroid = .656). Similar results were obtained in a discriminant analysis controlling for type of IVF.
Conclusions. Family environment and maternal well-being does differ according to maternal delivery age and this association is not due solely to longevity of partnership or use of donated female gametes. Further prospective work needs to determine whether this couple profile (high maternal depression, low paternal warmth in the couple relationship) was present at the start of fertility treatment or whether it is a consequence of reproducing late in the female life cycle.
Social egg freezing
G. Lockwood
Midlands Fertility Services, Aldridge, West Midlands, UK
The first human live births resulting from previously frozen oocytes date from the late 1980s when Chen utilized a freezing protocol that had proved successful with murine oocytes. Despite these initial successes, the technique was not widely adopted due to poor reproducibility of results, poor oocyte survival post thaw, low fertilisation rates and anxiety about cyto-skeletal damage. At that time it was estimated that 100 healthy oocytes were required to assure one live birth. There are five major areas in fertility treatment in which oocyte cryopreservation may be appropriate, and the first four are, I believe, non-controversial. Oocyte cryopreservation for young, single women about to undergo oncological therapy offers them a chance of a future genetic pregnancy. Whereas the types of cancers considered suitable for oocyte cryopreservation were initially restricted to the haematological (leukaemia, Hodgkin's and non-Hodgkin's lymphoma), or non-hormone dependent cancers (bowel, osteoma or sarcoma), the increasing prevalence of nulliparous women with pre-menopausal breast cancer (25% of diagnoses are in pre-menopausal women) has resulted in a relaxation of the previous rule that women with this diagnosis must never be treated with gonadotrophins. Increasingly, many oncologists take the view that as long as chemotherapy is commenced immediately after ovarian stimulation and oocyte retrieval has been performed, transient hyper-oestrogenaemia does not damage her prospect of achieving remission or cure. Oocyte cryopreservation in preference to IVF with cryopreservation of super-numery embryos may also be the choice of couples for religious or ethical reasons. Oocyte cryopreservation may come to be seen as a method by which the costs and risks of ovarian stimulation and oocyte retrieval can be minimized while still allowing the couple a cumulative chance of pregnancy equivalent to that achieved with repeated transfer of frozen embryos. ‘Poor ovarian reserve’ associated with a low response to ovarian stimulation and the production of a few oocytes, often of poor quality, is an increasingly common diagnosis in tertiary level fertility clinics. Some, but not all, of these women will be seeking to conceive in their late thirties or early forties and many will be aware that their best, if not their only chance of conceiving lies with the use of donor eggs. The use of oocyte cryopreservation techniques would allow ‘egg banks’ to be established and this would allow for quarantining of oocytes, allow for better ‘matching’ of donor and recipient, avoid the need for extended HRT to ‘schedule’ recipients' cycles and ensure anonymity. The successful endocrine treatment of girls with Turner's Syndrome (1 in 2000 live births) resulting in normal growth patterns and secondary sexual characteristic development is a real success story for gynaecological endocrinology. 95% – 98% of these young women will be sterile and require donor eggs to achieve pregnancy. If their mothers were offered oocyte cryopreservation at the point of their daughter's diagnosis then this would offer a prospect of motherhood with genetic identity that many would welcome. The prospect of women who are not in a position to embark on pregnancy now, but wish to become mothers in the future, choosing to have their eggs frozen as an ‘insurance policy’ against future sub-fertility has engendered the greatest disquiet about the technology of oocyte cryopreservation. Women are generally aware of the difficulties and dangers of late pregnancy; the delay in conceiving, the risk of miscarriage and chromosomal abnormality. In the UK 15% of all babies are born to women aged 35 and over and 9% of all first live births are to women in this age group. These are the lucky ones that actually have babies. There are many more that conceive and miscarry, or never even conceive. It is clear that a woman is far more likely to achieve a successful pregnancy aged 40+ with her own oocytes that were cryopreserved in her 30s than with her own ‘time expired’ oocytes in her 40s.
Howard Jacobs president's lecture
The role of the oocyte in regulating follicular development in mammals
K.P. McNatty
Wallaceville Animal Research Centre, Upper Hutt, New Zealand and School of Biological Sciences at Victoria University of Wellington, New Zealand
In mammals, ovarian follicular growth begins in late fetal or neonatal life and most stages (i.e. >80% of development) occur independently of the time of the menstrual or oestrous cycle, pregnancy or lactation. Moreover, apart from the final phases of growth when pituitary hormone support is essential, ovarian follicular development is thought to be regulated primarily by intraovarian factors. From gene-knockout studies in mice, naturally-occurring genetic mutations in sheep and humans and physiological studies in sheep, it is now evident that the oocyte plays a major role in orchestrating the growth of the follicle from the time primary follicles are formed and most likely continuing until ovulation and the follicular luteinisation process. During follicular growth, the granulosa cells immediately adjacent to the oocyte develop more specialised functions directly responsive to the oocyte and are referred to as cumulus cells, whereas the granulosa cells more peripherally located, become increasingly responsive to, and interactive with, the extra-ovarian endocrine system. Two oocyte-derived factors important for determining these follicular cell phenotypes are growth-differentiating factor 9 (GDF9) and bone morphogenetic factor 15 (BMP15). These and possibly other oocyte-secreted factors are thought to regulate metabolic co-operativity between the granulosa/cumulus cells and the oocyte and also to regulate the proliferation, steroidogenic activity and the responsiveness of granulosa cells to gonadotrophins. In sheep, both GDF9 and BMP15 influence the number of follicles maturing to ovulation in a dose dependent manner and BMP15 is known to achieve this by altering the responsiveness of follicles to gonadotrophins whereas the role of GDF9 in this process is not known. In humans, mutations in BMP15 are associated with infertility but the role of GDF9 remains uncertain. More information on these and other oocyte signalling molecules will provide new opportunities for fertility management and assessment of oocyte quality.
A review of the current literature on surrogacy
O.B.A. van den Akker
Psychology Institute, Aston University, Birmingham, UK
This review addresses the psychosocial research on surrogacy triads, the Surrogate relinquishing mothers, the Commissioning recipient mothers and offspring, and shows the main concerns of the research focused on the identification of shifting trends in the use of surrogacy over time in relation to a number of specific issues; attachment in and disclosure to surrogate offspring; the experiences of surrogate mothers relinquishing surrogate babies – particularly the motivations of surrogates; and changes in profiles of recipients of surrogate babies – the commissioning mothers. A number of sources were used to search the literature, including, Medline, Science Direct and PsychLit. Other references came from a number of books, including Leiblum (Citation1998), Hammer-Burns and Covington (Citation1999) and van den Akker (Citation2002). Virtually all studies used highly selected samples making generalizability difficult. There was a notable lack of theory, no RCT's or interventions, and only a handful of semi-epidemiological studies or studies comparing different populations. Few studies specifically questioned the meaning of and need for a family, or the influence and impact professionals, treatment availability and financial factors have on the choices made. Societal attitudes have changed dramatically in accepting single parent families, divorced, step, gay and otherwise constructed families. The review has demonstrated that the majority of infertile populations seeking to overcome infertility appear to value a maximum genetic link. Couples opting for surrogacy are cognitively much more comfortable with their unusual method of creating a family, and like divorced, gay, or adoptive families, have no problems showing this openly to those around them, although there are exceptions.
The function of surrogacy agencies
R. Carter
Childlessness Overcome Through Surrogacy (COTS), COTS Support Office, Skelton, North Yorkshire, UK
Surrogacy agencies induct and vet couples who want to have surrogate babies and link them with women who want to act as surrogate mothers. They also offer advice about the process and support from first meeting through conception, pregnancy and on to eventual handover and guidance regarding the legal process. COTS (Childlessness Overcome Through Surrogacy) is the largest surrogacy agency in the United Kingdom with around 160 active surrogates and almost 250 intended parent couples on its register. Paramount amongst COTS functions is the development of strategies which aim to ensure, as far as possible, that surrogate mothers hand over the babies to whom they have given birth to the couples who wish to parent them. Since 1988, when COTS formed, over 580 surrogate babies have been born via the agency and, in fact, very few have been kept by their surrogate mothers.
The role of children's reporter in parental order applications for children conceived through surrogacy arrangements
A. Haigh
C.Q.S.W. Service Manager of Barnardo's Family Connections, Ilford, Essex, UK
The role and task of the Children's Reporter
The legal framework
Practice issues arising out of working with commissioning families and surrogates
The identity needs of the individual throughout their life
Counselling in surrogacy arrangements
J. Williamson
Aberdeen Fertility Centre, Aberdeen Maternity Hospital, Aberdeen, UK
Surrogacy is a complex and emotionally charged arrangement that requires patience, commitment and a great deal of trust between all parties involved. Within the Fertility Centre setting such arrangements inevitably involve staff in a wide range of both practical and ethical considerations. The counsellor's role provides an independent and impartial source of support and help throughout the process. The implications of such an arrangement are complicated and far reaching. The session will explore these and the impact on the host surrogate, the commissioning couple (person) and the potential child and their immediate family and friends as well as the wider community. This is often conducted in an atmosphere of some client resistence to perceived interference. The areas explored will cover: review of Aberdeen's surrogacy arrangements over the past 9 years; who, why and how people arrive at the clinic to consider such an arrangement; the implications for all those involved; the before, during and after support for all those involved. There will be an opportunity for members of the audience to ask questions at the end of the session.
Managing surrogacy arrangements in licensed centres
A.E. Mowforth
Jessop Wing, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Surrogacy may be one of the most challenging areas of work in the Assisted Conception Unit. Technically it is not a difficult treatment and most often will only require standard elements of clinical and embryology management, but it is the working with several individuals that brings the challenge. Theoretically, all have a common goal, but practically they all approach from different angles. As team players they strive to work together but the comfort level is not always there for them or for the Health Care Professionals who attempt to manage the different elements of their treatment. Good surrogacy team work is a pleasure to be involved in; taking the time to give multidisciplinary care and support to all parties goes a long way towards building such a team. Counselling and Specialised Nursing skills are of paramount importance for the smooth running of surrogacy arrangements. This talk will discuss several surrogacy cases; covering basic medical history (reasons for surrogacy treatment); relationships of the parties involved; treatment planning and time scales; areas of concern for the professionals; areas of concern for those in treatment; outcomes and follow-up.
Ethics meeting: Fertility, feminism and the future
PGD and the facilitation of choice: the health care professionals' perspective
B. Farsides
Clinical and Biomedical Ethics, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
This paper reports on a study involving members of two pre-implantation diagnosis teams (Wellcome Trust Biomedical Ethics Project Facilitating choice, framing choice: experiences of staff working in pre-implantation genetic diagnosis Wellcome Trust Biomedical Ethics Project Grant no: 074935). Amongst other issues the study considered the individual team member's moral attitudes to the work that they do and the tensions that can arise when their own views conflict with those of other professionals or clients. The data shall be considered in the context of a discussion of women's choices regarding reproduction. Two medical sociologists Dr Clare Williams and Dr Kathryn Erich conducted an ethnographic study within the two units and interviewed staff members using a semi-structured interview schedule. These transcripts were studied by Prof Farsides who then conducted ethics discussion groups with the interviewees. The groups were evaluated by participants. Data was used to identify themes and issues of common concern. Individual staff members generally see PGD as offering valuable choices to their clients but vary in their moral attitudes to the actual choices couples could and do make in the context of PGD. Many favour the presence of strict regulation, and wish to place limits on what they seek to achieve in terms of testing in the future.
Fertility treatment and human rights
S. McLean
Institute of Law and Ethics in Medicine, Glasgow University, Glasgow, UK
It is not uncommon to hear discussion of the so-called right to reproduce. In this paper, it will be argued that no such right can reasonably be said to exist in a positive form. This language, therefore, is unhelpful in attempts to secure access to infertility services for the infertile, or indeed for those who wish to gain access to the services for other reasons. However, once infertility services are made available, a number of human rights may be engaged; for example, Articles 8, 12 and 14. In this discussion, we will explore the extent to which legally guaranteed rights can serve to reinforce or expand the availability of treatment to those wishing to access it.
Fathers are from Mars, mothers are from Venus: gender asymmetry in reproduction
G. Lockwood
Midlands Fertility Services, Aldridge, West Midlands, UK
“Why can't a woman be more like a man?”
Alan Jay Lerner, My Fair Lady
Professional principles versus patient choice
J. Speirs
ESRC Innogen Centre, Edinburgh University, Edinburgh, UK
Patient choice has been made a significant part of contemporary health care policy and politics. In some situations, such as Single Embryo Transfer, it appears as if patient choice has become a challenge to professional values and knowledge, with consequent ambiguity about where risk-bearing and autonomy are located. Based on data from my doctoral research about the use of personal (“own known”) donors, I shall suggest that possible conflict between choice and professional principles is not a new feature of assisted reproduction and that part of the perceived challenge derives from differing cultural perspectives about what is involved in being a mother or father, that is, on what constitutes a parent.
The lady vanishes: egg procurement, ethics and reproductive research
D. Dickenson
Birkbeck Institute for the Humanities, University of London, London, UK
Opponents of stem cell research usually concentrate on the linked assertions that an embryo is either a human being or a potential human being, and that it is wrong to destroy a human being in order to produce stem cell lines. Proponents' positions are more varied, but not varied enough to escape a charge of obsession with the status of the embryo. What unites the two warring sides in the stem cell battle is that both ignore the question of exploitation of egg donors – which seems rather blinkered, given that enucleated ova remain crucial in stem cell research. Only with the recent ‘defrocking’ of Prof. Woo Suk Hwang and the revelation that he had wasted over 2,200 eggs, from donors who included his junior researchers, has popular debate begun to cover the issue of where the ova are to come from. What ethical and legal conditions should be place on egg procurement in reproductive research?
Parents in a petri dish: the challenge of artificial gametes
A. Smajdor
Medical Ethics Unit, Faculty of Medicine, Imperial College, London, UK
A number of papers over the past few years have described the successful derivation of egg and sperm precursor cells from mouse embryonic stem cells – so-called “artificial” gametes. Although many scientific questions remain, this research suggests numerous new possibilities for stem cell research and assisted reproductive technology, if a similar breakthrough is achieved with human embryonic stem cells. The novel opportunities raised by artificial gametes also prompt new ethical questions, such as whether same-sex couples should be able to access this technology to have children who are genetically related to them both. The effects of artificial gametes are likely to have a significant impact on women both from a fertility perspective, and in terms of women's status as egg donors for research. However, unease about the prospects of obtaining gametes from stem cell lines may hamper research. If women – and society as a whole – are to benefit from the potential of artificial gametes, we all need to demystify our attitude to gametes and to concepts of genetic kinship.
Oral abstracts
OC1: Knowledge and attitudes of university students regarding gamete donation and loss of anonymity
J. Broderick & C. Hayden
Reproductive Medicine Unit, The General Infirmary at Leeds, Leeds, UK
Introduction. In April 2005 the UK government introduced legislation to allow donor conceived persons access to identifying information about their biological parents. There has subsequently been a substantial decline in the number of people coming forward to donate gametes, limiting the provision of this form of assisted conception. This study assesses university student attitudes towards gamete donation and how a loss of anonymity and other factors may affect their decision to become donors.
Methods. A cross sectional survey was carried out on Leeds University students recruited from a second year lecture core to mathematics, psychology or medicine. Fifty structured questionnaires were handed out in each lecture and completed voluntarily and anonymously. Questions assessed how payment and anonymity, or lack of it, would affect a student's decision to donate gametes. Their attitudes towards the rights of people to information about their genetic origins, gamete donation in general and the moral responsibility of gamete donors was established. Questionnaires were analysed based on the university degree the participant was reading and by gender.
Results and discussion. A response rate of 83% (n = 124) was achieved. More females (25.3%) than males (16.7%) said they would never donate their gametes. Both male and female potential donors were most likely to consider future donation to a friend or relative. More male (42.9%) than female (22.5%) potential donors would consider donation if a child could contact them in the future. Two thirds of potential male donors would consider donation for payment whereas only 25% of potential female donors would. The findings suggest that male university students may still represent a potential source of sperm donors under the current law.
OC2: An audit of information received by fertility patients
N.J.L. Francis, M. Chetty, J. Elson, & J. Edmondson
Sunderland Fertility Unit, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
Introduction. Explanation and provision of information form integral parts of the doctor-patient consultation and have been documented as important to infertile couples. In a recent patient journey project carried out by City Hospitals, Sunderland, however, many infertile couples commented on the inadequacy of currently provided information. The aim of this audit was to assess the content, timing and effect of written information received by fertility patients, and whether it reflects what patients want.
Methods. This prospective audit included all new referrals and first follow-up patients attending consultant led fertility clinics at University Hospital North Durham and Sunderland Royal Hospital over a four week period. Following NHS Trust registration, audit standards were investigated and data collected by interviewing each patient along with their partner (if present). A standard proforma was used to guide the interview and record the findings.
Results and discussion. All patients fitting the inclusion criteria agreed to participate. 42 were classed as new referrals and 16 as first follow-ups. Overall 13 patients (22%) had received leaflets since seeking help. The level and quality of information obtained from these leaflets was considered acceptable by all patients and the majority of leaflets had an overall positive effect. However, this study has shown that no written information is being provided to infertile couples at the initial GP consultation, and that existing leaflets, when received, are not providing the information that patients want. The provision of new and improved leaflets from primary care should therefore ensure that the majority of patients receive relevant written information at the most appropriate time. These recommendations are going to be used by both Sunderland and Durham PCTs in producing new patient information leaflets.
OC3: Surrogacy: experience in an IVF center in the UK
M. Sadhukhan, G. Lockwood, & A. Epen
Midlands Fertility Services, Aldridge, UK
Introduction. The first successful birth in UK following IVF surrogacy was reported from Bourn Hall clinic in 1989. In 1990 HFEA clarified the legal aspects of surrogacy. Surrogacy can be natural where the surrogate also acts as the egg donor and host where the embryos from the commissioning couple are transferred to the surrogate's uterus. At Midlands Fertility Services host surrogacy programme was available from 1992. We conducted an audit to review and evaluate the experience of IVF surrogate programme.
Methods. Retrospective study of case notes of surrogates and commissioning couples. An independent counsellor sees the commissioning couple and the surrogate before treatment.
Results and discussion. During 1992 – 2006, 45 patients attended the clinic for host surrogacy. 20 went through the host surrogacy programme. 19 women changed their mind after the first visit or later on. 4 women were declined treatment for medical and 2 for social reasons. The surrogates were all parous with ages ranging from 23 to 53 and were the commissioning couple's relative (including mother), friend or met through COTS. The commissioning couples were mostly in their 20s and 30s. The indications for surrogacy were absence of uterus (congenital or hysterectomy), repeated IVF failures and severe medical condition incompatible with pregnancy. 20 surrogate hosts had 29 embryo transfer cycles from 18 commissioning couples. There were 5 live births from 4 pregnancies (1 twin and 3 singletons). There were no miscarriages or ectopic pregnancies. The live birth rate per commissioning couple was 22.22% and 20% per surrogate host. Interestingly the pregnancy rate per embryo transfer was 13.79 which is much lower than other IVF cycles. The average number of embryos transferred per cycle was 1.89 and in 7 cycles one embryo was transferred. The huge (nearly 50%) drop-out rate stresses the importance of careful and on-going counselling.
OC4: Amino acid profiling of bovine oocytes as a measure of developmental competence
K.E. Hemmings1, H.J. Leese2, A.H. Balen3, & H.M. Picton1
1Reproduction & Early Development Group, University of Leeds, Leeds, UK, 2Department of Biology, University of York, York, UK, and 3Reproductive Medicine Unit, Leeds, UK
Introduction. Assisted conception is hampered by low success rates and high multiple birth rates. We have previously shown that the amino acid turnover of Day 2 – 3 human embryos competent to develop to the blastocyst stage differ from those embryos that arrest. Since embryonic genome activation does not occur until the 4 – 8 cell stage in humans these metabolic differences are likely to originate from the oocyte. Therefore, using bovine oocytes as a model for human we sought to determine whether differences in amino acid consumption/production could be detected between oocytes.
Methods. Bovine oocyte cumulus complexes were matured in defined serum-free in vitro maturation media for 16 hours at 39°C in 5% CO2 in air. Oocytes were denuded and cultured for 6 hours in individual 1 μl microdroplets of modified maturation media. The oocytes were individually fertilized, and cultured in IVF media (Cook Australia Ltd, Melbourne) in 6% CO2, 5% O2 and 89% N2 for 8 days. It was possible to monitor each presumptive zygote's progression to the blastocyst stage by adhering each zygote to the Petri dish using CellTak™ tissue adhesive at a distance of 160 μm apart (Gopichandran & Leese, Reproduction 131, 269, 2006). The amino acid content of spent media was measured using a Kontron 500 HPLC system.
Results and discussion. 200 oocytes were assayed and their developmental progress recorded. Serine, threonine and tyrosine all appeared in the media in significantly greater quantities in those oocytes that developed to the blastocyst stage compared to their counterparts that arrested (p < 0.05). When the amino acids were grouped according to their chemical characteristics there was a significant difference in the consumption/production of neutral amino acids. This data indicates that a link exists between amino acid metabolism and oocyte quality.
OC5: Advanced Glycation end products (AGE) and their receptor (RAGE) are present in diabetic sperm
D.A. Rogers1, I.M. Agbaje1, S. McCullough2, C.M. McVicar1, N. McClure1, & C. Mallidis1,2
1School of Medicine & Dentistry, Reproductive Medicine Research Group, Queens University Belfast, Institute of Clinical Science, Grosvenor Road, Belfast, BT12 6BJ, UK, and 2Department of Anatomy, Queens University Belfast, Medical Biology Centre, Lisburn Road, Belfast, UK
Introduction. Diabetes Mellitus (DM) is increasing at an alarming rate with an estimated 221 million people worldwide becoming affected by 2010. At least 90% of Type 1 diabetics are diagnosed under the age of 30 making it a common systemic disease affecting men during their reproductive years. Our research group has found an increase in sperm DNA damage in diabetic men. There is accumulating evidence that AGEs are important pathogenic mediators of almost all diabetic complications whether directly or via its receptor. AGE's have been shown to cause DNA damage in a variety of cell types.
The aim of this study was to determine the presence and localization of Carboxymethyl lysine (CML the commonest AGE) and RAGE on human ejaculated sperm and to determine any differences in quantity and location of expression.
Methods. Semen samples were obtained from nondiabetic (n = 31) and diabetic men (n = 21). Following semen analysis sperm smears were prepared and protein extracted. Immunocytochemistry was carried out to localise CML and RAGE using polyclonal primary antibodies 4G9 (Courtesy of Dept of Opthalmology, QUB) and anti-human RAGE (R&D systems, Oxon, UK). Subsequently the number of positively stained sperm were counted, characterised and compared. RAGE concentration was determined using a Duoset ELISA Kit (R&D systems, Oxon, UK).
Results and discussion. CML was present on the head and cytoplasmic droplets of sperm. RAGE was primarily present as a band at the equatorial region of the head. There was a significant increase in mean percentage of RAGE positive sperm (61% in diabetics verses 20% in non-diabetics p < 0.01). A finding reflected in RAGE concentration (diabetic 0.104 ± 0.016 pg/mg vs non diabetic 0.048 ± 0.004 pg/mg of protein p < 0.0001). The presence of AGE together with the differential localization and up regulation of RAGE in Diabetic men may in part explain the increase in DNA damage observed in sperm of diabetic men.
OC6: Drugs and ovarian cancer – is there a link to infertility?
M. Godwin
Midlands Fertility Services, Aldridge, West Midlands, UK
One in six couples will seek help because of difficulty in conceiving (Balen & Jacobs, Citation2003). The media attention given to the conspicuous success of ‘state of the art’ fertility treatments has encouraged many couples who in former years would have tolerated their childlessness to access treatment (Lockwood, Citation1998), which is understandable given the negative effects of infertility (Gibson & Myers, Citation2002). Concern has developed over recent years that women who have undergone ovarian stimulation may be at increased risk of developing ovarian cancer. This obviously has huge implications for those who embark on fertility treatments. The purpose of this paper is to analyse and critique the research regarding the link between the use of fertility drugs and incidence of ovarian cancer. Ovarian cancer kills over 6000 women every year and the 5 year survival rate is less than 50% despite aggressive therapy (McGinn & Haylock, Citation1998). Most cases of ovarian cancer are seen in women after the menopause and average age at diagnosis is 59 – 64 years (Balen & Jacobs, Citation2003). Increased risk relates to the number of ovulations that have occurred (McGinn & Haylock, Citation1998). The purpose of fertility drugs is to achieve superovulation. In fertility treatment ovarian stimulation is initiated with a variety of different medication protocols. Human menopausal gonadotrophins (hMG's) or recombinant preparations are used to induce multiple folliculogenesis, together with gonadotrophin releasing hormone (GnRH) agonists, which has resulted in greater ease of planning super ovulation stimulation than was previously possible with Clomiphene Citrate and gonadotrophins (Tarlatzis & Kolibianakis, Citation2002). The theories that underpin the current research suggest that epithelial inclusion cysts formed at each ovulation are stimulated to undergo malignant transformation by gonadotrophins (Balen & Jacobs, Citation2003). Therefore agents which provoke multiple ovulation will increase the risk of ovarian cancer. This would appear to be a logical conclusion since the more ovulation a woman has the greater the risk of ovarian cancer. It has also been hypothesised however, that there is a genetic link and that infertility and ovarian cancer are consequences of a common underlying genetic abnormality (Ponder, Citation1996). It has been suggested that there are several common mutations that could allow for an unknown proportion of sporadic ovarian cancer (Nieto et al., Citation1999). This would suggest that if a woman is infertile she is already predisposed to ovarian cancer, and it is this and not fertility drugs that will place her at risk of the disease. When considering the published research it must be recognised that only now are the early users of fertility treatment reaching the peak incidence of ovarian cancer. Furthermore, it could also be hypothesised that many women who access fertility treatment will tend to be older, and will therefore not have the protection that parity offers. The sequence of infertility treatments must also be considered. Previous to GnRH agonists being used the majority of patients had already received unsuccessful treatment with Clomiphene therefore distinguishing between an effect of the various treatments and of persisting infertility will ultimately be difficult. Research carried out to assess the risks associated with Clomiphene found an associated risk with ovarian cancer particularly if more than twelve cycles were used. A cohort of 3837 women who had been evaluated for infertility between 1974 – 1985 were reviewed. A total of 11 cases of ovarian cancer were identified. Clomiphene had been used by nine of the cases, five of whom had taken it for more than 12 cycles. The association was evident in both parous and nulliparous women, and those with and without ovulatory abnormalities (Rossing et al., Citation1994). As a result the Committee on Safety of Medicines currently recommends that Clomiphene should not be used for more than 6 cycles (MacLean, Citation2002). Land (Citation1993) reported ten cases of ovarian neoplasia developing during, or soon after ovulation induction therapy. Each of the women had received two or three cycles of IVF. Willemsen et al. (Citation1993), described twelve patients in whom granulosa-cell tumour was discovered after ovulation stimulation with Clomiphene and/or gonadotrophins. The authors acknowledged that a causal link between tumours and the medication could not be proved however the findings caused the use of fertility Drugs and their effects to be evaluated more closely. Unfortunately the study had many limitations, firstly it relied purely on case studies, and eight of the patients had used both Clomiphene and hMG for varying numbers of cycles. Shushan et al. (Citation1996) also concluded that the use of ovulation induction agents may increase the risk of epithelial ovarian tumours. The case control consisted of two hundred women with a histological confirmed diagnosis of epithelial ovarian cancer. Both hMG and Clomiphene had been used either alone or in combination, and although the sample size was relatively small, the authors did make adjustments when looking at which drugs individual women had used. They concluded that the use of hMG in particular may place women at risk. Other larger studies have not confirmed these findings. Dor et al. (Citation2002), carried out a historical cohort analysis of 5026 women who had undergone IVF treatment. No increased risk for cancer in women undergoing IVF treatment was found when compared to the general population. Patients had received at least one cycle, however the study did not identify if they discounted those women who had undergone multiply cycles, as it could be hypothesised that the more exposure to the drugs the greater the risk. A further limitation was that the patients underwent varying protocols of IVF, using both Clomiphene, hMG's and GnRH analogues. Venn et al. (Citation1995), reviewed 5564 women who had ovarian stimulation, and concluded that there was no significantly increased risk of cancer after treatment. In a subsequent study Venn et al. (Citation1999) included 29700, 20656 were exposed to fertility drugs and 9044 were not. On review the incidence of ovarian cancer was no greater than expected (by standardised incidence ratios). However the authors did conclude that there was an increased risk of a diagnosis of ovarian cancer in those women with unexplained infertility, independent of IVF exposure and invasive epithelial cancer risk. As discussed earlier in the text it has been hypothesised that there is a genetic link between ovarian cancer and infertility and Venn's study would appear to give some credence to this theory. Nieto et al. (Citation1999) conducted a retrospective study of ovarian cancer in first degree relatives of women with a past history of infertility. The findings suggest that there is a common genetic abnormality underlying infertility and ovarian cancer and this abnormality is restricted to a subgroup of women with infertility. It has been argued, however that the higher rates of ovarian pathology in untreated women could be because infertility patients will ultimately undergo many ultrasound scans which will increase pickup of these tumours, and so it would seem as yet there is no conclusive evidence.
To conclude, unfortunately it would seem that there is no firm evidence which informs clinicians and women of the safety of fertility drugs. It is apparent that there are flaws in the current research, and there does not appear to be a great deal of literature that looks at specific drugs in isolation. Those working in the field need to be aware of the current research, and women counselled prior to being given fertility drugs. In the author's experience very often several cycles of Clomiphene are prescribed in primary care prior to semen analysis being carried out, only to find that when more specialist help is sought by the couple there is male factor infertility and therefore Clomiphene was never going to be of use. This has huge implications for the women, especially given the current recommendations regarding the use of Clomiphene. Current research needs to be undertaken looking at specific drugs used, number of cycles and the age and parity of the women included, together with their contraceptive and family history in order that women can be given up to date and accurate information regarding the risks if any of the drugs they take during an IVF cycle.
OC7: Attitude towards elective single embryo transfer (eSet): a survey of UK IVF units
A. D'Angelo, S. Pallett, T. Leonard, C. Eyre, & A.M. Lower
The Isis Fertility Centre, Colchester, UK
Introduction. In July 2005 the Human Fertilisation and Embryology Authority (HFEA) announced their intention to review the clinical practice surrounding the number of embryos transferred during fertility treatment. The review will look at whether the UK should follow the model of some other European countries which regularly only transfer one embryo back into a woman following IVF. The aim of our survey was to assess the opinion and the clinical practice across the UK infertility units on this topic as well as their availability to take part to a large randomized controlled trial (RCT).
Methods. In August 2005 a short questionnaire was designed and sent to every licensed IVF unit in the UK. Data were collected and analyzed using Microsoft Excel.
Results and discussion. Seventy one IVF units were sent the questionnaire, 28 (39.4%) replied between 1 and 6 weeks. Sixteen units were NHS and 12 private. Eight (28.5%) units reported having experience with eSET whilst 20 (71.5%) had no experience. Out of the 20, 9 (45%) did not give any reasons. Out of the 8 only one unit provided full statistical details. This clearly shows that the concept of eSET has not been routinely adopted by UK IVF units. There could be many reasons for this; the three main reasons contained in the survey responses were: 1) possible decrease in success rates which would be reported in the HFEA patient's guide; 2) financial concerns; 3) poor embryo selection criteria available. Interestingly, 13 out of the 20 units with no experience of eSET said they would be willing to participate in a RCT, providing that there would be clear selection criteria as well as financial support. Finally, agreement needs to be reached on the best way to inform couples on the reasons for this new approach.
OC8: A randomised trial of 2295 women having ultrasound guided embryo transfers
A.J. Drakeley1, T. Aust1, R.L. Lunt1, J. Sklavounos1, P. Williamson2, R. Gazvani1, & C.R. Kingsland1
1Hewitt Centre for Reproductive Medicine, Liverpool Womens' Hospital, Liverpool, UK, and 2Statistics Department, Liverpool University, UK
Introduction. Ultrasound guidance for embryo transfers is recommended best practice as described by the 2004 NICE guidelines for infertility. This is based on a metanalysis of small underpowered trials. We conducted a large, appropriately powered randomised trial to test this statement.
Methods. A single centre randomised controlled trial of 2295 women undergoing embryo transfer between 2003 and 2005. After a pilot study, the trial was powered to demonstrate a 5% difference in clinical pregnancy rates using 80% power and alpha error 0.05, between women having either ultrasound guided or clinical touch (blind) embryo transfer. Randomisation was by computer generated random blocks and stratified for age and fresh/frozen. Randomisation, data entry and analysis was independent and for intention to treat. A data monitoring committee was used. Primary outcome measure was clinical pregnancy.
Results and discussion. There was no significant difference between the two groups. Twenty two percent of women with an ultrasound guided transfer had a clinical pregnancy versus 23% with clinical touch technique. Similarly 28% versus 29% for biochemical pregnancy. We conclude that when subjected to a large appropriately powered randomised controlled trial, using ultrasound guidance for embryo transfer does not increase clinical pregnancy rates.
OC9: What is the place of Tumor Necrosis Factor-A converting enzyme/ADAM 17 in human endometrium?
R.F.L. DuQuesnay, A.B. Abdul Aziz, C. Wright, A.W. Horne, R. Margara, & J.O. White
Institute of Reproductive and Developmental Biology, Imperial College London, UK, Department of Pathology, Hammersmith Hospital, London, UK, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, Scotland, Division of Paediatrics, Obstetrics and Gynaecology, Imperial College, London, UK, and Department of Reproductive Biology, The Clinical School, University of Wales, Swansea, Wales
Introduction. TACE/ADAM 17 is a membrane bound ‘sheddase’ which has been shown to mediate cleavage of the ectodomain of MUC1. Clearance of MUC1 is necessary to allow embryo implantation. Little is known about its regulation or temporal expression within the endometrium. We examined the endometrial expression of TACE throughout the menstrual cycle in normal fertile controls and compared expression at LH + 7 (Day 21) between fertile women and infertile women with polycystic ovarian morphology (PCO) on ultrasound scan.
Methods. Endometrial biopsies were obtained using pipelle from 10 women with unexplained primary infertility and PCO at LH + 7. Fertile controls had biopsies taken throughout the menstrual cycle with a total of 10 samples on Day 21. Two pathologists using Noye's criteria confirmed all specimens to be in date. RNA was extracted and analysed using RT-QPCR and formalin fixed, paraffin embedded sections of tissue were used for immunohistochemical analysis of TACE and MUC1. Staining intensity was assessed using the semi-quantitative HSCORE. A well-differentiated endometrial epithelial cell-line (Ishikawa) was used to assess in-vitro regulation of TACE by Western blotting and RT-QPCR.
Ethical approval was obtained from Hammersmith Hospitals Local Research Ethics Committee (number 98/5460).
Results and discussion. TACE is absent during the proliferative phase with the onset of expression during the early secretory phase at the apical surface of the glandular and luminal epithelial compartments and continuing throughout the cycle. This pattern is mimicked by the changes in TACE mRNA. Women with ovulatory PCO had reduced expression of TACE on Day LH + 7 although no significant difference in message was detectable. Immunohistochemically there was no correlation between expression of TACE and MUC1. In Ishikawa cells expression of TACE was suppressed in response to treatment with the synthetic androgen, R1881. We have demonstrated cyclical variation in the expression of TACE in the endometrium for the first time. Infertile women with ovulatory PCO are markedly deficient in TACE during the ‘window of implantation’ which may be as a direct result of low-level hyperandrogenemia. TACE does not appear to be the main mediator of MUC1 shedding in the endometrium.
(This work was supported by The Wellcome Trust (grant number 069773/Z/02/Z) and The Institute of Obstetrics and Gynaecology Trust Fund.)
OC10: Pregnancy outcomes after selective salpingography and tubal recanalization in a District General Hospital
J. Gemmell, R. Nanal, S. Sivalingam, & L. Cram
Department of Obstetrics and Gynaecology, Royal Alexandra Hospital, Paisley, Glasgow, UK, and Department of Radiology, Royal Alexandra Hospital, Paisley, Glasgow, UK
Introduction. The Royal College of Obstetricians and Gynaecologists has included selective salpingography and tubal recanalization (SS-TR) in its evidence-based clinical guideline for the management of infertility in secondary care. We here describe our experience with the procedure in a district general hospital (DGH) in the UK.
Methods. A retrospective study of patients undergoing selective salpingography and tubal recanalization was carried out over a period of 4 years. A total of 38 patients were identified and 30 case notes were reviewed.
Results and discussion. 16 (53.3%) patients had bilateral tubal block and 14 (46.6%) had unilateral tubal block. Tubal patency was achieved in 29 patients out of 30 who underwent SS-TR (96.6%). During the study period, in total there were seven spontaneous conceptions, three after clomiphene citrate treatment and one after in-utero insemination by partner (36.6% conception rate). Of these 7 (23.3%) resulted in live births, 2 (6.6%) resulted in miscarriages and 2 (6.6%) in ectopic pregnancies. No procedure related complications were reported. The results of this study emphasize that SS-TR is a safe, cost-effective and minimally invasive treatment option for proximal tubal blockage. We feel that its use should be encouraged in the infertility units located in a DGH where skilled clinicians and the facilities are available.
OC11: Primary offer of IVF is more cost-effective than IUI for couples eligible for either treatment modality
R. Mathur1, N. Pashayan2, & G. Lyratzopoulos3
1Cambridge University Teaching Hospitals Foundation Trust, 2Cambridgeshire Public Health Network Training Scheme, Nightingale Court, Ida Darwin, Fulbourn, Cambridge, CB1 5EE, and 3Norfolk Suffolk and Cambridgeshire Strategic Health Authority, Victoria House, Capital Park, Fulbourn, Cambridge, CB1 5XB
Introduction. In unexplained and mild male factor subfertility, both intrauterine insemination (IUI) and in-vitro fertilisation (IVF) are indicated as first line treatments. The success rate of IUI is low and many couples failing IUI subsequently require IVF. It is therefore important to examine the comparative outcomes, costs, and cost-effectiveness of primary offer of IVF, compared with primary offer of IUI followed by IVF for couples failing IUI. Some studies indicate that IUI may be more cost-effective than IVF in cases eligible for both. However, these studies have not accounted for subsequent Frozen Embryo Transfer (FET) which lowers the cost of IVF per live birth-producing pregnancy. More importantly, these studies do not take into account the eventual ‘transfer’ of most failed IUI patients to IVF, a crucial consideration for commissioners of healthcare services when both IUI and IVF are funded from the same budget (as in the UK NHS).
Methods. Mathematical modelling was used to estimate comparative clinical and cost effectiveness of either primary offer of one full IVF cycle (including FET(s) when applicable) or ‘IUI + IVF’ (defined as primary IUI followed by IVF for IUI failures) to a hypothetical cohort of subfertile couples who are eligible for both treatment strategies. Data used were derived from peer-reviewed literature and activity data of local infertility units.
Results and discussion. Cost-effectiveness ratios for IVF, unstimulated-IUI (U-IUI) + IVF, and stimulated IUI (S-IUI) + IVF were £12,600, £13,100 and £15,100 respectively. Compared to primary offer of IVF, for a hypothetical cohort of 100 couples eligible for both treatment strategies, 6 cycles of ‘U-IUI + IVF’ or ‘S-IUI + IVF’ would cost an additional £174,200 and £438,000 respectively. For the same hypothetical cohort, opportunity costs equate to between 54 and 136 additional full IVF cycles and 14 to 35 live birth producing pregnancies for ‘U-IUI + IVF’ and ‘S-IUI + IVF’ respectively. In cases where both IUI and IVF are indicated, primary offer of a full IVF cycle is less costly and more cost-effective than providing IUI (of any modality) followed by IVF. This information may aid commissioners and providers in targeting scarce resources available for publicly-funded fertility treatment.
OC12: Comparison of Medicult Sequential Medium ISM1 with non-Sequential universal IVF Medium in an IVF/ICSI programme
M.G. Steele, A. Kopakaki, R. Sriskandakumar, C. Papanikou, R. Sciorio, N. Mary, & K.J. Thong
Assisted Conception Programme, Royal Infirmary of Edinburgh, Edinburgh, UK
Introduction. Embryo culture conditions are central to the outcome of human IVF. The aim of this prospective study was to compare ISM1 with Universal IVF Medium, in terms of early embryonic development and clinical pregnancy rates, and to evaluate the effect of Uterine Transfer Medium (UTM), containing hyaluronate, on clinical pregnancy rates.
Methods. Oocytes from 141 IVF/ICSI cycles were allocated to ISM1 (A) or Universal IVF Medium (B) culture groups in alternating one week blocks. Embryos were transferred to the uterus in UTM (A) or Universal IVF Medium (B). A further group of ISM1 patients had their embryos transferred to the uterus in either ISM1 (C) or UTM (D). Allocation to groups C and D was also in alternating one week blocks. Statistical analyses were performed using Mann-Whitney and Chi-square tests.
Results and discussion. Fertilisation rates did not differ significantly between groups A and B. However, the median embryo cleavage rate (100.00%[50.00 – 100.00] vs 91.10%[0.00 – 100.00], p = 0.01), median embryo cell number on day 2 (3.20 [1.70 – 5.00] vs 2.57 [1.00 – 4.71], p < 0.0001) and day 3 (5.2 [3.30 – 8.00] vs 4.25 [3.00 – 9.86], p = 0.003) and percentage of treatment cycles with surplus embryos frozen on day 2 (50.00 [14/28] vs 13.04%[3/23], p = 0.005) and day 3 (52.00 [13/25] vs 19.23%[5/26], p = 0.01), were significantly higher in group A. The percentage of good quality embryos was significantly higher in group A on day 2 (69.77 [217/311] vs 60.27%[176/292], p = 0.01), but not day 3 (67.03 [124/185] vs 67.65%[115/170], p = 0.9). The clinical pregnancy rate was significantly higher in group A after day 2 embryo transfer (50.00 [20/40] vs 25.81%[8/31], p = 0.04), but not day 3 (33.33 [9/27] vs 29.63%[8/27], p = 0.8). Clinical pregnancy rates after day 2 (32.76 [19/58] vs 37.50%[21/56], p = 0.6) and day3 embryo transfer (35.14 [13/37] vs 29.79%[14/47], p = 0.6) did not differ significantly between groups C and D. ISM1 culture to day 2 supported faster embryo development, better embryo quality and a higher clinical pregnancy rate. Surprisingly, these effects (with the exception of embryo developmental rate) were not sustained upon culture to day 3. UTM had no effect on clinical pregnancy rates.
OC13: Infertility management in primary care with open access hysterosalpingography (HSG): pilot study evaluation
S. Wilkes1, A. Murdoch2, N. Hall1, A. Crosland3, D. Chinn1, J. Wilsdon4, & G. Rubin1
1Centre for Primary and Community Care, School of Health Natural and Social Sciences, Benedict Building, St George's Way, University of Sunderland, SR2 7BW, 2Newcastle Fertility Centre at LIFE, BioScience Centre, International Centre for Life, Times Square, Newcastle upon Tyne, NE1 4EP, 3School of Health, Community and Education Studies, Coach Lane, Benton, Northumbria University, Newcastle upon Tyne, NE7 7AX, and 4Deptartment of Radiology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP
Introduction. NICE have recommended HSG as a first line investigation for tubal assessment. Our aim was to evaluate HSG as an open access primary care investigation using both quantitative and qualitative methods.
Methods. Setting: We made open access HSG available to 6 general practices in Newcastle upon Tyne.
Design. The views of 11 GPs, 1 GP Registrar and 1 Nurse Practitioner were sought in 3 focus groups. Using hospital clinical records we tracked the outcome of infertile couples from the 6 pilot practices over 9 months. Outcome measures: 1) uptake of open access HSG. 2) Speed of access to specialist services. 3) Quality of the information recorded in the referral letter. Ethics approval: Newcastle and North Tyneside LREC.
Results and discussion. Of the 39 referrals, 6 HSGs were organised by GPs. Couples who had open access HSG showed a trend reaching a diagnosis and management plan earlier than those who were referred directly (mean difference – 4.0 weeks, 95% CI – 8.8 to 0.4 weeks). Less than 50% of recommended advice and investigations were recorded in the referrals. The majority of GPs felt they should do all they possibly could, whilst others felt it was the responsibility of the fertility specialist. Uncertainty and lack of knowledge was a common theme linked to the relative infrequency of GP infertility consultations and difficulty ‘keeping up to date’. Many GPs were unsure where HSG fitted in. Open access HSG allowed prompter access to specialist services with more complete information in the referral letter. It enabled a management plan to be established at the first specialist consultation. ‘Near-patient testing’ in primary care such as open access HSG, may reduce the overall patient journey (NHS Improvement Plan 2004). Open access HSG together with semen analysis and endocrine blood tests may allow GPs to manage the initial stages of the infertile couple.
OC14: The impact of switching donors on clinical pregnancy rate during treatment by therapeutic donor insemination (TDI)
S. Gascoyne, C. Faraci, G. Hamilton, & J. Kredentser
Heartland Fertility & Gynecology Clinic, Winnipeg, MB, Canada
Objective. To determine whether switching donors improves pregnancy outcomes during treatment by therapeutic donor insemination (TDI).
Design. A retrospective study reviewing data obtained from TDI cycles.
Materials and methods. 1158 TDI cycles occurring at a private fertility clinic between December, 1997 and April, 2005 were reviewed. Patients received a single insemination one day following positive identification of LH surge using 1 of 2 commercial urine surge prediction kits. Inseminations occurred during either natural or clomiphene citrate medicated cycles. Chemical pregnancy was determined using commercial urine HCG test kits 2 – 3 weeks after insemination. Pregnancy outcomes were analyzed according to number of cycles of treatment and to number of different donors used by each patient. All cycles involved donor semen purchased from a single commercial source.
Results. summarizes the relationship between number of different donors used and outcome of therapeutic donor insemination (TDI). Of 286 patients (1158 cycles), 121 patients completed 469 cycles involving at least one donor switch. Patients switched donors during treatment either because the current donor became unavailable or because the patient attributed her current lack of success to the donor semen in current use. Of 131 patients with positive pregnancy tests, 74 were patients inseminated with the same donor for all cycles while 57 patients achieved positive tests when they switched donors at least once during treatment. Several patients achieved more than one positive test and of the patients using more than one donor, similar numbers of pregnancies occurred before and after switching donors. Overall, biochemical pregnancy rate was 13.7% per cycle and the live birth rate was 9.4% per cycle.
Table I. Outcomes of patients undergoing TDI using different numbers of donors.
Conclusion. The results of the study indicate that switching donors does not increase the likelihood of pregnancy for TDI.
Support. None.
OC15: Endocrine and metabolic consequences of IVF conception are present in childhood
H. Miles
Liggins Institute and National Research Centre for Growth and Development, University of Auckland, Auckland, New Zealand
An increase in imprinted gene disorders such as Beckwith Wiedemann has been reported in children born following in vitro fertilisation (IVF). We hypothesised that IVF results in alteration in methylation of imprinted genes leading to measurable changes in phenotype and hormonal profile in mid-childhood. Healthy, pre-pubertal children born at term following singleton pregnancy were evaluated. Subjects comprised 56 children conceived using IVF with fresh embryo transfer (6.7±2.6 years, 25 male) and 69 naturally conceived controls (7.0±2.0 years, 27 male). Anthropometric measurements, bone age, DEXA scan (Lunar prodigy 2000), fasting blood test for markers of growth and metabolism were performed. As a group children born following IVF were taller than controls; this became more significant when corrected for mid-parental height (p < 0.001). There was sexual dimorphism with IVF girls showing most increase in height. There was no significant difference in body composition between the two groups. Despite correction for age, sex, height and DEXA percent fat mass, IVF children had higher IGF I (p = 0.003), IGF II (p < 0.001) and IGFBP3 (p = 0.009) levels. IVF children had more favourable lipid profile with higher HDL (p = 0.006) and a lower HDL:Cholesterol ratio and lower triglyceride level (p = 0.009). In mid childhood IVF children are taller with increased IGF I, IGF II and IGFBP3 levels. They also have a more favourable lipid profile. Differences observed in growth and metabolism may be due to epigenetic changes in imprinted genes.
OC16: Ovarian ageing in Caenorhabditis elegans as a model for maternal age-related aneuploidy in human embryos
Ellen van Binsbergen1, Dagmar R. Gutknecht2, Carla A.A. Dielis1, Harriet F. van Drie1, Marco C. Betist3, Egbert R. te Velde2, Hendrik C. Korswagen3, & Peter L. Pearson1,*
1Department of Medical Genetics, 2Department of Reproductive Medicine, University Medical Centre Utrecht, The Netherlands, and 3Hubrecht Laboratory and Centre for Biomedical Genetics, Utrecht, The Netherlands.
*Present address: Department of Evolutionary Biology, University of Sao Paulo, Brazil
Human females demonstrate an exponential increase in fetal loss combined with numerical chromosome abnormalities with rising maternal age. This has been attributed to oocyte ageing during meiotic arrest, which can extend up to several decades in humans. In a search for an animal model to study the mechanisms behind non-disjunction as a result of ageing, we have studied the affects of oocyte ageing in Caenorhabditis elegans. In C.elegans, oocytes can be arrested during the first meiotic prophase by preventing fertilisation. We demonstrate that an extended prophase I arrest of 7 days results in a decrease in brood size and a 75 fold increase in unhatched, developmentally arrested embryos. Three techniques were used to investigate the chromosomal content of the arrested embryos and showed monosomic, trisomic and mosaic chromosome patterns in which, contrary to expectation of the affects of ovarian ageing, both parents contributed to the abnormalities equally. The findings suggest that the aneuploidies are principally the result of mitotic non-disjunction occurring during early embryonic division. Intriguingly, within the monosomic embryos one third showed retention of a haploid autosomal chromosome pattern in which the retained set was either paternal or maternal in origin.and rarely a mixture of both. We could exclude parthenogenesis to explain this pattern since the X-chromosome was usually derived from both parents. We have no explanation for this unique finding of uniparental haploid embryos following fertilisation of aged worms. To unravel the mechanisms behind this phenomenon additional experiments are needed. Recent findings of a high level of mosaicism in human IVF embryos suggests that early embryonic nondisjunction also plays an important role in human embryo development. We consider C.elegans to be a suitable model organism to study the factors contributing to early mitotic non-disjunction in embryos and provide further insights into human embryonic loss through this mechanism.
OC17: Diabetes Mellitus: effects on sperm nuclear and mitochondrial DNA quality
I.M. Agbaje1, D. O'Neil, C. McVicar1, N. McClure1, A.B. Atkinson2, C. Mallidis1, & S.E.M. Lewis1
1School of Medicine, Reproductive Medicine Research Group, Queens University Belfast, UK, and 2Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK
Introduction. Diabetes Mellitus (DM) is the commonest endocrine disorder in man; its incidence is rising at an epidemic rate. Ninety percent of type 1 diabetics are diagnosed under the age of 30, consequently, many men are affected during their reproductive years. The effects of DM on male fertility have not been researched in detail. The few studies to date have been limited to conventional semen analysis and have reported conflicting results. The aim of this study was to evaluate semen profiles and sperm nuclear and mitochondrial DNA quality in diabetic and non-diabetic men.
Methods. Study approved by the local research ethics committee. Semen was obtained from type 1 diabetic (n = 26) and non-diabetic (n = 23) subjects after 2 – 5 days sexual abstinence. Semen profiles were determined according to WHO criteria; nuclear DNA fragmentation by COMET assay and mitochondrial DNA deletions by Long PCR.
Results and discussion. Sperm from DM males showed an increase in nuclear DNA fragmentation (53% ± 3 vs 32% ± 2; p < 0.0001) (mean ± SEM) and mitochondrial DNA deletion number (4.7 ± 0.4 vs 3.1 ± 0.4; p < 0.05) compared to controls. A trend toward increased deletion size (6.4 kb ± 0.1 vs 5.8 kb ± 0.4; p > 0.05) was also observed in diabetic subjects; in contrast, there was no significant difference in any of the conventional semen parameters. Routine semen analysis does not detect molecular aberrations of sperm. However, we have shown that DM is associated with an increase in sperm nuclear DNA fragmentation and mitochondrial DNA deletion number. This may have significant implications for the fertility of men with DM, as sperm DNA quality is closely associated with all fertility outcomes. Given the global epidemic of DM, it is crucial that its impact on male fertility is further defined.
(This work was kindly funded by the Research & Development Office Northern Ireland.)
OC18: Luteal phase support in IVF/ICSI: a postal survey of UK licensed centres
S. Baruah, A. Zosmer, A. Tozer, C. Davis, O. Djahanbakhch, & T. Al-Shawaf
Centre for Reproductive Medicine, St Bartholomew's Hospital, London, UK
Introduction. Luteal phase support (LS) for IVF/ICSI cycles is recommended by recent meta analysis (Daya & Gunby, Citation2004; Nosarka et al., Citation2005) and is universally practised. To identify practices of LS in IVF/ICSI cycles we conducted a postal questionnaire survey of all Centres licensed by the Human Fertilization and Embryology Authority (HFEA) in the UK.
Methods. The person responsible for each centre was identified from the HFEA registry of 2005. A questionnaire was sent to the person responsible to evaluate the usual practice of LS following ovarian stimulation.
Results and discussion. 69 centres were licensed by the HFEA to practice IVF/ICSI in 2005. Sixty two centres (89.8%) replied accounting for 23,324 cycles performed in 2002/2003 report. The results were analysed based on respondents. Of those who replied, 1.6% centres did not consider it as important part of IVF/ICSI cycle, 30.6% centres recognise it as ‘important’ while 64.5% considered LS in IVF/ICSI cycles as a ‘very important’ aspect of management. 97% use LS with the long down-regulation protocol, whilst only 65% consider LS as ‘very important’ in flare protocol. 36.67% of respondents use a combination of LS drugs. 57 [92%] centres used progesterone pessaries/suppositories for LS with the most common dose used being 400 mg twice daily (61%). Intra-muscular progesterone was used by 20 centres [32%], human Chorionic Gonadotrophin (hCG) by 27 [43%] and vaginal progesterone gel by 17 [27%] centres. The commonest practice was to start progesterone on the day of oocyte retrieval (48%), and 48% continued luteal support until 12 weeks' gestation. Eighteen centres (30%) used hCG selectively and the commonest dose used was 1500 IU (17.7%). In those who use hCG for LS, 33% of centres start 4 days from the hCG trigger and 48% of centres start on embryo transfer day. Oral progestogen was given for LS by 8% of respondents and 15% use estrogen tablets or patches. Thirty one of 39 centres recognised the need to do randomised trials on LS.
Conclusion. Although the importance of luteal phase support is well recognised and vaginal progesterone pessaries/suppositories were the preferred option, there were variations in regard to the type of preparation, dosage and duration of treatment. A large proportion of practices seem to use a combination of drugs. This survey highlights the need for more research into LS practice in IVF/ICSI, including patient acceptability and cost-effectiveness.
OC19: The relationship between follicular fluid aspirate volume and outcome in intracytoplasmic sperm aspiration (ICSI) cycles
N.E. Baskind, V. Sharma, S. Bhuiya, V. Mauro, &B. Dadebo
Assisted Conception Unit, St. James's University Hospital, Leeds, UK
Introduction. In natural cycles follicular growth and ultimate volume is directly correlated to the oocyte maturity. In gonadotrophin (Gn) stimulated cycles, a heterogeneous cohort of follicles is recruited, thus the follicular volumes at the time of oocyte retrieval is not uniform. Oocyte retrieval is generally timed according to mean follicular diameter of the leading follicle/s and/or plasma oestradiol level. In the absence of a more accurate parameter it is assumed that follicular growth and oocyte maturity are directly correlated. If this hypothesis was true, the oocytes with the highest developmental potential would only be retrieved from the large preovulatory follicles.
Methods. Data from 297 consecutive ICSI cycles conducted between January and December 2004 at St. James's University Hospital, Leeds, UK, were prospectively recorded. Specifically follicular volume of each follicle aspirated was correlated with the fate of the oocyte retrieved longitudinally with respect to oocyte maturity, fertilization rate, morphology of embryos in-vitro, embryo implantation and cryopreservation rate. Patient demographics, aetiology, type and dose of Gn, duration of stimulation and cycle outcome was also recorded. Follicle data was divided into five volume groups: 0 – 1 ml (G1), 1.5 – 3.0 ml (G2), 3.5 – 5.0 ml (G3), 5+ ml (G4) and unrecorded volumes (G5).
Results and discussion. The proportion of germinal vesicles and Metaphase I oocytes was highest in G1 and G5 and the proportion of Metaphase II was highest in G2 and G3. Metaphase II oocytes fertilized equally frequently and irrespective of follicle volume. The embryo cleavage rate, cell number and grade did not differ with follicular volume. Furthermore, there was no difference in the implantation rate. Embryos derived from G2 and G3 were more likely to meet the criteria for cryopreservation. Follicular volume is not an accurate predictor of oocyte maturity in multi-follicular super-ovulated ovaries. Oocyte maturation and antrum formation may be uncoupled and are not always synchronous.
OC20: Abandoned cycles in IVF. What is an acceptable incidence?
A. Chavez-Badiola, S.E. Papadopoulos, A.J. Drakeley, R. Gazvani, & C.R. Kingsland
Hewitt Centre for Reproductive Medicine, The Liverpool Women's Hospital, UK
Introduction. Success of assisted reproductive technologies is largely determined by ovarian response to gonadotropins. Despite all efforts, an inadequate response still constitutes a major concern leading to cycle cancellations. There is little evidence in literature regarding acceptable cancellation rates. Incidences quoted range between 6 and 71%.
Methods. A review of consecutive IVF treatment cycles performed in 12 months at the Hewitt Centre for Reproductive Medicine, Liverpool Women's Hospital, UK was undertaken to evaluate the incidence of abandoned cycles and their indications. Total gonadotrophin dose, age, FSH, and outcome in previous and immediate next cycle were analysed in relation to the indication of cancellation. Student's-T test was used for analysis (p < 0.05 was considered significant). Results are presented as percentages and mean (M) with standard deviations. Financial cost of abandoned cycles was estimated in GBP.
Results and discussion. 1116 IVF/ICSI cycles were started in the study period of which 8.5% (n = 95) resulted in cancelled cycles (M-age: 34 years; MFSH: 7.6 IU). Poor ovarian stimulation was indicated in 74.7% of cancellations (M-age: 33.8; M-FSH: 7.82 IU); hyperstimulation accounted for 22.9% (M-age: 34.7; M-FSH: 7.05 IU) and 2.4% were cancelled for other reasons. Of these women, 25% had had an immediate previous cycle abandoned while 13.7% had their next cycle abandoned. The overall cost of abandoned cycles was £61,440. Conclusions. It was not possible to evaluate whether our abandoned cycle rate falls within national standards due to a lack of a parameter to compare it against. National surveys and databases are needed to calculate the rate of abandoned cycles: A standard to compare against. Poor responses were the cause of two thirds of cancelled cycles and were more frequently related to a previous abandoned cycle (31%) when compared to over responders.
OC21: Glycosylation of maternal serum hCG in early pregnancy
M. Chetty, A.L. Johnson, A.J. Chapman, J. Elson, & J. Edmondson
Sunderland Reproductive Endocrinology Research Group, Sunderland Royal Hospital, Sunderland, UK
Introduction. Synthesis of human chorionic gonadotrophin (hCG) occurs predominantly within trophoblast cells of the blastocyst and both alpha and beta subunits undergo post-translational glycosylation. Glycosylation is considered to play an important role in the bio-availability and bio-activity of hCG. The structures of the oligosaccharide chains of urine hCG have been reported but urine hCG is known to undergo desialation relative to serum hCG. The aim of this study was to characterise glycosylation of maternal serum hCG in early pregnancy and to identify any differences in glycosylation by gestation and by pregnancy outcome.
Methods. Venous blood samples were taken from women in early pregnancy and gestational age calculated from menstrual dates and ultrasound scan findings. Pregnancy outcome was identified from the hospital patient database and outcomes dichotomised into viable and failed pregnancies. Ion-exchange, gel filtration, and lectin affinity chromatography were used to characterise the glycosylation of hCG in the samples. Findings were graphed and peaks of hCG immunoactivity were compared statistically using a Mann-Whitney test.
Results and discussion. Lectin-binding chromatography revealed 5 major isoforms in all samples. Samples from women with viable pregnancies at less than 8 weeks gestation showed a significantly different distribution from samples at later gestations. Samples taken from women at less than 8 weeks gestation in whom pregnancies failed, showed isoforms that significantly differed in their distribution from that of the viable pregnancies at similar gestations. These data show that glycosyl isoforms of hCG can be demonstrated in early pregnancy by lectin-binding chromatography. These isoforms are expressed differently in viable pregnancies before and after 8 weeks gestation. In pregnancies which fail the distribution of hCG isoforms differs from that seen in viable intrauterine pregnancies. This work provides us with further insight into the endocrinology of early pregnancy and possible mechanisms of early pregnancy failure.
OC22: Neurological developmental variations in assisted conception and spontaneous pregnancies
J. Joy1, C. Patterson2, N. McClure1, P.G. Hepper3, & I.E. Cooke1
1Obstetrics and Gynaecology, Institute of Clinical Science, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BJ, 2Epidemiology and Public Health, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BJ, and 3School of Psychology, Queen's University Belfast, Belfast, BT7 1NN
Introduction. Habituation, defined as decrement in response following repeated stimulation with the same stimulus, indicates Central Nervous System (CNS) integrity and has been confirmed in human foetuses. We compared habituation as a measure of neurological development in foetuses conceived by assisted reproduction techniques (ART) with spontaneously conceived foetuses.
Methods. This study based in the Fetal Behaviour Research Centre, Royal Maternity Hospital, Belfast included 20 women with singleton foetuses conceived by ART and 20 controls at 28 and 32 weeks gestation. Sound stimuli (250 Hz, 110 dB) at 10 second intervals for 2 seconds were administered. The end point was habituation (cessation of movement for five consecutive stimuli) or a maximum of 30 stimuli after which five stimuli of 500 Hz, 110 dB were administered followed by vibroacoustic stimulation if there was no previous response. Observations with high quality ultrasound were video-recorded. Tapes were blinded and analysed with a standardised scoring sheet.
Results and discussion. At 28 weeks more foetuses in the ART group responded to 250 Hz (80% vs 40%, p = 0.02) but there was no difference at 32 weeks (66.7% vs 70%, p = 0.9). There was no significant difference in habituation or trial at which habituation occurred at both gestations. Startle was assessed by comparing first response to 250 Hz in terms of amplitude, latency, speed and body parts moved. The ART group had significantly higher scores in all parameters (amplitude p = 0.003; latency p = 0.008; speed p = 0.004; body parts p = 0.002) at 28 weeks gestation. After adjustment for potential confounders the differences remained significant. At 32 weeks there was no difference in all these parameters.
Conclusions. Foetuses conceived by ART demonstrate no differences in habituation performance which suggests no of neurodevelopmental delay in utero compared with naturally conceived foetuses. ART would not appear adversely to affect higher aspects of CNS functioning in the foetus.
Poster abstracts
Assisted conception
P1: A new technique for the sterilisation of the ultrasound transducer used in egg retrieval procedures in IVF
E. Meridis, A. Talmor, C. Turner, S. Lavery, & G. Trew
IVF Unit, Hammersmith Hospital, London, UK
Introduction. The egg collection procedure plays a key role in every In Vitro Fertilization cycle. The laparoscopic method originally developed by Steptoe and Edwards in the 1970's for aspirating oocytes from graafian follicles has evolved to the trans-vaginal ultrasound-guided egg retrieval procedure currently used for the majority of cases. A key element for this procedure is the ultrasound transducer which is inserted vaginally covered with a latex cover to enable accurate needle entry and precise follicle aspiration. Unlike other materials that are also necessary for the oocyte retrieval procedure, the ultrasound transducer needs a uniquely designed technique for cleaning and sterilisation between cases.
Methods. The traditional technique that involves bathing the ultrasound transducer in an antiseptic solution for a certain amount of time has been replaced by a new sterilisation technique, using recent innovations in sterilisation technology and particularly the Tristel Sterilising Wipe (TSW) system. An observational study of the new technique for a period of one year and retrospective comparison with an historical control group has been carried out, with fertilization and pregnancy rates as primary end points, but also measuring parameters like cost effectiveness, time consumption and convenience of use.
Results and discussion. So far, results have shown no difference in oocyte fertilization rates or pregnancy rates between the new technique and the traditional one, proving that the Tristel Sterilising Wipe (TSW) system is efficacious and safe for use in an IVF setting. The new technique has also been found to be faster, easier to use and more cost effective than the traditional one. Final results will be presented on completion of the study. An IVF laboratory should always use materials, supplies and methodology that maintain the prospective developmental potential of each oocyte. The Tristel Sterilising Wipe (TSW) system seems to be a superior alternative to the traditional technique for ultrasound transducer sterilisation in transvaginal oocyte collection procedures.
P2: The place of clomifene for ovulation induction in an era of high-tech assisted reproduction
M.T. Bekhit, P.A. Greenwood, & D. Currie
Waveney Subfertility Unit, Department of Obstetrics & Gynaecology, James Paget Healthcare NHS Trust, Lowestoft Road Gorleston, Great Yarmouth, Norfolk, NR31 6LA, UK
Introduction. The clinical use of medical induction of ovulation is becoming increasingly questioned in the current era of assisted conception. This study aims to assess the effectiveness and outcome of clomifene therapy as a first line of treatment for couples with anovulatory (WHO II) and unexplained infertility at our subfertility clinic.
Methods. Eighty couples planned for clomifene therapy were included in this study. Analysis included: age, parity, menstrual pattern, duration of infertility, BMI, PCO status, dose of clomifene, number of treatment cycles and treatment outcome.
Results and discussion. Total number of women treated was 76 (4 never started treatment for social reasons). Pregnancy rate was 70% for women using 50 mg of clomifene, compared with 38% for those using 100 mg. Pregnancy rate was also higher in nulliparous women, those who had oligomenorrhea, and low BMI. No cases of ovarian hyperstimulation occurred. Clinical pregnancy rate was 49% (37/76). Nine women had early miscarriage (24%) and one had an ectopic pregnancy. Live birth rate was 36% (27/76), one had a singleton live birth after having an ectopic pregnancy and 2 women had twins (7%), both were dichorionic. One set of twins was delivered at 34 weeks by CS for IUGR with hypospadius in one baby, while the other set of twins were delivered by CS at 36 weeks. Cost of treatment (clomifene only) per baby was £40. Proper selection of couples for relatively simple, less invasive and less expensive treatment with adherence to good practice guidelines achieves pregnancies in a more ‘natural’ way and reduces stress, complications for women and the overall cost to the NHS.
P3: Quarterly means to monitor performance of a conservative IUI service
L. Randall, J. Hopkisson, T. Newton, N. Cotgrave-Keates, D. Littlehales, & M.J. Tomlinson
Department of Obstetrics & Gynaecology, Queens Medical Centre, Nottingham, UK
Introduction. With the recent implementation of NICE guidelines for fertility treatment, Intra-uterine insemination (IUI) is making a resurgence and many centres are providing up to 6 cycles as part of an NHS funded treatment program. This study examines the effectiveness (balanced with cost) of an NHS IUI service performing between 200 and 300 IUI cycles per year.
Methods. IUI data was monitored for 8 consecutive quarters between 2004 and 2006. A conservative approach was adopted involving initial stimulation with gonadotrophins in order to develop a single ovarian follicle. Men with severe male factor infertility were not accepted for treatment.
Results and discussion. 526 cycles were included in the analysis. The overall pregnancy rate was 10.6% (45 pregnancies, 37 live births) per cycle with only 3 twin pregnancies. Quarterly analysis allowed us to see the impact of both male and female factors on the quarterly results. Comparing the most (PR 18%) and least successful quarters (4% per cycle), both male and female factors were significant performance indicators. The median % normal sperm forms was 11.21% compared to 3.25% in the least successful quarter (p < 0.001). Nevertheless pregnancies were still achieved in couples in whom sperm concentration post preparation was deemed to be very poor. Follicular development was highly significant with those patients developing a single mature follicle having an average 9% overall success rate compared to those with more than one at almost 13%. A smaller group with multiple smaller follicles who were allowed to ‘coast’ one further day prior to hCG had an overall PR of 18% per cycle. There were few similarities between quarterly data sets with probably a more complex interplay of both male and female factors than the current analysis allows. In general, female factors seemed to dominate and good results were available in male factor patients, particularly those with reduced numbers. However, a halving of PR was observed in men with <10% rapidly progressive sperm and men with a post wash rapidly motile sperm concentration of less than 1 million per ml.
In conclusion, a conservative approach to IUI can give acceptable pregnancy results with few adverse consequences. Careful quarterly monitoring should eventually allow centres to optimise their service quality and possibly tailor the service to individual patient groups.
Clinical andrology
P4: Is the measurement of free and bioavailable testosterone of value in endocrinological assessment of the infertile male?
Y. Sajjad, V. Finney, E. Derious Barsoum, D.I. Lewis Jones, & W. Taylor
1Hewitt Centre for Reproductive Medicine, Liverpool Women's Hospital, Liverpool, and 2Royal Liverpool and Broadgreen University Hospital
Introduction. The importance of measuring free and bioavailable testosterone (T) in the management of infertile and aging males has yet to be fully established. LH causes release of testosterone from the testicular Leydig cells, which in turn has a negative feedback effect on the hypothalamus. Both T and FSH are necessary for normal spermatogenesis. In normal males 2% of T is free and 30% is bound with high affinity to sex hormone binding globulin (SHBG). The fraction of T not bound to SHBG is the bioavailable T. Within our unit as part of the routine investigation of male infertility patients with subnormal semen analysis a full hormone profile of LH, FSH, prolactin and total T is performed. In addition to this we analysed free T, and bioavailable T to investigate whether these parameters could be useful in the investigation of male factor infertility.
Methods. The patients are being recruited from the andrology clinic where in addition to the routine hormone profile performed for male infertility patients, free and bioavailable T are also analysed. So far 67 patients have been recruited to the study and recruitment will continue for until a minimum of ten patients in each group of subnormal semen analyses is achieved.
Results and discussion. Subnormal semen analyses were divided into groups depending on the type of abnormality. The average total testosterone for all groups was more than 12 nmol/l.
Total, free and bioavailable T were higher in the moderate oligoasthenozoospermia, severe oligoasthenozoospermia, cryptospermic and severe oligospermic patients compared to normospermic patients. The remaining groups all had significantly lower levels of total, free and bioavailable T levels. The provisional results shows the interesting finding of a decrease in free and bioavailable T levels which may be a cause of these patients' hypospermatogenesis.
Embryology
P5: A unique Mullerian anomaly of bicollis uterus and vaginal septum with abnormal cervical smears – a case report of pregnancy in such an anomaly
N. Deo & H.G. Annan
Department of Obstetrics and Gynaecology, Whipps Cross University Hospital, Leytonstone, UK
Introduction. Performing a cervical smear is technically difficult with certain mullerian anomalies. We encountered a case of bicollis uterus and vaginal septum who presented with difficulty in taking cervical smears and was reported to have an abnormal smear. This is the first reported case of pregnancy with this type of unique abnormality.
Methods. A 28 year old nulliparous woman presented to the GP for a routine cervical smear. There was some difficulty in obtaining the smear. The smear revealed moderate dyskaryosis. She was referred to the hospital for further management. Examination in the clinic revealed a double cervix with a vaginal septum. In view of the anomaly, Colposcopy was performed under anaesthesia and was confirmed to have a vaginal septum and two cervices. She underwent laparoscopy which revealed one uterus and normal adnexae. Hysteroscopy done from both cervices revealed a common uterine cavity with a normal endometrium. Colposcopy showed findings suggestive of CIN 1 – 2 and loop cone biopsies were taken from both cervices. The vaginal septum was excised with diathermy. The histology of the loop cones revealed inflammatory changes with no evidence of dysplasia. An IVU was done which did not show any abnormality. She had natural conception six months later. The pregnancy was uncomplicated. She went into spontaneous labour at 40 weeks gestation delivered vaginally, a 3.4 kg baby in good health and condition.
Results and discussion. This unique mullerian anomaly which does not conform to our classical understanding of mullerian development may be due to minor mesonephric defects or to an alternative mechanisms of mullerian development. Women with two cervices and a vaginal septum may pose difficulties during taking cervical smears and the same may be done under anaesthesia. Since they are exposed to the same oncogenes the risk of developing carcinoma exists in both cervices. Vaginal septae could become a source of vaginal dystocia or lacerations. As it was excised, it prevented these potential obstetric complications. Excision of the septae may reduce the technical difficulty of taking cervical smears and general anaesthesia may not required for cervical screening in the future. It is the first reported case of pregnancy and hence we can assume that women with this anomaly can be offered vaginal delivery.
Infertility-female
P6: Culture of ovine ovarian cortex as a tool to quantify the ovotoxicity of chemotherapy agents on the ovary
H.M. Picton, M. Gunson, S. Harris, A.J. Rutherford, V. Sharma, & A. Glaser
Reproduction and Early Development Research Group, Department of Obstetrics & Gynaecology, University of Leeds, Leeds, UK
Introduction. Girls and young women may suffer reduced fertility and/or total sterility as a late effect of treatment with chemotherapeutic agents. This phenomenon occurs as a consequence of the ovotoxic impact of chemotherapy drugs on the primordial follicle reserve. However, it is difficult to accurately predict the extent of this damage. This work aimed to evaluate sheep ovarian cortex culture as a tool to directly quantify the effects of exposure to the chemotherapy agent Cisplatin on the primordial follicle reserve.
Methods. Replicate samples of ovine cortex were sectioned to approximately 100 μm and were cultured in defined serum-free media at 37°C in 5% CO2 in air. On day 2, tissue was exposed to 0 or 7 μg/ml of Cisplatin for 24 hours. Tissue was washed and the culture continued for a further 6 days. To quantify tissue damage a colorimetric assay for lactate dehydrogenase (LDH) content was conducted on spent culture media collected on days 1, 2, 4, 6 and 8. Measurement of the ratio of glucose:lactate in spent culture media was used to evaluate cellular metabolism following cisplatin exposure. At the end of culture tissue was fixed for histological evaluation.
Results and discussion. Preliminary analysis of 24 tissue pieces from 3 replicate cultures indicated that sheep cortex survived for 8 days following exposure to 7 μg/ml of Cisplatin. No significant differences were detected in tissue weights or glucose:lactate ratios between treated and control tissues. Measurable levels of LDH (range 1.62 × 10−4 to 2.13 × 10−4 U/ml) were detected in spent media before and after Cisplatin exposure; changes in LDH levels were not significantly different between treated and control tissue. These preliminary results suggest that the culture of sheep ovarian cortex may be a useful model to predict the ovarian impact of repeat exposure to chemotherapy drugs in vitro.
(Funded by Candlelighters Childrens Charity.)
Reproductive surgery
P7: Surgical management of endometriomas in an IVF setting. A review
A. Chavez-Badiola, S.E. Papadopoulos, A.J. Drakeley, R. Gazvani, & C.R. Kingsland
Hewitt Centre for Reproductive Medicine, The Liverpool Women's Hospital, Liverpool, UK
Introduction. Endometriosis is frequently encountered in subfertile patients. It is the primary indication for up to 14% of IVF cycles. There are controversies about the impact of laparoscopic surgery for endometriomas in an IVF setting. Discussion includes ideal surgical approach, impact of surgery in final outcomes and the potential risks of conservative management.
Methods. A systematic review in PubMed, the Cochrane Database for Systematic Reviews and Aditus was carried out. Important references from papers obtained, background articles, guidelines and reviews by experts in the subject were also analysed.
Results and discussion. ESHRE and the RCOG guidelines suggest the need for surgical management of endometriomas larger than 3 cm prior to IVF and laparoscopic approach is the gold standard. There is increasing evidence in the literature supporting conservative management in patients with asymptomatic endometriomas prior to IVF. Regarding the laparoscopic management of endometriomas three approaches have been described: cystectomy, fenestration with vaporisation and ultrasound-guided drainage, with or without sclerotherapy. Cystectomy provides with material for pathological analysis of the pseudocyst, offering an added advantage over drainage and fenestration. Unlike fenestration and vaporisation, it does not require special equipment (CO2 laser/diathermy). On the other hand, ultrasound guided drainage is, in the short term, the least expensive option, but has the highest recurrence rates as well as the highest risk of infection and abscess formation. With respect to the outcomes it appears that skills of the surgeon are more important than the technique employed. Using appropriate surgical techniques, the damage to healthy ovarian tissue can be kept to a minimal and without impact on IVF outcomes. Lack of evidence showing clear benefits with intervention, the known potential risks, delay in treatment and financial implications associated with surgery would seem to incline the balance towards the conservative management of endometriomas. Unfortunately most studies also fail to take into consideration the potential risks associated with the conservative management and these risks in themselves may justify surgical intervention.
Conclusion. Meticulous surgical techniques for the management of endometriomas are of paramount importance to avoid damage of healthy ovarian tissue. There is not strong enough evidence upon which to base a recommendation regarding the optimal approach in the management of endometriomas in an IVF setting. However, before further guidelines are issued, both the potential benefits and risks associated with different management options, including conservative approaches, must be evaluated and taken into account in the equation.
Research models in reproduction
Animal models for ovarian functions
Bruce Campbell
Division of Obstetrics and Gynaecology, Queen's Medical Centre, Nottingham, UK
It is necessary to understand the basic physiology underlying the complex processes of oogenesis and folliculogenesis to address common causes of infertility and to devise innovative strategies to increase the efficiency of assisted reproduction technologies. Availability of suitable ovarian tissue is a major constraint to research in this area in humans and this paper reviews the similarities and differences in ovarian physiology of available animal models in relation to the human before concentrating on several whole animal and cell culture models developed in monovulatory domestic ruminants (sheep and cattle). These species represent a physiologically relevant model to elucidate basic mechanisms prior to more focused clinical investigations, and the development of whole animal and cell culture models in ruminants have allowed basic investigations into the endocrine and local mechanisms regulating pre-antral and antral follicle development. Studies on pre-antral follicle have utilised both in vivo (the ovarian autograft model) and in vitro approaches to examine the local and endocrine control of follicle and oocyte development and both these model systems have direct clinical relevance in terms of preservation of fertility. Studies on the gonadotrophic control of antral follicle development have been facilitated by the development of GnRH-agonist and GnRH-antagonist suppression and gonadotrophin replacement model systems which are directly analogous to the clinical situation. The identification of naturally occurring mutations in sheep which exhibit altered ovarian function in combination with physiological cell culture models have highlighted the essential importance of somatic and oocyte secreted local factors which modulate the gonadotrophic signals which control the terminal stages of follicular growth and differentiation. In conclusion, the domestic ruminant represents a valuable model system for the elucidation of the endocrine and local mechanisms controlling both early and terminal stages of follicle development in monovulatory species. The results of many of these investigations have direct strategic relevance within clinical medicine.
Rodent models of the developmental origins of adult disorders
Simon Langley-Evans
School of Biosciences, University of Nottingham, Sutton Bonington, UK
The environment encountered in fetal and neonatal life exerts a profound influence upon physiological function and risk of disease in adult life. Epidemiological evidence suggests that impaired fetal growth followed by rapid catch-up in infancy is a strong predictor of obesity, hypertension, non-insulin dependent diabetes and coronary heart disease. Whilst these associations have been widely accepted to be the product of nutritional factors operating in pregnancy, evidence from human populations to support this assertion is scarce. Studies in rodent species clearly demonstrate that there is a direct association between nutrient imbalance in fetal life and later disease states, including hypertension, diabetes, obesity and renal disease. These associations are independent of changes in fetal growth rates. Experimental studies examining the impact of micro- or macronutrient restriction and excess in rodent pregnancy provide clues to the mechanisms that link fetal nutrition to permanent physiological changes that promote disease. Exposure to glucocorticoids in early life appears to be an important consequence of nutrient imbalance and this may lead to alterations in gene expression that have major effects upon tissue development and function. Epigenetic mechanisms, including DNA methylation may also be important processes in early life programming.
Sheep models of adolescent pregnancy
Jacqueline Wallace
Rowett Research Institute, Buckburn, Aberdeen, UK
The risks of miscarriage, prematurity and low birth weight are particularly acute in adolescent girls who are still growing at the time of conception. The role of maternal nutrition in mediating pregnancy outcome in this vulnerable group has been examined in sheep models. Sheep offer several advantages over laboratory rodents as clinically relevant paradigms. Relative to the human, these include the ability to study singleton pregnancies, comparable birth weight, similar organogenesis for all major systems, equivalent rates of fetal protein accretion and a similar ratio of maternal:fetal body weight. Furthermore, sheep have a relatively long gestation length and when required the mother and fetus can be catheterised to measure fetal endocrine status, nutrient uptakes and fetal metabolism. When singleton bearing adolescent dams are overnourished to promote rapid maternal growth throughout pregnancy, growth of both the placenta and fetus is impaired, and birth occurs prematurely relative to control adolescents of equivalent age (model 1). Studies at mid-gestation, prior to alterations in placental mass, suggest that reduced proliferation of the fetal trophectoderm, impaired angiogenesis, and attenuated uteroplacental blood flows are early defects in placental development. By late pregnancy, relative placental mass is reduced by 45%. The asymmetrically growth restricted fetuses are hypoxic, hypoglycemic and have reduced insulin and IGF- concentrations. However, fetal utilisation of glucose and oxygen remain normal on a fetal weight basis. This suggests altered sensitivities to metabolic signals and may have implications for subsequent metabolic health. At the other end of the nutritional spectrum, many girls who become pregnant have inadequate or marginal nutritional status during pregnancy. This situation is replicated in model 2, whereby dams are prevented from growing during pregnancy by relatively underfeeding. Limiting maternal intake in this way gradually depletes maternal body reserves leading to a lower transplacental glucose gradient and a modest slowing of fetal growth in late pregnancy. These changes appear to be independent of alterations in placental growth per se. Thus, while the underlying mechanisms differ, maternal intake at both ends of the nutritional spectrum is a powerful determinant of fetal growth in pregnant adolescents.
The value of non-human primates in elucidation of the effects of hormone and growth factor manipulation on reproduction
Hamish Fraser
MRC Human Reproductive Sciences Unit, University of Edinburgh, Edinburgh, UK
Novel drugs, such as those being developed to manipulate angiogenesis, which affect the reproductive system may have potential for contraception and for the treatment of reproductive disorders. However, they also may cause marked changes in the endocrine system for prolonged periods or have other unwanted effects on the reproductive tract. The population which may receive clinical benefit reproductive medicine is unusual in that the majority will be relatively young and have either no disease, as in contraception, or the condition will not be life-threatening, e.g. endometriosis or infertility. Thus, it is crucial that the effects of such compounds be carefully investigated in animal models whose reproductive function closely resembles that of the human. The common marmoset and macaques are the most widely used species, but neither is identical to the human so that the issue of their use is complex and requires ongoing examination and dialogue.
Our experience has been based upon treatment schedules with GnRH analogues or inhibitors of angiogenesis at specific stages of the reproductive cycle.
The issue is whether effective use of these species helps ensure that the period between basic research and clinical application is one during which new discoveries may be made and mechanisms of action explored more deeply.
Early embryos – mouse and domestic animalmodels
Henry Leese
Department of Biology, University of York, York, UK
Human embryos for research purposes are a precious resource; they are available in only small numbers and their quality is generally poor since the best are transferred as fresh embryos or cryopreserved for replacement in a subsequent cycle. These considerations make it essential to underpin research on human embryos with research on animal models. The mouse has long provided the standard model of preimplantation development; other small animal models are provided by the rat, guinea pig, hamster and some marsupials. While mouse embryos have many advantages as model systems, they are not as close to the human in terms of their early development and metabolism than those of domestic animals – mainly cows, pigs, rabbits and sheep – and non-human primates. Further differences between species are encountered during the later preimplantation period and at implantation itself. There is no ideal research model of the early embryo; rather, a range of models should be used, acknowledging their strengths and weaknesses, to build up a body of information, which can provide knowledge of early embryo biology and help ensure the safety and efficacy of embryo-based biotechnologies in man and domestic animals.
Human models for the investigation of labour
Steve Thornton
Department of Obstetrics and Gynaecology, University of Warwick and University Hospital Coventry and Warwickshire, Coventry, UK
The mechanisms underlying the onset of term and preterm labour are relatively poorly understood. This has hampered development of pharmacological agents to manipulate uterine activity, which are important for the effective treatment of conditions such as preterm labour, postpartum haemorrhage and failure to progress in labour. Our work has concentrated on investigating the underlying physiological and pathophysiological mechanisms of labour and has almost exclusively used human tissue. This has a number of advantages but is also associated with many specific procedures and regulations.
A common criticism of using animal models is that the results may not be completely applicable to humans. Although the use of human tissue overcomes this potential weakness, there are a number of specific difficulties. One of the major problems is that the environment cannot be controlled so (for example) tissue taken from women before the onset of labour may not be comparable with tissue taken after this time. This makes it difficult to specify which differences are due to pharmacological treatments, the environment and labour.
There are also a number of other specific issues such as obtaining written, informed consent, collection of tissue in the operating theatre and the subsequent storage of tissue. The procedures for consent have become increasingly complex in recent years and these will be outlined briefly. There is also a need to follow recent guidelines for tissue storage from the Human Tissue Authority and the main principles will be outlined. Furthermore, there is a need to obtain approval from local hospital Trust R&D departments and the procedure for this will also be reviewed.
In summary, there are many scientific techniques, which are appropriate to use in samples taken from human subjects. However, there are increasingly complex procedures and protocols, which must be followed to comply with current legislation.