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Objective To determine whether the presence of soluble human leukocyte antigen G (sHLA-G) affects implantation and pregnancy outcomes in vitro. Design A multicenter retrospective study. Setting Six certified in vitro fertilization (IVF) units. Patient(s) Embryos obtained from 2,040 patients from six different IVF clinics. Intervention(s) Soluble HLA-G determination on day-2 embryos after intracytoplasmic sperm injection, with embryos transferred on day 3 using the sHLA-G data. Main Outcome Measure(s) Ongoing pregnancy rate (10- to 12-week ultrasound finding). Result(s) All embryos were individually cultured, and a chemiluminescence enzyme-linked immunosorbent assay was used to detect the presence of sHLA-G in the culture medium surrounding the embryos. Embryos were selected based on a positive sHLA-G result and a graduated embryo scoring (GES) score >70, or on embryo morphology if the test was negative. In all centers, a positive sHLA-G result was associated with an increase in the odds of an ongoing pregnancy. The incidence of an ongoing pregnancy was 2.52 times greater in embryos transferred on day 3 with a positive sHLA-G test result than the incidence of an ongoing pregnancy in embryos with a negative sHLA-G test result. Conclusion(s) Data from this multicenter study confirm that sHLA-G expression is a valuable noninvasive embryo marker to assist in improving pregnancy outcomes, with the theoretical potential to reduce multiple pregnancies.

Objective To study the biochemical and morphologic implications of different hormonal levels on endometrial development during assisted reproductive technology (ART) cycles. Design Prospective, controlled study. Setting University center. Patient(s) Eleven women during a natural cycle (controls) and 11 oocyte donors during an ART cycle (treated). Intervention(s) At the time consistent with day-3 ET, a transvaginal ultrasound, an endometrial biopsy, and blood sampling were performed. Morphology and thickness of the endometrial stripe were recorded. Real-time reverse transcriptase–polymerase chain reaction was used to measure messenger RNA (mRNA) levels for estrogen receptor (ER)-α, ER-β, P receptor (PR)-A, and PR-B in the endometrial tissue. Main Outcome Measure(s) To evaluate morphologic and biochemical endometrial development. Result(s) Endometrium was mostly trilaminar (proliferative-like pattern) and thicker in the treated group, as opposed to homogeneous and thinner in the controls. The PR-B mRNA expression increased 41% in treated patients; PR-A mRNA expression, instead, was unchanged. Serum E 2 and P were higher in the treated group than in controls. In contrast, FSH and LH levels were lower in the treated group. Conclusion(s) When compared with natural cycles, exposure of the endometrium to high hormone levels during ovarian stimulation significantly increased PR-B receptor expression at the time of ET. Concurrently, a proliferative-like endometrial pattern persisted. These findings reflect a delayed endometrial development in ART.

Objective To establish fertile and subfertile groups of males in couples presenting with endometriosis-related infertility in the female. Design Retrospective study of semen profiles on partners of women undergoing surgery for endometriosis-related infertility. Setting University-affiliated assisted reproduction center. Patient(s) One hundred seventeen partners of females undergoing surgery for endometriosis related infertility. Main Outcome Measure(s) Fertility potential according to Tygerberg strict criteria for sperm evaluation. Result(s) A total of 65.8% of the semen analysis were reported normal according to the Tygerberg strict criteria and 34.2% were reported subfertile. Of the total, 11.96% of the patients studied had a severe defect (azoospermia, double, and triple defects). Conclusion(s) Labeling of the male in couples presenting with infertility as fertile, subfertile, or infertile plays an important role in decision making regarding management of the female presenting with endometriosis-related infertility. It is important that in future studies on the effect of surgery on improving pregnancy outcome in patients with endometriosis the semen profile be reported and thresholds used should be mentioned. This will contribute significantly to the future comparison of data on the impact of the male factors in couples presenting with endometriosis-related infertility.

Objective To develop a method whereby sperm with phosphatidylserine externalization can be separated from those without this feature. Because annexin V binds phosphatidylserine, this study is using this feature to select functional spermatozoa. In addition, the relationship between annexin V binding in human spermatozoa and normal sperm morphology according to strict criteria was to be assessed. Design Prospective study. Setting Department of Obstetrics and Gynaecology of Stellenbosch University at Tygerberg Academic Hospital, Tygerberg, South Africa. Patient(s) Semen from 14 healthy sperm donors. Exclusion criterion was the presence of less than 20 × 10 6 /mL total motile spermatozoa in the original sample. Main Outcome Measure(s) Annexin V-negative sperm, annexin V-positive sperm, normal sperm morphology. Intervention(s) An aliquot of a semen sample after double density gradient centrifugation was incubated with annexin V fluorescein isothiocyanate conjugate (FITC). Cell fluorescence signals were determined using a FACScalibur flow cytometer equipped with a FACSSort fluidic sorting module. The sorting procedure delivered two sperm subpopulations: annexin V-negative and annexin V-positive. Morphology slides were made and the sperm morphology was assessed according to strict criteria. Result(s) There was a significant enrichment of annexin V-negative sperm as well as morphologically normal sperm in the annexin V-negative subgroup after separation with flow cytometry. The percentage of morphologically normal sperm increased from 8.3% in the control to 11.9% in the annexin V-negative fraction, whereas the percentage of annexin V-positive sperm decreased to 5.7%. Conclusion(s) The annexin V-negative sperm subpopulation had morphologically superior quality sperm compared to annexin V-positive sperm. It is important to select morphologically normal sperm during intracytoplasmic sperm injection (ICSI) as it may contribute to increased implantation and pregnancy rates (PR).

In this retrospective cohort study of 102 ovarian stimulation cycles for IVF/intracytoplasmic sperm injection using GnRH antagonist and gonadotropins, we sought to assess the effect of high E(2) levels on endometrial stripe thickness and its association with pregnancy outcomes and serum E(2) levels. We found no significant correlation between serum E(2) levels (both peak and area under the curve E(2) concentration) and the endometrial thickness. However, there was a statistically significant inverse relationship with early pregnancy loss (31%) if the endometrial thickness was9.8 mm (sensitivity 71%; specificity 76%).

The aim of this literature search is to establish if metformin is efficacious when given to clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS) patients.Medline database was searched from 1 January 1980 to 1 January 2005. Inclusion criteria were prospective randomized control trials where metformin was randomized either with placebo or CC to induce ovulation in the CC-resistant patient.Group 1: Four trials were prospective double-blind placebo controlled. When the data of the four trials were pooled, the overall effect of the addition of metformin in the CC patient was P=.0006 with a 95% confidence interval (CI) of odds ratio (OR) 1.81-8.84. Group 2: In two trials the randomization was only prospective. When the data of these two trials were pooled, the overall effect of the addition of metformin in the CC-resistant patient was P.0001 with a 95% CI of OR 6.24-70.27. Groups 1 and 2: The combined data show an overall effect of P.0001 with a 95% CI of OR 3.59-12.96.The addition of metformin in the CC-resistant patient is highly effective in achieving ovulation induction.

Simultaneous sampling from the antecubital vein (ACV) and a heated superficial hand vein (HSHV) at 10-minute intervals was performed in 6 women for determination of glucose, insulin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, estradiol (E 2 ), progesterone (P 4 ), testosterone (T), and dehydroepiandrosterone sulfate (DHEAS). Strong correlations were identified for each parameter between the two vessels, with luteinizing hormone (LH) and follicle-stimulating hormone (FSH) pulse patterns nearly superimposable between antecubital vein (ACV) and superficial hand vein (HSHV) samples.

Objective To investigate whether there is an impact of different sources of reactive oxygen species (ROS) on sperm functions. Design Prospective study. Setting Patients at the Center for Dermatology and Andrology, Giessen, Germany. Patient(s) Semen collected from 63 randomly collected patients attending the IVF unit of the University of Giessen, Germany. Intervention(s) Only patients with nonleukocytospermia were included in this study. Main outcome measure(s) Sperm count and motility before and after sperm separation by swim-up, morphology, DNA fragmentation, and extrinsic (by leukocytes) and intrinsic ROS production (by spermatozoa) were evaluated. Result(s) Leukocytes correlated significantly with extrinsic ROS production (r = 0.576), but markedly less with intrinsic ROS production (r = 0.296). Sperm count, morphology, and motility in the ejaculate were markedly more affected by extrinsic than by intrinsic ROS. The DNA fragmentation was strongly positively correlated with intrinsic ROS production, whereas this correlation was weaker for extrinsic ROS production. No correlation was found between DNA fragmentation and the number of leukocytes, whereas the correlations with motility in the ejaculate and the motile sperm count after swim-up were highly significant. Moreover, significant differences were observed for extrinsic and intrinsic ROS production between groups of patients having a high (≥1 × 10 6 /mL) and a low number ( 6 /mL) of leukocytes in the ejaculate. Conclusion(s) The origin of ROS seems to have an influence on the site of the damage. Because leukocyte counts 6 /mL caused a significant decrease of motility and DNA integrity, the threshold given by the World Health Organization (WHO) should be re-evaluated.

Objective To investigate sperm DNA damage in relation to fertilization and pregnancy. Design Prospective study. Setting The Institute of Reproductive Medicine, Giessen, Germany. Patient(s) Semen collected from 249 patients attending the IVF program. Main outcome measure(s) The percentage of terminal deoxynucleotidyl transferase-mediated dUDP nick-end labeling- (TUNEL-), Fas-, and annexin-V-positive sperm and the proportion of green-fluorescing sperm in the acridine orange stain was determined and correlated with sperm concentration, motility, fertilization, and pregnancy. Result(s) Significant correlations with the concentration of motile sperm were only found for the acridine orange stain (before and after sperm separation) and for the TUNEL assay (after sperm separation). Moreover, patients whose sperm had a high percentage of DNA fragmentations showed significantly lower pregnancy rates (TUNEL assay: 19.05% vs. 34.65%; acridine orange stain: 24.58% vs. 37.93%). The apoptosis parameters (annexin V binding and Fas expression) showed no statistically significant differences. Conclusions Our data clearly demonstrate that DNA fragmentation, as determined by the TUNEL assay, is predictive for pregnancy in IVF. This implies that spermatozoa with DNA fragmentation can still fertilize an oocyte but that when paternal genes are "switched on," further embryonic development stops, resulting in failed pregnancy. It seems that, at least in the patients we analyzed, apoptosis in the sperm does not play a role for fertilization. This would imply that DNA fragmentation in human spermatozoa is caused by external factors, such as reactive oxygen species, rather than by apoptosis.

Objective To evaluate the possible relationships between sperm morphology, acrosome responsiveness to solubilized human zona pellucida, and sperm–zona binding potential among [1] consecutive andrology referrals and [2] randomly selected in vitro fertilization (IVF) cases. Design Prospective analytical study. Setting Academic training hospital. Patient(s) Randomly selected couples consulting for infertility. Intervention(s) Acrosome reaction response to solubilized human zona pellucida was recorded. Main outcome measure(s) We determined the difference in the percentage of sperm that acrosome reacted after exposure to solubilized zona pellucida and spontaneous acrosome reaction. The results were expressed as percentage zona induced acrosome reaction (ZIAR). Result(s) Data were analyzed using correlation coefficients (r) and receiver operator characteristics (ROC curve analyses). The ROC curve analyses indicated ZIAR to be a sensitive indicator for fertilization failure during IVF therapy, with sensitivity and specificity of 81% and 75%, respectively. For andrology referrals, a positive and statistically significant correlation existed between ZIAR data and sperm morphology (r = 0.65) and sperm–zona binding (r = 0.57). Conclusion(s) ZIAR results provide further information regarding dysfunctional sperm and can be used as an additional diagnostic test. Our results predicted fertilization failure during IVF treatment.

Objective: To develop a training program with intervals of continuous quality control assessments for the evaluation of strict sperm morphology. Design: Prospective analytical study. Setting: Academic hospital and academic institution setting. Patient(s): Healthy sperm donors. Intervention(s): Nine individual andrology laboratories in Switzerland were invited to participate in a training course for strict sperm morphology, which was followed up every 3 months by a continuous quality control program. Each laboratory received six slides over a period of 9 months, during which time the results were forwarded to the reference laboratory. Papanicolaou stain sperm slides were prepared and shipped to participating laboratories every 3 months. Main Outcome Measure(s): Percentage of normal spermatozoa. Result(s): The mean (±SE) percentage of normal sperm reported by the reference laboratory compared with the participating laboratories for slides 1–6 were 11.4 ± 1.6 vs. 17.3 ± 6 ( P >.2), 6.0 ± 1.3 vs. 8.6 ± 2.5 ( P >.2), 9.0 ± 0 vs. 9.6 ± 3 ( P >.2), 1 ± 0 vs. 1.2 ± 0.2 ( P >.2), 23.3 ± 0.3 vs. 28.0 ± 1.3 ( P >.2), and 2.0 ± 0 vs. 6.1 ± 1.2 ( P >.2), respectively. Technician proficiency was reported to differ by Conclusion(s): The results illustrate that training and proficiency testing can be conducted on a national and international level with the support of a reference laboratory. Global quality control measurements in andrology laboratories should become mandatory, since these results indicate that continuous quality control for laboratory technicians can be successful.

Objective: To evaluate the level of variance produced in a multicenter study with the use of a computer-assisted sperm morphology analyzer. Design: A multicenter, prospective, blinded study. Setting: Assisted reproduction research laboratories. Patient(s): Semen samples produced for assisted reproductive procedures. Intervention(s): Hamilton Thorne Research (Beverly, MA) integrated visual optical system semen analyzers were used at five different centers to evaluate the same set of 30 slides that were prepared and numerically coded at Tygerberg Hospital in Tygerberg, South Africa. Main Outcome Measure(s): The percentage of normal sperm. Result(s): Interlaboratory coefficients of variation (CVs) ranged between 16.31% and 23.09%. One of the participating laboratories produced an approximately 14% (−6.5–7.7) limits of agreement analysis, with a CV of 11.36%, for its duplicate readings. The use of a 10% normal sperm morphology cutoff point to determine discordance levels produced rates ranging between 10% and 23.3% for the interlaboratory and intralaboratory readings. This level of discordance equates with ≤7 of the corresponding readings from two laboratories falling into a different normal sperm morphology group (≤10% or >10%). Conclusion(s): The magnitudes of variation produced by the readings performed in our study reached the same level as for the manual evaluation of sperm morphology. A

Objective: To assess the relationship between sperm morphology and motion parameters and sperm-zona pellucida (ZP) binding capacity under hemizona assay (HZA) conditions and to determine the discriminatory power of the HZA for the prediction of in vitro sperm fertilizing ability. Design: Prospectively designed study. Setting: Academic tertiary centers. Patient(s): One hundred ninety-six couples undergoing IVF therapy participated in this study. Intervention(s): Hemizona assay and IVF results were determined for each couple. Main Outcome Measure(s): Computerized sperm motion analysis, sperm morphology (strict criteria), and HZA results were correlated with fertilization outcome. Result(s): Among sperm parameters from the original ejaculates, morphology was the best predictor of sperm-ZP binding ability; hyperactivated motility was the best predictor of HZA results after swim-up separation of the motile sperm fractions. The HZA index provided the highest discriminatory power for fertilization success/failure, with an overall accuracy of 86%. Conclusion(s): Sperm morphology and hyperactivated motility showed a high correlation with the capacity of sperm to achieve tight binding to the ZP. The excellent positive and negative predictive values of the HZA for fertilization outcome provide additional support for the use of this functional bioassay in the decision-making process within the assisted reproduction setting.

Objective To evaluate the IVOS (Hamilton Thorne Research Version 2.1 Dimension Program, Beverly, MA) system's ability to predict fertilization in vitro in a prospective study. Design A prospective clirical study. Setting Hospital-based academic ART program. Patients Eighty patients from the IVF-GIFT program were evaluated. The same semen sample was analyzed on a day-to-day basis by both laboratory (manual method) and the computerized system for percentage normal morphology, concentration/mL, motility, and forward progression. Only patients with two or more metaphase II (Mil) oocytes available were allowed into the study and excluded where the male partner had antisperm antibodies or qualified for intracytoplasmic sperm injection ( Statistical Analysis Logistic regression analysis was used to study predictors of fertilization in vitro. Results Three hundred thirty-eight oocytes were obtained from 80 patients of which 239 fertilized. The logistic regression analysis of the manual method (percentage normal morphology) and IVOS indicated that both were predictors of fertilization. Sperm morphology as evaluated by IVOS in patients with 6 motile spermatozoa/mL retrieved after swim-up was a significant predictor of fertilization as was the number of oocytes obtained. Thus, the more oocytes obtained in the lower morphological groups, the better the chance of fertilization. The fertilization rate in the morphology group 0% to 4% normal forms was 45.6% (37/81) and in the group >14% normal forms was 85.2% (69/81). Conclusions It was shown that in patients where ≤10 × 10 6 motile spermatozoa were obtained, the role of morphology (evaluated by IVOS) as well as the number of oocytes were important predictors of fertilization. The computer can assist to identify these patient with a poor prognosis for fertilization.

Objective To determine the sensitivity and clinical significance of fluorescein isothiocyanate wheat germ agglutinin (FITC-WGA) staining of human spermatozoa. Design Percentage FITC-WGA staining was assessed in the different morphological zones of human spermatozoa and compared with fertilization rates of metaphase II oocytes in vitro. Patients Spermatozoa and oocytes were obtained from normospermic (n = 12) and male factor patients (n = 15) attending the Tygerberg Hospital's IVF clinic. Main Outcome Measures Aliquots of swim-up spermatozoa used in the IVF laboratory were examined for the presence and morphological localization of WGA receptors. Fertilization rates were expressed as the percentage of metaphase II oocytes with successful fertilization. Results Human spermatozoa capacitated in vitro for use in an IVF program showed variations in the percent positive staining of the acrosomal region which correlated with IVF rates in both patient groups studied. Values of FITC-WGA acrosomal staining of 35% WGA acrosomal staining corresponded with IVF rates >50%. Significant differences between acrosomal and equatorial region staining from normozoospermic samples and male factor samples also were observed. Conclusion The results indicate the practical use of the WGA assay for molecular assessment of male fertilizing capacity in conjunction with an assisted reproductive program

To investigate the predictive value of sperm morphology assessed by strict criteria on IVF outcome.Retrospective analysis of all IVF cycles (January 1987 to December 1992).All patients were assigned to one of three groups based on sperm morphology: P-pattern (4% normal forms), G-pattern (4% to 14% normal forms), and N-pattern (14% normal forms). Morphology pattern was related to other semen characteristics and IVF outcome.Despite corrective measures at oocyte insemination, the fertilization rate was significantly different among the three morphology groups, PGN. N-pattern sperm produced a mean fertilization rate over 85% regardless of low motility or concentration. In a cohort study, P-pattern cycles produced a lower implantation rate and lower ongoing pregnancy rate, independent of the lower fertilization rate.Strict morphology is an excellent biomarker of sperm fertilizing capacity, independent of motility and concentration. P-pattern sperm may denote a poorer prognosis for establishing a pregnancy, even after a satisfactory fertilization rate is achieved.

Study Objective To determine the impact of sonographically identified large uterine fibroids (>5 cm in diameter) on obstetric outcomes. Design Retrospective cohort study. Setting University teaching hospital. Patient(s) Women with singleton gestations (n = 95) noted to have uterine fibroids on obstetric ultrasonography from September 2009 through April 2010 and age-matched controls (n = 95). Intervention(s) None. Main Outcome Measure(s) Obstetric outcomes including short cervix, preterm premature rupture of membranes, and preterm delivery. Result(s) Compared to women with no fibroids or small fibroids (≤5 cm), women with large fibroids (>5 cm) delivered at a significantly earlier gestational age (38.6 vs. 38.4 vs. 36.5 weeks). Short cervix, preterm premature rupture of membranes, and preterm delivery were also significantly more frequent in the large fibroid group, and were associated with number of fibroids >5 cm in diameter. Blood loss at delivery was significantly higher in the large fibroid group (486.8 vs. 535.6 vs. 645.1 mL), as was need for postpartum blood transfusion (1.1 vs. 0.0 vs. 12.2%). Conclusion(s) Women with large uterine fibroids in pregnancy are at significantly increased risk for delivery at an earlier gestational age compared to women with small or no fibroids, as well as obstetric complications including excess blood loss and increased frequency of postpartum blood transfusion.

To determine the effect of oocyte maturity on pregnancy rate (PR) in patients undergoing gamete intrafallopian transfer (GIFT) procedures for infertility and in whom male partners had either normozoospermia or teratozoospermia.A prospective study using a combination of clomiphene citrate and human menopausal gonadotropin for ovulation induction was carried out. Five hundred thirty-seven GIFT treatment cycles were analyzed, and 423 cycles yielded four or more oocytes. Patients were divided into two groups according to the sperm morphology: those with less than 14% normal forms and those with greater than 14% normal morphology (as judged by strict criteria). These two groups were divided into a further five subcategories depending on the number of metaphase II oocytes transferred.In the group less than 14% normal forms (category I; 4 metaphase I oocytes replaced), three pregnancies resulted from 33 cycles (9.09%), and in category V (4 metaphase II oocytes transferred) the PR was 15% (14/95) per cycle. In the group with greater than 14% normal forms, in category I, the PR was 16% (3/19) per cycle, and in category V, the PR was 33% (20/61) per cycle. The effect of morphology (less than 14% normal forms versus greater than 14% normal forms) on pregnancy outcome is significant (P = 0.0161). The overall effect of increasing the number of metaphase II oocytes on the pregnancy outcome was not significant (P = 0.1098). However, in the group with greater than 14% normal forms, there was a significant improvement in PR (P = 0.04) in category V.During this prospective study, it was shown that sperm morphology plays a significant role in the pregnancy outcome in a GIFT program.

Objective To evaluate the immediate effect of hands-on training on the quality of technical skills of laboratory technicians. Design Retrospective analytical study. Setting Academic institutions and private infertility clinics. Participants One hundred and ten laboratory technicians. Intervention(s) None. Main Outcome Measure(s) First, 110 participants from 16 African countries attended 5-day semenology workshops at Tygerberg Hospital. During these workshops the methodology as described by the World Health Organization manual for the analysis of human semen, namely, sperm concentration, motility, vitality, and morphology, formed part of the curriculum. Second, two experienced morphology readers from the Tygerberg group presented 23 1-day sperm morphology workshops in nine other countries. Result(s) The semenology workshops indicated a significant improvement in the evaluation of sperm concentration only, whereas pretraining and posttraining results for motility did not differ. Vitality reports did not differ from those of the experienced worker in the first place. Calculation by means of a linear regression model showed a significant decrease in the mean posttraining scores from the pretraining scores for the sperm morphology courses. Conclusion(s) Training improved technical skills for the evaluation of morphology and sperm concentration. The evaluation of graded sperm motility seems to be more difficult to teach over a short period.

Objective To achieve a better understanding of the variability in sperm and oocyte binding capacities will optimize use of the hemizona assay (HZA) as a predictor of sperm function. Design Limitations of the HZA were more clearly delineated by current studies: (1) variability of sperm binding capacity of men over a 90-day interval; (2) variability of sperm binding using different oocytes; and (3) lower limits of the number of sperm bound from the fertile control in two laboratories. Patients Semen was obtained from proven fertile men and one subfertile individual. Main Outcome Measure The number of sperm tightly bound to the hemizona were measured and compared. Results In the initial study, 6 fertile control men exhibited a similar degree of variability in zona binding when studied over a 90-day interval. Average sperm binding for individuals ranged from 68 to 127. Second, 3 of the 15 simultaneous assays showed very low numbers of sperm bound, indicating that 20% of the zonae had poor binding. Third, from 18 men who had 0% fertilization in an in vitro fertilization system using mature oocytes, evaluation of their sperm by HZA was performed. The sperm bound poorly and the 95% confidence interval was 20 sperm bound. Thus, the fertile controls should bind > 20 sperm to distinguish them from the infertile group in the HZA system resulting in a valid assay. Conclusions With these guidelines, applications of the HZA may be made with greater reassurance of a valid bioassay of sperm fertilizing potential.

Sixteen couples were diagnosed as having immunological infertility. To detect sperm-bound immunoglobulin (Ig), i.e., IgA, IgG, and IgM antibodies, the direct immunobead test (IBT) was used. In each individual patient, the direct IBT was greater than or equal to 70% positive for either IgA or IgG or both. The indirect IBT was positive for IgA and IgG antibodies in the serum of all the patients. Semen was collected in 15 mL medium (Ham's F10 [Gibco, Grand Island, NY] + 10% whole blood serum) and prepared with the wash and swim-up method. Patients in the study group were treated for their immunological infertility problem by performing the gamete intrafallopian transfer (GIFT) procedure. An ongoing pregnancy was achieved in 7 of the 16 (43%) couples treated with the GIFT procedure with an ongoing pregnancy rate of 24.1% (7 of 29) per cycle. The GIFT procedure appears to be an effective and safe way of treating male immunological infertility.

To identify determinants of the serum concentration of hCG levels after triggering of ovulation with exogenous hCG during controlled ovarian stimulation cycles for in vitro fertilization with or without intracytoplasmic sperm injection.Retrospective cohort study.University Medical Center.One hundred-fifteen women who underwent conventional in vitro fertilization/intracytoplasmic sperm injection cycles from March 2003 to March 2005.All patients underwent ovarian hyperstimulation with gonadotropins and GnRH-antagonist for pituitary downregulation. Patients were started on oral contraceptives 1 month before the stimulation. Gonadotropins were administered from stimulation day 1 until the day of the hCG trigger, and GnRH-antagonist was added from the day when at least one follicle reached 14 mm in diameter and continued until hCG administration. The hCG was administered in 5,000-IU, 10,000-IU, or 15,000-IU doses on the day of ovulation triggering.We performed a stepwise multiple regression analysis to predict which variable would influence the serum concentration of hCG when measured the day after the administration of exogenous hCG.Body mass index (kg/m2) and number of follicles14 mm were the only determinants of the hCG concentration (cumulative R2 = 0.30; P.001). Patient age, estradiol peak, number of oocytes retrieved, length of stimulation, and length of GnRH-antagonist administration in days were not associated with serum hCG levels.Knowing that the number of larger follicles and the patient's BMI are the major determinants of the hormone's clearance in the body can help in the hCG dose titration during ovarian stimulation.

Objective: To examine the ability to use parameters obtainable from an oral glucose tolerance test to predict insulin action as determined under hyperinsulinemic, hyperglycemic conditions. Design: Prospective clinical investigation. Setting: University medical center clinical research unit. Patient(s): Healthy male volunteers. Intervention(s): Oral glucose tolerance test and hyperglycemic (+125 mg/dL) clamp studies. Main outcome measure(s) Glucose and insulin (I) levels, rate of glucose uptake (M) under hyperglycemic conditions, and M/I ratios. Result(s): Among individuals with normal glucose tolerance, as assessed by an oral glucose tolerance test, the fasting insulin level is the glucose tolerance test parameter that correlates best with insulin action during a hyperglycemic clamp. Conclusion(s): Measurement of fasting serum insulin levels in conjunction with an oral glucose tolerance test improves the ability to assess insulin action. Such combinations may improve the ability to diagnose insulin-resistant states.

Objective To examine the effect of fibrin sealant on mRNA expression of factors regulating plasminogen activator activity in human peritoneal cells. Plasminogen activator activity is thought to play a pivotal role in degradation of the proteinaceous mass that develops after surgical procedures. Reduction of plasminogen activator activity, as occurs with tissue trauma, results in increased postoperative adhesion development. Design Tissue culture for 6, 12, 24, and 48 hours. Setting University research laboratory. Patients Source of mesothelial cells with fibroblasts. Intervention(s) Measurement of mRNA expression of tissue plasminogen activator (t-PA) and plasminogen activator inhibitor 1 (PAI-1). Main outcome measure(s) Multiplex reverse transcriptase/polymerase chain reaction (RT/PCR) was used to determine relative change in t-PA and PAI-1 mRNA levels under six conditions: [1] fibrin sealant (Tisseel®); [2] fibrin sealant (Tisseel®) two components diluted 1:2; [3] fibrin sealant (Tisseel®) sealer protein component reconstituted without aprotinin (a protease inhibitor); [4] fibrin sealant (Tisseel®) sealer protein component reconstituted without aprotinin, both components diluted 1:2; [5] fibrin sealant (Tisseel®) components diluted to physiologic concentrations; and [6] control (culture media). Results The mRNA levels of t-PA and PAI-1 by human peritoneal cells were unchanged during 48 hours. In mesothelial cells, the addition of the compositions increased t-PA mRNA levels. A selective increase was observed in the normal peritoneal fibroblasts at the later time points; similar increases were identified in adhesion fibroblast cultures. In mesothelial cells, the more concentrated compositions generally increased PAI-1 mRNA above control levels, whereas in normal peritoneal fibroblasts PAI-1 levels generally remained unchanged. In contrast, in adhesion fibroblasts, PAI-1 levels decreased over time with treatment. Conclusion(s) Fibrin sealant, in the presence and absence of aprotinin, increases both t-PA and PAI-1 expression by human peritoneal cells; changes not seen with physiologic concentrations of fibrin sealant. These observations suggest that in addition to its ability to help achieve hemostasis, fibrin sealant affects the healing process by altering components of the plasminogen activator system, which may be of benefit in the reduction of postoperative adhesions.

Objective The value of sperm morphology as a predictor of a man's fertilizing potential has often been challenged because of different classification systems used to distinguish between normal and abnormal spermatozoa. The study aimed to monitor the reading skills of 53 laboratory technologists who are enrolled in a continuous quality control program for sperm morphology assessment. Design Prospective analytical study. Setting Academic hospital and academic institution setting. Patient(s) Sperm samples from the sperm donor program and andrology technicians from sub-Saharan Africa. Intervention(s) Papanicolaou-stained sperm slides were prepared and shipped on a quarterly basis to participating laboratories. Papanicolaou-prestained sperm morphology slides were used as test material for 21 months. Main outcome measure(s) Percentage normal spermatozoa. Result(s) A new statistical model was developed to record reading skills of the participating technicians. Reading skills were classified as marginal (5.7% of cases), good (11.3% of cases), and excellent (83% of cases). Participants maintained their morphological reading skills and agreed with the reference laboratory by not exceeding a SD limit of 0.2 to set stringent standards for the program. Conclusion(s) Technician proficiency can be monitored using the results of a quality control program. A continuous quality control program can be initiated only after intensive training, because baseline values at the onset of the quality control program serves as an internal reference value.

Objective To investigate the effects of decreasing androgen levels on insulin action, in view of the relationship between hyperandrogenism and impaired insulin action in women with polycystic ovary syndrome. Design Prospective, clinical study. Setting University hospital. Patient(s) Ten normal healthy men. Intervention(s) Gonadotropin-releasing hormone (GnRH) agonist, 3.75 mg, administered monthly for 3 months. Main outcome measure(s) Insulin action (M/I ratio). Result(s) The M/I ratio decreased from 0.24 ± 0.04 to 0.17 ± 0.04 after GnRH agonist therapy. Conclusion(s) In normal men, administration of a GnRH analogue was associated with a decrease in both testosterone levels and insulin action.

Objective: To determine the clinical value of automated normal sperm morphology outcomes. Design: Prospective clinical study. Setting: Clinical and research assisted reproduction laboratory. Patient(s): Two hundred seven GIFT cycles. Intervention(s): The wife was induced to superovulate, laparoscopically aspirated, and the gametes were transferred laparoscopically. The husband's sperm morphology was evaluated with use of a sperm morphology analyzer using the strict criteria classification system. Main Outcome Measure(s): Normal sperm morphology, IVF, and pregnancy outcomes. Result(s): The logistic regression model showed that normal sperm morphology was significantly associated with fertilization in vitro, as dependent (age) and independent variables. Analyzing the fertilization rates across the 5% normal sperm morphology cutoff point, a fertilization rate of 39.39% (≤5%) compared with 62.92% (>5%) was obtained. The logistic regression model showed that normal sperm morphology was also a significant predictor of pregnancy when allowing for the number of oocytes transferred and female age. Analyzing the pregnancy rates across the 5% normal sperm morphology cutoff point, pregnancy rates of 15.15% (≤5%) and 37.36% (>5%) were obtained. Conclusion(s): Normal sperm morphology as evaluated by the automated semen analyzer (IVOS) was shown to adhere to the same fertility cutoff point (5%), as determined by the manual evaluation of sperm morphology. Automated normal sperm morphology outcomes also were found to be significant predictors of IVF and pregnancy in a GIFT program.

Objective To determine the relationships between sperm acrosin activity, sperm morphology evaluated according to strict criteria, visually observed acrosomal morphology, and IVF rates. Design Prospective analytic study. Acrosin activity was determined on all semen samples together with a standard semen analysis. Emphasis was placed on sperm morphology and especially a novel criterion viz acrosome morphology (acrosome index) as recorded with bright field microscopy. Setting University-based tertiary care center. Patients Thirty-three couples undergoing IVF or GIFT with two or more metaphase II ova inseminated in vitro. Main Outcome Measure In vitro fertilization rates of inseminated ova. Results Strong correlations were found between acrosome index, normal sperm morphology, and IVF rates. An acrosome index cutoff value could be established at >10% normal acrosomes for IVF rates of ≥50% (sensitivity and specificity=100%) and an acrosin activity cutoff value at > 18 µIU/10 6 sperm. A multiple linear regression analysis showed that the acrosome index and acrosin activity added a significant contribution to the explanation of the variation in the fertilization rates. Conclusions A strong positive correlation was found between acrosome index and IVF rates. Although the numbers of the study are small, the results indicate that the acrosome index possibly may be regarded as an additional tool in the prediction of IVF outcome and especially may be of value in the group of men with severe teratozoospermia, i.e., ≤4% morphologically normal spermatozoa.

Objective Fluorescent in situ hybridization of decondensed sperm nuclei was employed to evaluate the effectiveness of the Ericsson albumin gradient enrichment technique of Y-bearing sperm. Design Mature human spermatozoa were separated from donor- and randomly selected patient semen using three different albumin density layers. Sperm nuclei, in the albumin layer with highest density, were decondensed and the percentage Y-bearing sperm was determined by fluorescent in situ hybridization. Results A slight, although statistically significant, increase in percentage Y-bearing sperm was observed. Conclusion Although statistically significant, the clinical relevance of the small increase in Y-bearing sperm remains uncertain. A randomized controlled clinical study should help to clarify the above laboratory results.