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Objective: To determine and compare the long-term effects of prednisone and deflazacort on the functional status of children with Duchenne muscular dystrophy., Design: A total of 49 boys with Duchenne muscular dystrophy, between the age of 12 and 15 yrs, who were observed over a 7-yr period were reviewed retrospectively. Eighteen had been treated with prednisone, 12 with deflazacort, and 19 had no drug treatment. All boys treated with steroids received medication for >2 yrs before losing their ambulation. Lower and upper limb motor functions, pulmonary function, prevalence of surgery for scoliosis, and side effects were compared., Results: Boys in the steroid groups were significantly more functional and performed better on all tests than boys not treated (P < 0.05). There was no significant difference between the deflazacort- and prednisone-treated groups (P > 0.05). The number of boys having scoliosis surgery in treated groups was significantly less than nontreated boys (P < 0.05). The control group's pulmonary capacity was decreasing and significantly less than both prednisone- and deflazacort-treated boys. Both deflazacort and prednisone had beneficial effect on pulmonary function and scoliosis. Cataracts, hypertension, behavioral changes, excessive weight gain, and vertebral fracture were noted as serious side effects., Conclusions: Prednisone and deflazacort have a significant beneficial effect on slowing the disease progress. Their usage in Duchenne muscular dystrophy may prolong ambulation and upper limb function with similar potency. Both steroids also improve pulmonary function, in addition to delaying the need for spinal interventions, with similar therapeutic profiles.

Familial Mediterranean fever (FMF) is a multisystemic autosomal recessive disease, occasionally accompanied by sacroiliitis. Transient and non-erosive arthritis of the large joints is the most frequent articular involvement. Amyloidosis is also the most significant complication of FMF, leading to end stage renal disease. Here we present three cases of FMF with sacroiliitis and review the literature for spinal arthritic involvement of FMF. All cases were referred to our clinic with a diagnosis of seronegative spondyloarthropathy and with low back pain sourced by sacroiliitis. They also had homozygous M694V gene mutations and negative HLA B27 antigens. Molecular analysis of the gene mutation is recommended during the evaluation of uncertain cases in order to clarify diagnostic discrimination. We suggest that FMF with sacroiliitis, which is rare in rheumatological practice, should be considered in the differential diagnosis of seronegative spondyloarthropathy or other rheumatologic diseases causing spinal involvement.

The success of assisted reproduction, although gradually increasing over the years, is still less than satisfactory. Many couples have benefited from this treatment; however, many have also been left frustrated following multiple failed attempts. Couples who fail to conceive after multiple IVF/intracytoplasmic sperm injection (ICSI) treatments often seek treatment options that are new and that have not been offered before. Some of these include immunological testing and treatment, allogenic lymphocyte therapy, intratubal transfer of zygotes and embryos, blastocyst transfer, sequential embryo transfer, assisted hatching, co-cultures, and preimplantation genetic screening for aneuploidy. Although the evidence behind some of these is more robust, most suffer from lack of well designed randomized trials comparing them with other treatment options. Randomized studies are extremely difficult to conduct, as couples will resist being randomized into a treatment group where previously failed procedures will be repeated. In the mean time, assisted reproduction programmes should resist offering treatment options that are not evidence based, or at least they should share with the couple the information that is available and should stress that none of these is a panacea for their problem.

Reflex sympathetic dystrophy (RSD) may be a misdiagnosis or at least not descriptive enough in patients with atypical hand posture and atypical edema. Seven patients with the previous diagnosis of RSD were investigated further because of inconsistent clinical picture with the underlying pathology and bizarre course of the disease. Four patients had clenched fist and three had factitious edema. These seven patients underwent psychological examination, and MMPI was applied to all. In two of these no psychological disorder was obtained according to DSM-IV. One patient could not adapt to MMPI. In two anxiety disorders, in one depression, and in one patient conversion disorder was diagnosed. We suggest that these patients are not motivated enough to improve their conditions and expectations of such patients may show some differences depending on the environment.

Recurrent implantation failure is a distressing phenomenon, both for the infertile couple and for the physician responsible for their treatment. Aetiology is often not clear and treatment options are vague. Particularly when transferred embryos are of good quality, recurrent implantation failure may be attributed to less than optimal embryo transfer technique, pathological lesions of the uterine cavity, the presence of hydrosalpinges, fibroids and endometriosis. Poor embryo quality, especially when repetitive, is a major impediment to successful implantation and cannot be corrected at the present time. Molecular abnormalities at the endometrial level and abnormal embryo-endometrium dialogue may be responsible for some cases of recurrent implantation failure. Furthermore, there may be over- or under-expressed genes that may be related to successful implantation. At the present time, the physician confronted with a couple presenting with recurrent implantation failure should discuss openly the potential causes of this phenomenon, with special emphasis on correctable causes, and offer remedies that are evidence based.

This study was undertaken to compare the outcome of day 3, day 5, and frozen-thawed embryo transfer cycles where embryo culture was undertaken using the G1.2-G2.2 versus GIII series sequential media. A total of 400 day 3, 73 day 5 and 126 frozen-thawed embryo transfer cycles were analysed. Treatment cycles were quasi-randomized on the day of oocyte retrieval to embryo culture in G1.2-G2.2 versus GIII series sequential media. Randomization was undertaken according to alternating weekdays. Significantly more embryos were of grade 1 or 2 quality on day 3 in the GIII group (P < 0.05). Likewise, more embryos in the GIII group had eight blastomeres on day 3 (P < 0.05) and were able to hatch spontaneously (P < 0.05). For day 3 embryo transfer cycles, implantation and clinical pregnancy rates were 14.4 and 25.7% versus 37.8 and 50.3% in G1.2-G2.2 and GIII groups respectively (P < 0.05). For day 5 embryo transfer cycles, implantation rates were significantly higher (29 versus 45%; P < 0.05) in the GIII group. There was a trend towards higher pregnancy rates; however, this did not reach statistical significance due to fewer cycles analysed in this group. In-vitro culture in GIII series sequential media yields better quality embryos that implant more efficiently, compared with culture in G1.2-G2.2 media.

Co-cultures have been advocated in assisted reproduction owing to the inadequacy of simple media to support embryo development beyond the cleavage stage. Different human and non-human cells and cell lines have been used for co-cultures. High rates of blastocyst formation have been reported with the use of co-cultures, and they have been proposed as a salvage treatment option in couples with repeated implantation failures. Since the advent of complex sequential media, which yield very high blastocyst formation and blastocyst implantation rates, the need for co-cultures has been questioned. Upon review of the literature, it is evident that well-designed randomized studies that compare co-cultures with simple or sequential media do not exist. Progression to the blastocyst stage for cleavage stage embryos appears to be similar, if not better, for embryos that are cultured in modern sequential media, rendering the use of co-cultures obsolete. Furthermore, there is no consensus regarding the necessity of sequential media, as similar results have been obtained with a single medium formulation that supports all stages of the preimplantation period. Whether co-cultures are beneficial in patients with repeated implantation failures, however, should be investigated in randomized trials. Co-cultures still serve as powerful tools for understanding embryo metabolism. Furthermore, co-cultures may be instrumental in studying expression of implantation-related genes and embryo-endometrium interaction.

A retrospective study of 5,982 embryos in 619 blastocyst-stage embryo transfer cycles revealed that detection of multinucleated blastomeres either on day 2 or 3 signifies a poor prognosis for blastocyst formation and that no good-quality blastocyst can be expected from an embryo with more than one multinucleated blastomere. Patients should be counseled regarding a poor prognosis when multiple embryos with multinucleated blastomeres are present.

The relationship between pronuclear morphology on the one hand, and embryo development and chromosomal status on the other, was evaluated in 68 couples scheduled to undergo preimplantation genetic diagnosis because of advanced maternal age or recurrent implantation failure. Zygotes were grouped according to their pronuclear (PN) morphology. During the period from fertilization to embryo transfer, cleavage rate, embryo quality, blastocyst formation and results of the chromosomal analysis of 240 embryos were recorded. Both embryo cleavage characteristics and chromosome constitution were related to PN morphology. Embryos developing from zygotes with the normal PN pattern (pattern 0) cleaved faster and formed embryos with better morphology as compared with zygotes with abnormal PN patterns. Aneuploidy rate of embryos derived from zygotes with the normal PN pattern, with a single PN anomaly and with a double PN anomaly was 25.6, 73 and 83% respectively. Chromosomally normal embryos with the normal PN pattern progressed to the blastocyst stage at a higher rate (90%) than chromosomally normal embryos with a single (61%) or a double (40%) PN anomaly. The same relationship applied to chromosomally abnormal embryos. It is concluded that PN morphology predicts both the risk of embryo developmental arrest and that of chromosomal abnormalities.

Although, it is well known that pre-incubation of oocytes prior to conventional IVF improves fertilization and pregnancy rates, there are conflicting results regarding the effect of pre-incubation time in ICSI. This study evaluated the role of pre-incubation of oocytes on outcome in intracytoplasmic sperm injection (ICSI) cycles. A total of 1260 patients undergoing their first ICSI cycles were evaluated retrospectively. In patients undergoing ICSI during the year 2000 (Group I, n = 670), oocytes were injected immediately after retrieval, whereas in patients undergoing ICSI during 2001 (Group II, n = 590), oocytes were incubated for 2-4 h prior to injection. The mean age of patients was 33.9 +/- 5.04 years and 34.1 +/- 5.06 years in groups I and II, respectively. The number of oocytes with a first polar body (MII) and fertilization and cleavage rates were higher, and embryo quality was significantly better in group II. In contrast, the total numbers of oocytes without a first polar body (MI), those where germinal vesicle breakdown had not occurred (GV), and empty zona oocytes were higher in group I. No difference was found in the number of embryos transferred or implantation or clinical pregnancy rates. This study demonstrated that pre-incubation of oocytes prior to ICSI is associated with improved maturation of oocytes, fertilization and embryo quality.

Embryo culture can serve as a strong diagnostic tool, yielding useful information regarding the implantation potential of the human embryo. The information thus gained is useful for quality control of the embryology laboratory, success rates of the IVF/intracytoplasmic sperm injection (ICSI) programme, and counselling of the couple following failed cycles. Zygotes can be scored and zygote quality has been associated with further embryonic development and cleavage stage embryo quality. Early cleavage, cleavage rate, cleavage stage embryo grade and subsequent progression of these embryos to the blastocyst stage have all been shown to be individual and collective markers for the implantation-competent human embryo. This manuscript discusses embryonic markers of normality/quality throughout in-vitro culture starting with the zygote and ending with the blastocyst.

The purpose of this study was to assess the outcome of blastocyst transfer in relation to the presence or absence of excess blastocysts available for cryopreservation. The study was designed as a retrospective case series in a tertiary care private hospital. The study group consisted of 450 blastocyst stage embryo transfer cycles. In 139 cycles there were excess freezeable blastocysts (group 1), in 78 cycles there were excess but unfreezeable blastocysts (group 2), and in 233 cycles there were no excess blastocysts (group 3). A mean of three blastocysts was replaced in all groups. Treatment cycle characteristics, implantation and pregnancy rates following fresh and cryopreserved blastocyst transfer were assessed in each group. More embryos reached the blastocyst stage in group 1 and more blastocysts were of good quality. In group 1, clinical pregnancy and implantation rates (71 and 41%) were significantly higher compared with groups 2 (56 and 27%) and 3 (43 and 19%). Embryos that were selected for transfer among a cohort of good quality blastocysts yielded the highest implantation and pregnancy rates. Given a clinical pregnancy rate of 71%, an implantation rate per embryo of 41%, and a multiple pregnancy rate of 58%, serious consideration should be given to a single blastocyst transfer in these patients.

Objective: To compare the outcome of zona-intact versus zona-free blastocyst transfer., Design: Prospective, randomized study., Setting: Tertiary care private hospital IVF center., Patient(s): A total of 240 patients undergoing blastocyst stage ET (119 zona intact and 121 zona free)., Intervention(s): In vitro culture of embryos to the blastocyst stage was followed by random allocation to zona-intact or zona-free transfer., Main Outcome Measure(s): Treatment cycle characteristics, implantation, and pregnancy rates., Result(s): Transfer of zona-free blastocysts was associated with a higher implantation rate. Subgroup analysis, however, indicated that better outcome was achieved only in the group that received poor-quality blastocysts. Patients undergoing blastocyst transfer for the first time did not seem to benefit from zona-free blastocyst transfer., Conclusion(s): Zona-free blastocyst transfer increases the success of blastocyst-stage transfer in patients with poor-quality blastocysts.

Objective: To evaluate the relationship between embryo cleavage time and implantation and pregnancy rates in women undergoing intracytoplasmic sperm injection (ICSI) for male factor infertility., Study Design: A total of 78 patients undergoing their first ICSI cycle were evaluated prospectively. Embryos were assessed for early cleavage to the two-cell stage 27 hours after injection., Results: Early cleavage of at least one embryo was observed in 48 cycles (group I). None of the embryos cleaved early in the remaining 30 cycles (group II). There was no difference regarding mean patient age, duration of ovarian stimulation, number of gonadotropin ampules used, number of oocytes retrieved, fertilization, cleavage rates and embryo quality between the two groups. Implantation and clinical pregnancy rates were significantly higher in group I than II (17.9% and 45.8% vs. 5.1% and 16.7%, respectively; P < .05). Furthermore, progression to the blastocyst stage in excess embryos was significantly higher in group I than II (56.7% vs. 25.0%, P < .05)., Conclusion: Pregnancy and implantation rates were higher in patients who have early cleaving embryos; absence of early cleavage was associated with a poor outcome.

Prader-Willi syndrome (PWS) is a neurogenetic disorder that results from the lack of transcripts expressed from the paternal copy of the imprinted chromosomal region 15q11-q13 (refs. 1,2). In some patients, this is associated with a deletion of the SNURF-SNRPN exon 1 region inherited from the paternal grandmother and the presence of a maternal imprint on the paternal chromosome. Assuming that imprints are reset in the germ line, we and others have suggested that this region constitutes part of the 15q imprinting center (IC) and is important for the maternal to paternal imprint switch in the male germ line. Here we report that sperm DNA from two males with an IC deletion had a normal paternal methylation pattern along 15q11-q13. Similar findings were made in a mouse model. Our results indicate that the incorrect maternal methylation imprint in IC deletion patients is established de novo after fertilization. Moreover, we found that CpG-rich regions in SNURF-SNRPN and NDN, which in somatic tissues are methylated on the maternal allele, are hypomethylated in unfertilized human oocytes. Our results indicate that the normal maternal methylation imprints in 15q11-q13 also are established during or after fertilization.

Recent studies indicate a strong paternal influence on embryo development and progression of the embryo to the blastocyst stage. The aim of this study was to compare, during extended culture, the in-vitro development of embryos resulting from intracytoplasmic sperm injection (ICSI) of ejaculated spermatozoa (group 1, n = 347), epididymal (group 2, n = 22) or testicular (group 3, n = 18) spermatozoa from obstructive azoospermic and testicular spermatozoa from non-obstructive azoospermic (group 4, n = 31) subjects. Fertilization and blastocyst formation rates were significantly lower in group 4 (P < 0.05). The incidence of expanded and hatching blastocysts was significantly lower in group 4 (P < 0.05). Overall in 93.2% ejaculate ICSI cycles, blastocysts were transferred on day 5. This was significantly higher than the 62% day 5 transfers in the non-obstructive azoospermic group (P < 0.05). Implantation rate per embryo was significantly higher in the ejaculate ICSI group compared with the other groups (P < 0.05). Clinical pregnancy per transfer was similar between groups; however, significantly fewer multiple pregnancies were encountered in the non-obstructive azoospermic group (P < 0.01). In conclusion, the source of the spermatozoa, most likely to be indicative of the severity of spermatogenic disorder, affects the rate of blastocyst formation and blastocyst implantation. Spermatozoa from non-obstructive azoospermic subjects, when utilized for ICSI, result in embryos that progress to the blastocyst stage at a lower and slower rate and implant less efficiently.

Purpose: The aim was to evaluate the effect of aspirin on pregnancy and implantation rates in an unselected group of patients undergoing intracytoplasmic sperm injection (ICSI)., Methods: Two hundred and seventy-nine patients were randomized to receive 80 mg of aspirin (n = 139) or no treatment (r = 136) starting from the first day of controlled ovarian hyperstimulation., Results: Duration of stimulation, gonadotropin consumption, peak estradiol, number of oocytes retrieved, fertilization rate, cleavage rate, and number of embryos transferred were similar in the two groups. Implantation and clinical pregnancy rates were 15.6% and 39.6% versus 15.1% and 43.4% in aspirin treated and untreated groups, respectively (P > 0.05)., Conclusions: Low-dose aspirin administration does not improve implantation and pregnancy rates in an unselected group of patients undergoing ICSI.

Objective: To determine the relationship between blastocyst quality and the results of embryo transfer at the blastocyst stage., Design: Retrospective case analysis., Setting: Tertiary care private hospital IVF center., Patient(s): A total of 350 blastocyst-stage embryo transfer cycles., Intervention(s): In vitro culture to the blastocyst stage was undertaken in 350 ICSI cycles where four or more cleavage-stage embryos were available on day 3., Main Outcome Measure(s): Relationship between blastocyst quality and implantation and clinical and multiple pregnancy rates., Result(s): Transfer of at least one grade 1 or grade 2 blastocyst or one hatching blastocyst was associated with very high implantation and pregnancy rates. However, transfer of grade 3 blastocysts yielded very low implantation and pregnancy rates., Conclusion(s): There appears to be a strong correlation between blastocyst quality and success of blastocyst transfer.

The aim of this study was to evaluate whether the extraction of testicular spermatozoa with percutaneous versus open biopsy has an effect on the treatment outcome with intracytoplasmic sperm injection (ICSI) in men with non-obstructive azoospermia. Regardless of testicular size, follicle stimulating hormone concentration, and previous biopsy result, percutaneous testicular sperm aspiration (PTSA) using a 21-gauge butterfly needle was attempted first and if this failed testicular sperm extraction (TESE) was performed. In 63 men spermatozoa were found with PTSA whereas in 228 men TESE had to be undertaken. More men in the PTSA group had previously been diagnosed with hypospermatogenesis (82 versus 50%). Compared with the PTSA group, more men in the TESE group had germ cell aplasia (27 versus 10%) or maturation arrest (22 versus 8%). There was no difference between the groups regarding mean age of men and their partners, duration of stimulation, oestradiol concentration on the day of human chorionic gonadotrophin, number of oocytes retrieved, fertilization rate, and embryo quality between the two groups. The number of embryos transferred (4.38 versus 3.90) was significantly higher in the PTSA group (P < 0.05), reflecting the increased number of embryos available for transfer. Implantation rate per embryo was 20.7% in the PTSA and 13.3% in the TESE group (P < 0.05). Clinical pregnancy rates were 46 and 29% in the PTSA and TESE groups respectively (P < 0.05). Clinical abortion rates were similar (21.2 versus 24%). It is concluded that in men with non-obstructive azoospermia, easier sperm retrieval, which is most likely indicative of a more favourable histopathology, is associated with higher implantation rates per embryo.

Progression to the blastocyst stage of embryos derived from testicular round spermatids in men with non-obstructive azoospermia was studied. A total of 56 men were studied in whom partial spermatogenesis failure had occurred where only very few spermatozoa (fewer than the number of oocytes retrieved) were extracted from multiple testicular biopsy specimens. Oocytes remaining after intracytoplasmic injection of testicular spermatozoa (group 1) were injected with round spermatids (ROSI, group 2). Only embryos derived from group 1 were transferred. Remaining embryos were observed under culture for 8 days and their progression to the blastocyst stage was recorded. Of the 546 oocytes injected with testicular spermatozoa, 404 (73.9%) showed evidence of 2-pronuclear (2PN) fertilization. Injection of testicular round spermatids resulted in 2PN fertilization rate of 50% (P < 0.05). Using a four-point grading system, 53% of the good quality embryos (grade 1 or 2) in group 1 reached the blastocyst stage compared with 25% in group 2 (P < 0.05). The rate of progression to the blastocyst stage of grade 3 and grade 4 embryos was 46 and 8.5% in the two groups respectively (P < 0.05). Using a different three-point grading system for the blastocysts, 75.3% of the blastocysts in group 1 were either grade 1 or grade 2 and 24.7% were grade 3. However, in group 2 all blastocysts were grade 3. All embryos observed in group 1 reached the blastocyst stage by day 5 or 6 compared with 25% of the embryos reaching the blastocyst stage by this time in group 2. While 31.2% of the blastocysts in group 1 showed evidence of spontaneous hatching in vitro, none of the blastocysts in group 2 hatched. In conclusion, progression to the blastocyst stage occurred at a much lower and slower rate in embryos derived from testicular round spermatids. Furthermore, all blastocysts resulting from ROSI were of poor quality and none showed spontaneous hatching. These results may explain the dismal outcome associated with ROSI.

We have shown previously that germ cells recovered from some men with maturation arrest can resume spermatogenesis in vitro and give rise to late elongated spermatids. This study relates the ability of germ cells to differentiate in vitro to the stage at which spermatogenesis is blocked in vivo and to the patient's serum FSH concentration. The presence of germ cells at different stages of spermatogenesis was assessed, before and after culture, by classical cytology, by fluorescence in-situ hybridization and by immunocytochemistry with a germline-specific marker. The proportion of cases of maturation arrest at the primary spermatocyte, secondary spermatocyte and spermatid stage in which in-vitro resumption of meiosis was achieved was 24.3% (9/37), 100% (3/3) and 51.1% (23/45) respectively. Serum FSH concentrations were higher than normal in most cases. However, lower values were measured in patients in whom in-vitro spermatogenesis was achieved compared with those in whom no progression was detected. These data show that, under the conditions of this study, germ cells from men with very high serum FSH concentrations (>20 IU/l) are less likely to resume spermatogenesis in vitro than those coming from men with only moderate increase (10-20 IU/l).

Objective: To analyze the performance of two different embryo transfer catheters (Wallace and Frydman) in an in vitro fertilization (IVF)-intracytoplasmic sperm injection (ICSI) program., Study Design: Four hundred twenty-eight IVF or ICSI embryo transfer cycles were analyzed. A trial transfer was performed before the initiation of controlled ovarian hyperstimulation to determine the choice of embryo transfer catheter, Wallace or Frydman. Actual transfer was undertaken with the catheter chosen from the trial transfer., Results: During actual embryo transfer, 214 (93.5%) of the intended 229 Wallace transfers were successful, and in 15 transfers the Frydman catheter was used. Of the intended 199 Frydman transfers, all were successful. Clinical pregnancy rate, implantation rate per embryo and ectopic pregnancy rate per transfer for the Wallace catheter were 41.6%, 16% and 0.9%, respectively. Respective rates for the Frydman catheter were 36.0%, 14.4% and 0.9% (P > .05 for all variables). Trial catheterization prevented most of the unanticipated procedural difficulties during the actual transfer., Conclusion: Both Wallace and Frydman catheters performed similarly, although there was a slight but nonsignificant increase in clinical pregnancy rates with the Wallace catheter.

Objective: To evaluate the association between serum P levels on the day of hCG administration and the outcome of intracytoplasmic sperm injection (ICSI)., Design: Retrospective case study., Setting: Assisted reproduction unit of a tertiary care private hospital., Patient(s): Nine hundred eleven ICSI cycles that proceeded to ET were studied., Intervention(s): The decision to administer hCG was based on serum E2 levels and follicle size. Serum P was measured from frozen sera obtained on the day of hCG administration. Cycles were stratified according to serum P levels of <0.9 ng/mL (n = 298) or > or =0.9 ng/mL (n = 613). This cutoff level was selected because it yielded the highest sensitivity and specificity according to a receiver operator characteristic curve., Main Outcome Measure(s): Implantation and clinical pregnancy rates., Result(s): In cycles with high serum P levels, more oocytes were retrieved and more embryos were available for transfer. Clinical pregnancy rates per ET in the low and high P groups were 36.9% and 45.4%, respectively (P<.05). The implantation rate per embryo was similar in the two groups (14.9% and 16.4%, respectively, in cycles with P levels <0.9 vs > or =0.9 ng/mL). Abortion rates were 22.7 and 25.8%, respectively (P>.05)., Conclusion(s): Our data showed no adverse effect of high serum P levels on the day of hCG administration on implantation rates after ICSI and ET.

The aim of this study was to determine the effect of 24-h in-vitro culture of testicular spermatozoa in recombinant follicle stimulating hormone (recFSH) supplemented medium versus simple medium on sperm motility, and to analyse the outcome of intracytoplasmic sperm injection (ICSI) of such spermatozoa. A total of 143 positive testicular sperm extraction procedures in men with non-obstructive azoospermia was evaluated prospectively. Extracted testicular tissue samples were randomized to be cultured in vitro for 24 h in simple medium or recFSH supplemented media. ICSI was performed with spermatozoa cultured in recFSH (n = 73) or in simple medium (n = 70). Sperm motility following in-vitro culture, embryo quality after ICSI, and implantation and pregnancy rates were assessed. Of the 898 MII oocytes available in the recFSH group, 646 (71.9%) were injected with spermatozoa showing either twitching or progressive motility. However, only 29.1% of the oocytes in the simple medium group (245/841) were injected with motile spermatozoa (P < 0.05). Fertilization rate (68.8 versus 42.1%), implantation rate per embryo (20.1 versus 13.2%), and clinical pregnancy rate (47. 9 versus 30%) were significantly increased in the recFSH group compared with the simple medium group respectively (P < 0.05). In conclusion, in-vitro culture with recFSH appears to increase the motility of testicular spermatozoa, thus increasing the success of ICSI.

In this study, we compared the fertilization rate and embryo quality after intracytoplasmic sperm injection (ICSI) as they relate to oocyte morphology. A total of 654 ICSI cycles yielding 5903 metaphase II oocytes were observed. The oocytes retrieved in these cycles were divided into (i) normal oocytes, (ii) oocytes with extracytoplasmic abnormalities (dark zona pellucida and large perivitelline space), (iii) oocytes with cytoplasmic abnormalities (dark cytoplasm, granular cytoplasm, and refractile body), (iv) oocytes with shape abnormalities, and (v) oocytes with more than one abnormality (double and triple abnormalities). Intracytoplasmic vacuoles and aggregates of smooth endoplasmic reticulum were not recorded separately. The fertilization rate and quality of morphologically graded embryos did not differ between the groups. There were 77 cycles where all transferred embryos were derived from abnormal oocytes, and 164 cycles where all embryos were derived from normal oocytes. These cycles were studied further. The two groups were comparable regarding mean female age, duration of infertility, duration of ovarian stimulation, number of ampoules of gonadotrophin injected, and number of oocytes retrieved. Two clinical pregnancy rates (44.4 versus 42.1%) and implantation rates per embryo (10.3 versus 13.2%) were similar. In conclusion, in couples undergoing ICSI, abnormal oocyte morphology is not associated with a decreased fertilization rate or unfavourable embryo quality. Furthermore, embryos derived from abnormal oocytes yield similar clinical pregnancy and implantation rates when transferred compared with embryos derived from normal oocytes.

Transitional mutations at CpG dinucleotides account for approximately a third of all point mutations. These mutations probably arise through spontaneous deamination of 5-methylcytosine. Studies of CpG mutation rates in disease-linked genes, such as factor VIII and FGFR3, have indicated that they more frequently originate in male than in female germ cells. It has been speculated that these sex-biased mutation rates might be a consequence of sex-specific methylation differences between the female and the male germ lines. Using the bisulfite-based genomic-sequencing method, we investigated the methylation status of the human factor VIII and FGFR3 genes in mature male and female germ cells. With the exception of a single CpG, both genes were found to be equally and highly methylated in oocytes and spermatocytes. Whereas these observations strongly support the notion that DNA methylation is the major determining factor for recurrent CpG germ-line mutations in patients with hemophilia and achondroplasia, the higher mutation rate in the male germ line is apparently not a simple reflection of sex-specific methylation differences.

Excess embryos from patients undergoing intracytoplasmic sperm injection and embryo transfer for male infertility were cultured to determine the rate and timing of their progression to the blastocyst stage. In 194 embryo transfer cycles, four embryos with the morphologically best grading were transferred and at least two embryos were cultured. The cycles were classified as: group 1: no excess embryos reached blastocyst stage, group 2: >50% of embryos reached blastocyst stage by days 4-5, group 3: <50% of embryos reached the blastocyst stage by days 4-5, group 4: >50% of the embryos reached blastocyst stage by days 6-7, group 5: <50% of the embryos reached blastocyst stage by days 6-7. All groups were similar regarding female age, duration of infertility, and parameters of ovarian stimulation. In group 1, clinical pregnancy and implantation rates were 14 and 11% respectively, and were similar to those of group 4. In group 2, clinical pregnancy and implantation rates were 75 and 33%. Multiple implantations occurred in 81% of group 2 or 3 cycles, compared to none in group 1 cycles. The results suggest that the development potential of the embryo is intrinsic, and that embryos which carry a high potential for development yield a high clinical pregnancy rate and multiple implantations.

Purpose: Our purpose was to determine the feasibility and efficacy of performing testicular or epididymal sperm retrieval prior to the injection of human chorionic gonadotropin (hCG)., Methods: This report deals with 87 sperm-positive percutaneous epididymal sperm aspiration (PESA), percutaneous testicular sperm aspiration (PTSA), or testicular sperm extraction (TESE) cycles. All sperm retrieval procedures were performed prior to administration of hCG to the women. Retrieved spermatozoa were cultured in vitro in simple medium for approximately 40 hr prior to intracytoplasmic sperm injection., Results: In all but one cycle in which TESE was performed for nonobstructive azoospermia, motile sperm were available for ICSI. The overall fertilization rate was 53%. Pregnancy rate per transfer and implantation rate per embryo were 41.2 and 15.7%, respectively., Conclusions: Satisfactory fertilization and pregnancy rates can be achieved when PESA, PTSA, or TESE is performed prior to the injection of hCG followed by in vitro culture of spermatozoa approximately 40 hr before ICSI. Scheduling of testicular or epididymal sperm retrieval cases in this way appears to ease the workload on laboratory and operating room personnel. Furthermore, withholding hCG when sperm is absent may obviate the unnecessary risk of ovarian hyperstimulation when spermatozoa cannot be retrieved.

In non-obstructive azoospermia spermatozoa can usually only be isolated from the testicles, and thus the most promising treatment model is testicular sperm extraction (TESE). Hormone concentrations, testicular volume determinations and testicular biopsy results are not uniform enough to select potential candidates for successful TESE and intracytoplasmic sperm injection (ICSI) approaches in advance. The aim of this study was to assess the efficacy of using ICSI with testicular spermatozoa in cases of non-obstructive azoospermia and to compare the inclusion criteria and sperm existence in the testicles in sperm obtainable and non-obtainable groups. All men showed either complete or incomplete (n = 14) maturation arrest in spermatogenesis, severe hypospermatogenesis (n = 10) or Sertoli cell-only syndrome (n = 5) in their testicular biopsies. Only 14 out of a total of 29 men provided enough spermatozoa for the ICSI procedure, while no spermatozoa were found in the testicular samples of the remaining 15 men. Out of 123 oocytes obtained from 14 females, 101 were injected with the husbands' testicular sperm cells. Total fertilization failure was observed in three cases. Of 39 oocytes fertilized, 38 cleaved. The fertilization and cleavage rates were 38.6 and 97.4% respectively. The pregnancy rate was 20.7% per initiated cycle. In the group from whom spermatozoa were obtainable, the pregnancy rate was 42.9% per initiated cycle and 54.5% per embryo transfer. A total of six pregnancies were achieved, of which two were twins and four were singletons. One singleton pregnancy resulted in abortion in the first trimester. There was no statistical difference concerning the serum follicle stimulating hormone concentration, testicular volume and biopsy results in groups in which spermatozoa were obtainable or not. In conclusion, although the association of TESE with ICSI obtained pregnancies for some patients with non-obstructive azoospermia, further studies are needed to determine the inclusion criteria for successful TESE.

Thirty-two infertile couples with obstructive and non-obstructive azoospermia were included in this study. Testicular sperm extraction (TESE) was performed in 16 obstructive azoospermic cases where microsurgical sperm aspiration (MESA) or percutaneous sperm aspiration (PESA) were impossible because of totally destroyed epididymis and 16 non-obstructive azoospermia cases with severe spermatogenetic defect where the testicles were the only source of sperm cells. A total of 288 oocytes was obtained from 32 females and 84% were injected. The fertilization rates (FR) with 2 pronuclei (PN) and cleavage rate were 50.8 and 68.2% respectively. A total of 15 pregnancies was achieved (53% per embryo transfer), nine from the obstructive and six from the non-obstructive group. Four pregnancies resulted in clinical abortion (26.6%). The ongoing pregnancy rate was 39.2% per embryo transfer (ET) and 34.3% per started cycle. A high implantation rate was also achieved (26.6% in non-obstructive and 30% in obstructive azoospermia group). Using testicular spermatozoa in combination with ICSI in both obstructive and non-obstructive azoospermic groups, high implantation and pregnancy rates can be achieved.

A brief review of methods used in treating anterior crossbites has been outlined. Another approach was also presented using interdental segmental osteotomies to mobilize individual teeth and fixed splints to stabilize the realigned segments. The advantage of this treatment is the expedience with which final results can be obtained and the relative ease in accomplishing the surgical and prosthodontic procedures.

We decided to implement a family education program in our methadone maintenance clinic as a means of reaching out to family members. In the course of designing and implementing the program, we uncovered a variety of problems concerned with staff's perception of their roles and their attitudes toward parents. This paper discusses the growing awareness of these problems, which seem to be of significant generic importance to any agency involved in setting up a new program. We also discuss the effects of these problems, attempts at resolution, and suggest some general criteria for evaluation.

According to Bell, "the aim of bone grafting is to place a readily vascularizable osteogenic organic structure in intimate contact with a vascular osteogenic cancellous host bed." To accomplish these objectives, a tunneling procedure was developed. This technique provided a circumferentially intact vascular bed, which minimized the edema usually caused by interference with venous and lymphatic drainage. Together with adequate graft stabilization and maxillomandibular fixation, this surgical approach deceased shearing forces, permitted unimpeded capillary ingrowth, minimized hematoma and dead-space formation, and maximized the viability of the graft.