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The Internet of Things (IoT) is a network connecting physical objects with sensors, software and internet connectivity for data exchange. Integrating the IoT with medical devices shows promise in healthcare, particularly in IVF laboratories. By leveraging telecommunications, cybersecurity, data management and intelligent systems, the IoT can enable a data-driven laboratory with automation, improved conditions, personalized treatment and efficient workflows. The integration of 5G technology ensures fast and reliable connectivity for real-time data transmission, while blockchain technology secures patient data. Fog computing reduces latency and enables real-time analytics. Microelectromechanical systems enable wearable IoT and miniaturized monitoring devices for tracking IVF processes. However, challenges such as security risks and network issues must be addressed through cybersecurity measures and networking advancements. Clinical embryologists should maintain their expertise and knowledge for safety and oversight, even with IoT in the IVF laboratory., (Copyright © 2023 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Lipid disorders are now considered causal for atherosclerotic cardiovascular disease (ASCVD) which remains one of the most important contributors to morbidity and mortality in the developed world. Identification and early treatment of lipid disarrays remains the cornerstone of good clinical practice to prevent, halt and even reverse ASCVD. Guidelines for lipid management are imperative to help promote good clinical practice. Given the detail involved in comprehensive guidelines and the multiple areas of knowledge required by clinical practitioners, abbreviated, easy to understand, practical versions of guidelines are required to ensure dissemination of the most important information. The recent ESC lipid guidelines 2019 and the ESC guidelines on CVD prevention in clinical practice 2021 (1,2), provide an excellent detailed summary of all the latest evidence supporting lipid interventions that reduce ASCVD., Method: We therefore developed a single-page document with hyperlinks to help practitioners gain easy access to practical information on lipid management. It has been developed for future electronic use in clinical practice., Conclusion: It is presented here in a tabular format together with printable versions of the associated hyperlinks that provide the additional information required in decision making. It is hoped to audit the impact of this approach to help guide future ways of disseminating the latest clinical guideline updates., (© 2023. The Author(s).)

Research Question: Assisted reproduction laboratories record instrument performance periodically. No standardized guidelines have been produced for this activity despite mandatory auditing systems in several countries. This study of 36 laboratories in 12 different countries was conducted to assess differences and similarities between quality assurance programmes using an adaptable cloud-based quality-control app for instrument monitoring., Design: A total of 36 deidentified IVF laboratories that subscribed to the same quality-assurance application were studied. Data were evaluated based on instrument types allocated to 10 domains: incubators, gas tanks, warming surfaces, refrigerators and freezers, cryo-storage, environment, water purification, peripheral equipment, checklists and miscellaneous., Results: The incubator domain constituted the greatest proportion of parameters (35%), followed by surface warming instruments at 15%. Most incubator O 2 readings were monitored between 4.5 and 5.5%, and between 5.5 and 6.5% for CO 2 . The altitude of the laboratory was poorly correlated with the CO 2 setting. Incubator display and measured values of gases and temperature by built-in sensors vary considerably compared with third-party sensors. A quality-control diligence score or mean average data points was calculated for each laboratory. This score is independent of number of instruments or laboratory size. Higher scores were associated with laboratories in countries with government regulations and mandatory auditing systems., Conclusions: Major differences exist in instrument monitoring practices among laboratories. Although incubator monitoring is the largest domain, many other sensitive instruments are diligently monitored by most laboratories. International standardization and guidelines are needed., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Heterozygous familial hypercholesterolemia (HeFH) is an autosomal dominant condition with a population prevalence of 1 in 500, and is associated with significant cardiovascular morbidity and mortality. It may be caused by mutations in the low-density lipoprotein (LDL) receptor, apolipoprotein B100 (Apo B100), or proprotein convertase subtilisin/kexin type 9 (PCSK9) genes, with over 1,000 causative mutations described. Statin therapy in HeFH is considered effective and safe. Audit data suggest that approximately 80% of the putative HeFH population remains unidentified and, therefore, there is a need to develop a strategy for the identification of affected individuals so that early lipid-lowering treatment may be offered. There is good evidence showing the effectiveness and acceptability of HeFH screening programs in Europe. The authors describe a protocol for an all island approach to HeFH detection in the Republic of Ireland/Northern Ireland. Index cases will be identified by opportunistic screening using the Simon Broome, or Make Early Diagnosis to Prevent Early Death (MedPed) and World Health Organization (WHO) criteria. Patients identified as "definite," "probable," or "possible" HeFH criteria will be offered genetic testing. The authors expect causative mutations to be identified in approximately 80% of patients with "definite" HeFH but in only approximately 20% of patients with "possible" HeFH. Cascade screening will be undertaken in first-degree relatives of the index case using genetic testing (where a causative mutation has been identified), or otherwise using LDL cholesterol concentration. The establishment of a HeFH screening program on an all-island basis will require: expansion of the existing molecular genetics diagnostic services, the establishment of a cohort of nurses/genetic counselors, a HeFH database to support cascade testing, the development of a network of lipid clinics (in a primary or secondary care setting), and an educational initiative to raise awareness of HeFH among healthcare professionals and the general population.

Lipid guidelines typically focus on total cholesterol +/- low-density lipoprotein cholesterol levels with less emphasis on high-density lipoprotein cholesterol (HDL-C) or triglyceride assessment, thus potentially underestimating cardiovascular (CV) risk and the need for lifestyle or treatment optimization. In this article, we highlight how reliance on isolated total cholesterol assessment may miss prognostically relevant lipid abnormalities; we describe from the European Systematic COronary Risk Evaluation (SCORE) data set how incorporation of HDL-C may improve estimation of CV risk; and, finally, we critically evaluate the evidence base surrounding triglycerides and CV risk.

There is a known correlation between morphology and euploidy, but we believe that the association between the two embryo selection systems is too marginal to claim that it is absolute and that one can simply replace one system by the other. The optimal way to select euploid embryos is through a combination of morphology determination and preimplantation genetic diagnosis.

Preimplantation genetic diagnosis (PGD) for gender selection for non-medical reasons has been considered an unethical procedure by several authors and agencies in the Western society on the basis that it could disrupt the sex ratio, that it discriminates against women and that it leads to disposal of normal embryos of the non-desired gender. In this study, the analysis of a large series of PGD procedures for gender selection from a wide geographical area in the USA shows that, in general, there is no deviation in preference towards any specific gender except for a preference of males in some ethnic populations of Chinese, Indian and Middle Eastern origin that represent a small percentage of the US population. In cases where only normal embryos of the non-desired gender are available, 45.5% of the couples elect to cancel the transfer, while 54.5% of them are open to have embryos transferred of the non-desired gender, this fact being strongly linked to cultural and ethnic background of the parents. In addition this study adds some evidence to the proposition that, in couples with previous children of a given gender, there is no biological predisposition towards producing embryos of that same gender. Based on these facts, it seems that objections to gender selection formulated by ethics committees and scientific societies are not well founded.

Background: The aim of this study was to evaluate the effect of ovarian stimulation with LH-containing gonadotropins (human menopausal gonadotropin, hMG), on ploidy of human cleavage-stage-embryos., Methods: A total of 104 women, at ages 27-43 years, undergoing one cycle of controlled ovarian hyperstimulation for IVF in combination with preimplantation genetic diagnosis, were eligible for enrollment in this retrospective, controlled cohort study. Ovarian stimulation included down-regulation with long agonist and stimulation with either recombinant FSH or hMG. Since the ploidy of embryos changes with female age, patients were matched for age and dosage of the respective gonadotropin., Results: Despite similar numbers of chromosomally normal embryos in both groups, women undergoing hMG stimulation demonstrated significantly higher percentages of diploid embryos than did the FSH-stimulated patients (69.8 versus 45.3%; P < 0.01)., Conclusions: Long protocol LH-containing ovarian stimulation improves embryonic ploidy in comparison to pure FSH stimulation. This observation may explain higher IVF pregnancy rates, reported for hMG stimulation in some studies.

Previous studies assessing the relationship between embryo development, maternal age and chromosome abnormalities were either small or analysed mostly embryos not suitable for replacement. The present study includes >6000 embryos, including many suitable for replacement. Embryos with the best morphology and development were 44% euploid in patients younger than 35, decreasing to 21% in patients 41 and older. The worst morphology group had only 30% normal embryos from patients younger than 35, and 12% in embryos from patients 41 and older. Thus morphological analysis was able to improve the population of normal embryos only from 30 to 44% in the best of cases. Regarding specific abnormalities, 20% of embryos were aneuploid, 32% aneuploid plus other abnormalities, and the rest had post-meiotic abnormalities. Of those, only aneuploidy increased with maternal age. There were no big differences in the frequency of chromosome abnormalities depending on patient indication, within a similar age group. In summary, previous trends detected in suboptimal embryos were also confirmed in the best embryos for replacement. Although dysmorphism and advanced maternal age are both related to chromosome abnormalities, these parameters can yield at most <50% euploid embryos, and other techniques such as preimplantation diagnosis are required to ensure that only euploid embryos are replaced.

This study examines the relationship between common morphological anomalies of cleaving embryos and their ability to form apparently normal blastocysts in vitro. The impact of cleavage rate, fragmentation, and multinucleation on compaction, cavitation, along with inner cell mass and trophectoderm formation has been assessed. The study population consisted of 102 patients who elected or were selected to have a day 5 embryo transfer. Clinical pregnancy and implantation rates were 66.7 and 49% respectively. Slow and fast cleavage had a significant negative association with normal blastocyst formation. Only 13.8% (67/484) of embryos with <7 cells and 27.5% (25/91) of those with >9 cells on day 3 formed blastocysts with apparently normal morphology, compared to 41.9% (252/602) with 7-9 cells on day 3 (P < 0.001). Fragmentation had a negative impact on normal blastocyst formation. Embryos with >15% fragmentation formed normal blastocysts at a significantly lower rate (46/279; 16.5%) than embryos with 0-15% fragmentation (311/935; 33.3%) (P < 0. 001). Furthermore, the pattern of fragmentation was associated with blastocyst formation. Type IV fragmentation led to a significant reduction in blastocyst formation (25/170 or 14.7%), compared to types I, II and III which performed much better (38.6, 32.9 and 32.4% respectively). Only 15.9% (22/138) of embryos with one or more multinucleate cells on day 2 and/or 3 formed normal blastocysts compared with 31.9% (335/1051) (P < 0.001) of those without multinucleation. Collectively, the data suggest that cleavage anomalies, some of which do not preclude development after short-term culture, may reduce the developmental competence of embryos after prolonged culture.

Objective: To evaluate the effects of sperm placement during ICSI relative to the M-II spindle location on fertilization and preimplantation development., Design: Retrospective analysis of oocyte fertilization and embryo development with respect to sperm deposition site during ICSI., Setting: A program of IVF-ET., Patient(s): Seven hundred seventy-six patients., Intervention(s): Egg quality, sperm deposition site, and polar-body position were recorded during ICSI; fertilization was assessed on day 1; embryo development was evaluated on days 2 and 3., Main Outcome Measure(s): Fertilization, embryo development, and implantation rates., Result(s): Normal fertilization is not affected by polar-body orientation, with the exception of a significantly lower fertilization rate from a 9 o'clock polar-body orientation. Injections with the polar-body positioned at 7 or 11 o'clock result in the greatest number of high-quality embryos, significantly more than the adjacent 6 or 12 o'clock polar-body orientations and irrespective of oocyte anomaly frequency. Embryos originating from the 7 or 11 o'clock polar-body category implant at a higher rate, although the data are not significant., Conclusion(s): The placement of the sperm during ICSI relative to the presumed location of the meiotic spindle significantly impacts fertilization and high-quality embryo development. Sperm deposition in the M-II spindle area should be avoided. It appears that development, and not fertilization, is improved by decreasing the distance between the sperm cell and the spindle.

Objective: To evaluate the effects of fragmentation and fragment removal in day 3 human embryos on implantation and pregnancy., Design: Retrospective analysis of ETs homogeneous with respect to embryo fragmentation., Setting: A program of IVF-ET., Patient(s): The study population consisted of 2,410 patients., Intervention(s): The degree and pattern of fragmentation were evaluated on days 2 and 3; microsurgical fragment removal was performed after assisted hatching on day 3., Main Outcome Measure(s): Clinical pregnancy and implantation rates., Result(s): The degree and pattern of fragmentation significantly impact pregnancy and implantation. With the application of microsurgical fragment removal before ET, embryos with 6%-35% fragmentation implant with similar frequency. The presence of large fragments (type IV) is detrimental to the developing embryo, whereas localized or small and scattered fragments do not significantly affect implantation., Conclusion(s): The potential of fragmented embryos for implantation is determined partly by the distribution of fragments. Adoption of an embryo classification system reflecting types of fragmentation is advisable. The use of microsurgical fragment removal significantly alters the course of development for some embryos and improves their implanting potential.

The correlation between human zygote morphology and chromosomal anomalies after cleavage has not been well characterised. Commonly observed morphological qualities at the zygote stage have provided little insight into further development, and therefore selection for cryopreservation or transfer appears to be less specific than that at later stages of preimplantation development. The purpose of this work was to evaluate the relationship between aberrant pronuclear morphology and chromosomal anomalies after cleavage. Monospermic zygotes exhibiting two pronuclei where diameters differed by at least 4 microns were found to arrest at a significantly higher rate than zygotes with pronuclear diameters differing by less than 4 microns. In addition, a higher incidence of day 2 multinucleation was observed. Embryos deriving from zygotes with dysmorphic pronuclei that were not replaced or cryopreserved by day 3 of development were separated and fixed for fluorescence in situ hybridisation analysis of chromosomes X, Y, 13, 18 and 21. A significantly higher incidence of mosaicism was found in this group compared with others that had developed from zygotes with normal pronuclear morphology. Although the mechanism leading to this form of divergent pronuclear morphology is unclear, results suggest a correlation with oocyte cytoplasmic immaturity.

Objective: To determine some of the unresolved questions related to chromosome anomalies in early human embryos, such are the detection of any advanced maternal age effect; the complete assessment of mosaicism, which requires analysis of all cells; and the relationship with embryonic dysmorphism. Fluorescence in situ hybridization has been used in this study to answer these issues., Design: Fluorescence in situ hybridization analysis of human embryos using simultaneously probes for three or five chromosomes. Five hundred twenty-four cleavage-stage human embryos obtained by IVF were analyzed by fluorescence in situ hybridization. Embryos were allocated into three groups according to morphological and developmental characteristics (arrested; slow and/or fragmented; morphologically and developmentally normal). The embryos also were analyzed according to maternal age., Results: Dysmorphic embryos had higher rates of polyploidy and diploid mosaicism. Aneuploidy increased with maternal age in nonarrested embryos. Preimplantation genetic diagnosis successfully detected these abnormalities., Conclusion: This study demonstrates that, in morphologically and developmentally normal human embryos, cleavage-stage aneuploidy significantly increases with maternal age. The results suggest that implantation failure in older women largely could be due to aneuploidy.

Although many scientists view cloning as a useful procedure for scientific research into early embryo development -- one that cannot currently be used to produce multiple copies of humans -- the popular literature has led some individuals to view it as sinister. To address the concerns of the public, various conceptions of cloning are distinguished and their basis in fact analyzed. The possible uses, benefits, and detriments of both embryo splitting and nuclear transplantation are explained. Once the nature and purposes of cloning are understood, and the distinctive ethical dilemmas created by embryo splitting and nuclear transplantation are sorted out, these procedures should be clinically implemented to assist in vitro fertilization treatment for those who are infertile and to further other therapeutic and investigational efforts in medicine.

We describe a patient with the lupus anti-coagulant who had recurrent episodes, over a 2 year period, of a severe and disseminated intravascular coagulopathy. This patient also had positive serological assays for syphilis and anti-cardiolipin antibodies. Associated with the coagulopathy were co-expressed episodes of liver disease, ultimately terminating in fulminant liver failure. At autopsy the features were characteristic of the Budd-Chiari syndrome. This is the first report to document how consumptive coagulopathy may present as a dominant feature of the anti-phospholipid syndrome. It also clearly describes an immune mediated thrombotic mechanism as a cause of hepatic veno-occlusive disorders. Furthermore, this case highlights the varied clinical spectrum of the anti-phospholipid syndrome and suggests that a high index of suspicion is required to ensure its diagnosis.

The relationship between cholesterol synthesis and uptake in proliferating lymphocytes has been examined. [14C]Acetate incorporation into lymphocytes cultured under lipoprotein-deficient conditions increased initially in response to mitogen, decreased after 24 h, and increased rapidly between 72 and 96 h. Addition of LDL (10 micrograms/ml) to the culture during the 'trough' period caused [14C]acetate incorporation to return rapidly to baseline, while at peak periods LDL suppression of cholesterol synthesis was minimal. Lymphocytes cultured in the presence of the HMG-CoA reductase inhibitor, mevinolin, exhibited a time-dependent increase in their capacity to incorporate [14C]acetate into cholesterol, evident when mevinolin was removed by washing prior to assay. PHA enhanced 125I-labelled LDL receptor-mediated binding by lymphocytes cultured in lipoprotein-deficient medium over a 4 day period and mevinolin augmented the effect. [3H]Thymidine incorporation into mitogen-stimulated lipoprotein-deficient cultures was inhibited up to 75% by mevinolin (1 mumol/l). LDL (2.5-10 micrograms/ml) substantially reversed this inhibition in 72 h cultures, but only partially overcame inhibition in cells cultured for 96 h. Results suggest that endogenous cholesterol synthesis may be obligatory for lymphocyte proliferation after the initial round of cell division.

This study investigates the relationship between Type 2 (non-insulin-dependent) diabetes mellitus and hypercholesterolaemia with regard to delivery of cholesterol to cells and regulation of endogenous cholesterol synthesis. The ability of LDL, from hypercholesterolaemic and Type 2 diabetic patients, to suppress cellular cholesterologenesis and to enhance mitogen-stimulated lymphocyte proliferation was compared. Cholesterol synthesis was estimated by measuring [14C]-acetate incorporation into cholesterol and lymphocyte proliferation was assessed by [3H]-thymidine incorporation into mitogen-stimulated normal lymphocytes. The results indicate that LDL from both Type 2 diabetic patients in poor metabolic control and hypercholesterolaemic patients was significantly less effective (p less than 0.001) than LDL from non-diabetic normocholesterolaemic subjects in suppressing cholesterol synthesis in lymphocytes. LDL from all hypercholesterolaemic patients enhanced lymphocyte proliferation to a greater extent than LDL from normocholesterolaemic subjects and this effect was significantly increased using LDL from Type 2 diabetic, hypercholesterolaemic patients. Both suppression of [14C]-acetate incorporation and enhancement of [3H]-thymidine uptake could be related to an increased esterified/free cholesterol ratio in the LDL particle. The fact that cholesterol synthesis and cell proliferation were markedly altered by the above changes in LDL composition suggests a mechanism for cellular cholesterol accumulation in the Type 2 diabetic patient, even in the absence of elevated serum cholesterol levels.

Changes in plasma catecholamines, lipoproteins and dietary intake were examined in 13 medical students during a 3-month period prior to their examinations, and in 12 controls. In the medical students mean +/- s.e.(mean) plasma cholesterol increased over the study period (3.98 +/- 0.16 v. 4.26 +/- 0.16 mmol/l, P less than 0.05) and this was reflected by a rise in low-density lipoprotein cholesterol (2.53 +/- 0.15 v. 2.71 +/- 0.17 mmol/l, P less than 0.05). Both supine adrenaline (0.45 +/- 0.05 v. 0.70 +/- 0.07 nmol/l, P less than 0.01) and noradrenaline (2.74 +/- 0.18 v. 3.40 +/- 0.31 nmol/l, P less than 0.05) increased over this period. Apart from a decline in the modest alcohol consumption (9.1 +/- 3.45 v. 2.6 +/- 1.4 g/day, P less than 0.02) there was no change in dietary intake in the medical students. There were no significant changes in plasma catecholamines, lipoproteins or dietary intake in control subjects over the study period. Changes in catecholamines and lipoproteins occurring in association with chronic psychological stress may contribute to the increased coronary heart disease mortality associated with Type A behaviour and stressful life events.

The effects of catecholamines on the regulation of lipoprotein metabolism have not been defined. We examined the effects of subcutaneously administered slow-release preparations of norepinephrine (2 mg/kg) and isoproterenol (0.2 mg/kg) on the serum lipoproteins of New Zealand White rabbits. Drugs or control suspension were administered daily to three groups of normally fed and three groups of cholesterol-fed rabbits, and lipoprotein analysis was performed at intervals over a 60-hour period. In the normally fed animals, norepinephrine increased the serum levels of triglyceride and phospholipid by factors of 2.4 (P less than .01) and 1.35 (P less than .05), respectively, compared with control animals at 60 hours, but had no effect on serum cholesterol. All components of serum very low density lipoproteins (VLDL: triglyceride, cholesterol, phospholipid, and protein) were significantly (P less than .01) elevated by norepinephrine in the normally fed animals. In the cholesterol-fed animals, norepinephrine at 60 hours significantly increased total serum cholesterol, triglyceride, and phospholipid concentrations by factors of 1.7 (P less than .05), 5.0 (P less than .01), and 1.6 (P less than .05), respectively, compared with controls. The norepinephrine effects in these animals was due to significant elevation of total VLDL and low density lipoproteins (LDL) and all their elemental components. Isoproterenol produced no significant effect on serum lipoprotein levels in the normally fed rabbit, but in cholesterol-fed animals it produced a rise in total serum VLDL and LDL triglyceride concentrations compared with controls at 60 hours. These data demonstrate that catecholamines are involved in the regulation of lipoprotein metabolism.