Fertility Workup Research Articles

Thyroid function in neonates conceived after hysterosalpingography with iodinated contrast.

STUDY QUESTIONDoes exposure to preconceptional hysterosalpingography (HSG) with iodinated oil-based contrast affect neonatal thyroid function as compared to iodinated water-based contrast?SUMMARY ANSWERPreconceptional HSG with iodinated contrast did not influence the neonatal thyroid function.WHAT IS KNOWN ALREADYHSG is a commonly applied tubal patency test during fertility work-up in which either oil- or water-based contrast is used. Oil-based contrast contains more iodine compared to water-based contrast. A previous study in an East Asian population found an increased risk of congenital hypothyroidism (CH) in neonates whose mothers were exposed to high amounts of oil-based contrast during HSG.STUDY DESIGN, SIZE, DURATIONThis is a retrospective data analysis of the H2Oil study, a randomized controlled trial (RCT) comparing HSG with the use of oil- versus water-based contrast during fertility work-up. After an HSG with oil-based contrast, 214 women had an ongoing pregnancy within 6 months leading to a live birth compared to 155 women after HSG with water-based contrast.PARTICIPANTS/MATERIALS, SETTING, METHODSOf the 369 women who had a live born infant, 208 consented to be approached for future research and 138 provided informed consent to collect data on the thyroid function tests of their offspring (n = 140). Thyroid function tests of these children were retrieved from the Dutch neonatal screening program, which includes the assessment of total thyroxine (T4) in all newborns, followed by thyroid-stimulating hormone only in those with a T4 level of ≤ −0.8 SD score. Furthermore, amount of contrast medium used and time between HSG and conception were compared between the two study groups.MAIN RESULTS AND THE ROLE OF CHANCEData were collected from 140 neonates conceived after HSG with oil-based (n = 76) or water-based (n = 64) contrast. The median T4 concentration was 87.0 nmol/l [76.0–96.0] in the oil group and 90.0 nmol/l [78.0–106.0] in the water group (P = 0.13). None of the neonates had a positive screening result for CH.The median amount of contrast medium used was 9.0 ml [interquartile range (IQR), 6.0–11.8] in the oil-group and 10.0 ml [IQR, 7.5–14.0] in the water group (P = 0.43). No influence of the amount of contrast on the effect of contrast group on T4 concentrations was found (P-value for interaction, 0.37).LIMITATIONS, REASONS FOR CAUTIONA relatively small sample size and possible attrition at follow-up are limitations of this study. Although our results suggest that the use of iodinated contrast media for HSG is safe for the offspring, the impact of a decrease in maternal thyroid function on offspring neurodevelopment could not be excluded, as data on maternal thyroid function after HSG and during conception were lacking.WIDER IMPLICATIONS OF THE FINDINGSAs HSG with oil-based contrast does not affect thyroid function of the offspring, there is no reason to withhold this contrast to infertile women undergoing HSG. Future studies should investigate whether HSG with iodinated contrast influences the periconceptional maternal thyroid function and, consequently, offspring neurodevelopment.STUDY FUNDING/COMPETING INTEREST(S)This study received no funding. The original H2Oil RCT was an investigator-initiated study that was funded by the two academic institutions (Academic Medical Center and VU University Medical Center) of the Amsterdam UMC. The funders had no role in study design, collection, analysis and intrepretation of the data. I.R. reports receiving travel fee from Guerbet. C.B.L. reports speakers fee from Ferring in the past and research grants from Ferring, Merck and Guerbet. K.D. reports receiving travel fee and speakers fee from Guerbet. B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck KGaA and Guerbet and travel and research grants from Merck KGaA and Guerbet. V.M. reports receiving travel fee and speakers fee as well as research grants from Guerbet. The other authors do not report conflicts of interest.TRIAL REGISTRATION NUMBERNetherlands Trial Register NTR 7526 (Neonates born after the H2Oil study), NTR 3270 (original H2Oil study), www.trialregister.nl

Estimation the Level of Follicular Fluid Follistatin in Women Undergoing Intracytoplasmic Sperm Injection

Objectives: A prospective study carried out in Kirkuk city from 15th of January 2019 to 10th of April 2019 , included 45 women who were enrolled in assisted reproductive technology (ART) programs in infertility Centre /Kirkuk, Iraq. Patients and method: All women were subjected to the basic fertility work-up at the infertility center which consists of history taking,physical examination, ovulation detection, evaluation of tubal patency and uterine cavity . The average age of the included women ranged between 20 and 42 years old. All women were enrolled in short protocol type of IVF/ICSI cycle and they had normal menstrual cycles. Nearly 5 ml of follicular fluid was obtained from all women undergoing ICSI for estimation of follistatin level by ELISA technique. Results : The present study showed that 31.1% (14 of 45) of women underwent ISCI technique became pregnant and 68.9% were non-pregnant (31of 45). The highest mean of age were recorded among pregnant women compared with non-pregnant women (32.21± 6.68 v.s31.80±5.38 year) although the result was non-significant (P: > 0.05). The highest mean of BMI were recorded among non-pregnant women compared with pregnant women (23.92 ± 1.55 v.s 25.36±1.99 kg/m2), the result was significant. The highest mean level of follicular fluid follistatin evaluated in pregnant compared with non pregnant (10.20±0.30 v.s 9.83±0.58 ng/ml) although the result was high significant difference (p: < 0.05). The study showed that there was negative correlation of follicular fluid follistatin level with age in pregnant women (r= -0.3), with positive correlation of with age in non-pregnant women. Conclusions: There was a highly significant relation of follicular fluid follistatin with pregnancy outcomes after ICSI.

Does Laparoscopy and Hysteroscopy Have a Place in the Diagnosis of Unexplained Infertility?

The standard fertility workup includes assessment of ovulation, semen analysis, and evaluation of tubal patency. If the fertility workup is found to be normal, a diagnosis of unexplained infertility is made. The role of laparoscopy in fertility workup has been a matter of debate. The current review presents the evidence for and against laparoscopy and hysteroscopy during fertility workup and subsequently prior to fertility treatment. After appraising the literature, we found the role of diagnostic laparoscopy in fertility workup is limited and is dependent on factors like prevalence of pelvic infection, setting, and availability of expertise. Moreover, whenever a laparoscopy is planned as a part of the fertility workup, the preparation should include ability to carry out simultaneous therapeutic intervention to maximize the benefit. Similarly, the routine use of hysteroscopy in women with unexplained infertility cannot be recommended. There is a need to investigate the impact of choice of tubal test on chances of spontaneous conception and treatment outcomes in women with unexplained infertility. Our future research agenda should also include high-quality multicenter randomized trials assessing the cost-effectiveness of screening and operative hysteroscopy prior to intrauterine insemination or in vitro fertilization.

A comparative study of semen parameters of men undergoing fertility treatment from urban population residing in Delhi/NCR region and semi-urban population from adjoining states

Objective: To analyze the difference in semen parameters of men from urban areas of Delhi/NCR with those residing outside Delhi region. Material and Methods: A retrospective cross-sectional study was undertaken at tertiary level center located in New Delhi region between the period of August 2019 to January 2020. A total of 657 men undergoing fertility workup during their infertility treatment were included in the study with 521 (79.2%) men from Delhi/NCR region (urban) and another 136 (20.7%) men from outside Delhi region (semi-urban) with mean age of both the group was 35.6 ± 5.7 years. Results and Discussion: It was observed in both the groups that there was no statistical difference noted in mean ± SD of in semen volume (1.79 ± 0.84 vs 1.78 ± 0.83), sperm concentration (49.9 ±32.4 vs 49.8 ± 32.4), total motility (58 ± 22.5 vs 58.1 ± 22.5), progressive motility (32.3 ±13.8 vs 32.2 ± 13.8) P = 0.95 and sperm morphology (2.3 ± 2.2 vs 2.3 ± 2.2). The prevalence of male factor subfertility was higher in men residing outside Delhi as compared to men of Delhi 53.1% versus 56.6% respectively and overall combined male factor in study population including the men from both the group was 58%. Conclusion: There were no significant differences in semen parameters including sperm concentration, total motility progressive motility, total motile concentration and sperm gross morphology in the men residing in urban area of Delhi and those residing in semi-urban area outside Delhi/NCR for up to three years period.

Transvaginal hydrolaparoscopy and laparoscopy.

To evaluate the findings of outpatient transvaginal hydrolaparoscopy (THL) in comparison with diagnostic laparoscopy combined with chromopertubation in subfertile women. In a retrospective study in four large teaching hospitals, all subfertile women who underwent a THL and a conventional laparoscopy as part of their fertility work-up in the period between 2000 and 2011 were studied. Findings at THL were compared with findings at diagnostic and therapeutic laparoscopies. Tubal occlusion, endometriosis and adhesions were defined as abnormalities. Out of 1119 women, 1103 women underwent THL. A complete evaluation or incomplete but diagnostic procedure could be performed in 989 (89.7%) and 28 (2.5%), respectively. An incomplete non-diagnostic procedure was performed in 11 (1.0%) women. Failure of THL occurred in 75 women (6.8%) and 40 of these women (3.6%) subsequently underwent laparoscopy. Laparoscopy was performed in a total of 126 patients with a median time interval of 7 weeks (interquartile range [IQR] 3-13 weeks). Of 64 patients who successfully underwent both THL and laparoscopy, concordant findings were found in 53 women and discordant results in 11 women, 6 of which were caused by tubal spasm. Sensitivity of THL in detecting abnormalities was 100% and specificity was 22.2%, with a likelihood ratio of 1.29. THL in an outpatient setting can detect anatomical abnormalities comparable to the more invasive reference standard diagnostic laparoscopy. If THL succeeds, there is no need to add a diagnostic laparoscopy in the work-up.

C-reactive protein as a marker of persistent Chlamydia trachomatis infection is not associated with tubal factor infertility-an independent clinical validation study.

STUDY QUESTIONDoes C-reactive protein (CRP), as a marker of persisting low-grade inflammation, identify Chlamydia trachomatis IgG antibody test (CAT)-positive women who are at the highest risk for tubal factor infertility (TFI)?SUMMARY ANSWERNo association was found between slightly elevated CRP (seCRP) levels and TFI in our CAT-positive patient population.WHAT IS KNOWN ALREADYIn the fertility work-up, CAT is used to estimate the risk for TFI and to select high-risk patients for additional invasive diagnostic procedures (e.g. hysterosalpingography and laparoscopy). However, a high number of false positives exist among CAT-positive patients. In a previous study, it has been suggested that women with TFI may be identified more accurately when combining CAT with CRP, a marker for persistent low-grade inflammation.STUDY DESIGN, SIZE, DURATIONOur original retrospective cohort consisted of 887 consecutive female patients who visited the fertility clinic of a tertiary care centre between 2007 and 2015. All CAT-positive women who underwent laparoscopy (as the reference test for evaluation of tubal function) and who had not undergone previous pelvic surgery were included in the study. CRP was determined in spare serum samples, and medical data was obtained by chart review.PARTICIPANTS/MATERIALS, SETTING, METHODSA total of 101 women (11.4%) were CAT-positive, and 64 of these 101 women (7.2%) met all inclusion criteria. CAT was performed with an ELISA. TFI was assessed by laparoscopy and strictly defined as extensive peri-adnexal adhesions and/or distal occlusion of at least one tube. In spare sera, CRP was performed with a high-sensitivity CRP ELISA, and CRP levels between 3 and 10 mg/L were defined as positive. Analyses were corrected for BMI, endometriosis and smoking.MAIN RESULTS AND THE ROLE OF CHANCEThere was no statistically significant association between seCRP level and TFI after adjusting for BMI, endometriosis and smoking (odds ratio 1.0; 95% CI 0.3–3.3; n = 64).LIMITATIONS, REASONS FOR CAUTIONOur retrospective study had a small sample size due to a low CAT-positivity rate and a conservative clinical policy with regard to invasive diagnostic testing. Additionally, CRP levels were only measured once, while they may change throughout the menstrual cycle and in time.WIDER IMPLICATIONS OF THE FINDINGSContrary to previous findings, our results show CRP is not suitable as a marker of persistent low-grade inflammation in CAT-positive women. Other inflammatory markers and immunogenetic host factors should be studied on their clinical validity and utility to improve non-invasive risk assessment for TFI in the fertility work-up.STUDY FUNDING/COMPETING INTEREST(S)This work was partially supported by the European EuroTrans-Bio Grant [Reference number 110012 ETB] and the Eurostars grant (E!9372). S.A.M., a full-time employee of Amsterdam University Medical Centres location VUMC (0.56 fte) and the Maastricht University Medical Center (0.44 fte), is the founder (2011) and CEO of TubaScan Ltd, a spin-off company, Dept. of Medical Microbiology and Infection Prevention, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands. S.O. and E.F.v.E. at the time of conducting this research had a partial appointment at TubaScan Ltd.

Defects in sperm capacitation and fertilizing ability are highly prevalent in men undergoing fertility workups, even if normospermic

Defects in sperm capacitation and fertilizing ability are highly prevalent in men undergoing fertility workups, even if normospermic

Bone mineral density is preserved in men with idiopathic infertility.

Lower semen quality is associated with increased mortality and morbidity, which may include osteoporosis. To assess whether infertile men have a lower bone mineral density (BMD) compared with fertile men at the time of fertility workup. A total of 146 men from infertile couples with unexplained impaired semen quality, characterized by sperm concentration<20 million/mL, progressive motility<50% or<12% morphologically normal spermatozoa. Men with infertility due to a genetic etiology or a condition that could cause testicular damage were excluded. A total of 271 men from couples with an ongoing naturally conceived pregnancy served as a control group. Lumbar, femoral, and total body BMD were measured by dual X-ray absorptiometry. Infertile men had similar BMD compared with fertile men (Beta coefficient (g/cm2 ) and 95% confidence interval for the difference between the two groups: -0.02 (-0.05; 0.01) for lumbar BMD, -0.02 (-0.05; 0.01) for femoral neck BMD, -0.01 (-0.04; 0.02) for total femur BMD, and -0.01 (-0.03; 0.01) for total body BMD). Semen parameters were not associated with BMD measurements. Furthermore, BMD did not differ between infertile men with the lowest semen quality vs. infertile men with better semen quality nor between infertile men with low testosterone vs. fertile men with normal testosterone levels. Bone mineral density is preserved in men with unexplained infertility at the time of fertility workup.

The Potential Role for Host Genetic Profiling in Screening for Chlamydia-Associated Tubal Factor Infertility (TFI)-New Perspectives.

Host immunogenetic factors can affect late complications of urogenital infections with Chlamydia trachomatis. These findings are creating new avenues for updating existing risk prediction models for C. trachomatis-associated tubal factor infertility (TFI). Research into host factors and its utilization may therefore have future implications for diagnosing C. trachomatis-induced infertility. We outline the epidemiological situation regarding C. trachomatis and TFI in high-income countries. Thereupon, we review the main characteristics of the population undergoing fertility work-up and identify screening and diagnostic strategies for TFI currently in place. The Netherlands is an exemplary model for the state of the art in high-income countries. Within the framework of existing clinical approaches, we propose a scenario for the translation of relevant genome-based information into triage of infertile women, with the objective of implementing genetic profiling in the routine investigation of TFI. Furthermore, we describe the state of the art in relevant gene- and single nucleotide polymorphism (SNP) based clinical prediction models and place our perspectives in the context of these applications. We conclude that the introduction of a genetic test of proven validity into the assessment of TFI should help reduce patient burden from invasive and costly examinations by achieving a more precise risk stratification.

Screening hysteroscopy in subfertile women and women undergoing assisted reproduction.

Screening hysteroscopy in infertile women with unexplained infertility, or prior to intrauterine insemination (IUI) or in vitro fertilisation (IVF) may reveal intrauterine pathology that may not be detected by routine transvaginal ultrasound. Hysteroscopy, whether purely diagnostic or operative may improve reproductive outcomes. To assess the effectiveness and safety of screening hysteroscopy in subfertile women undergoing evaluation for infertility, and subfertile women undergoing IUI or IVF. We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL CRSO, MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (September 2018). We searched reference lists of relevant articles and handsearched relevant conference proceedings. Randomised controlled trials comparing screening hysteroscopy versus no intervention in subfertile women wishing to conceive spontaneously, or before undergoing IUI or IVF. We independently screened studies, extracted data, and assessed the risk of bias. The primary outcomes were live birth rate and complications following hysteroscopy. We analysed data using risk ratio (RR) and a fixed-effect model. We assessed the quality of the evidence by using GRADE criteria. We retrieved 11 studies. We included one trial that evaluated screening hysteroscopy versus no hysteroscopy, in women with unexplained subfertility, who were trying to conceive spontaneously. We are uncertain whether ongoing pregnancy rate improves following a screening hysteroscopy in women with at least two years of unexplained subfertility (RR 4.30, 95% CI 2.29 to 8.07; 1 RCT; participants = 200; very low-quality evidence). For a typical clinic with a 10% ongoing pregnancy rate without hysteroscopy, performing a screening hysteroscopy would be expected to result in ongoing pregnancy rates between 23% and 81%. The included study reported no adverse events in either treatment arm. We are uncertain whether clinical pregnancy rate is improved (RR 3.80, 95% CI 2.31 to 6.24; 1 RCT; participants = 200; very low-quality evidence), or miscarriage rate increases (RR 2.80, 95% CI 1.05 to 7.48; 1 RCT; participants = 200; very low-quality evidence), following screening hysteroscopy in women with at least two years of unexplained subfertility.We included ten trials that included 1836 women who had a screening hysteroscopy and 1914 women who had no hysteroscopy prior to IVF. Main limitations in the quality of evidence were inadequate reporting of study methods and higher statistical heterogeneity. Eight of the ten trials had unclear risk of bias for allocation concealment.Performing a screening hysteroscopy before IVF may increase live birth rate (RR 1.26, 95% CI 1.11 to 1.43; 6 RCTs; participants = 2745; I² = 69 %; low-quality evidence). For a typical clinic with a 22% live birth rate, performing a screening hysteroscopy would be expected to result in live birth rates between 25% and 32%. However, sensitivity analysis done by pooling results from trials at low risk of bias showed no increase in live birth rate following a screening hysteroscopy (RR 0.99, 95% CI 0.82 to 1.18; 2 RCTs; participants = 1452; I² = 0%).Only four trials reported complications following hysteroscopy; of these, three trials recorded no events in either group. We are uncertain whether a screening hysteroscopy is associated with higher adverse events (Peto odds ratio 7.47, 95% CI 0.15 to 376.42; 4 RCTs; participants = 1872; I² = not applicable; very low-quality evidence).Performing a screening hysteroscopy before IVF may increase clinical pregnancy rate (RR 1.32, 95% CI 1.20 to 1.45; 10 RCTs; participants = 3750; I² = 49%; low-quality evidence). For a typical clinic with a 28% clinical pregnancy rate, performing a screening hysteroscopy would be expected to result in clinical pregnancy rates between 33% and 40%.There may be little or no difference in miscarriage rate following screening hysteroscopy (RR 1.01, 95% CI 0.67 to 1.50; 3 RCTs; participants = 1669; I² = 0%; low-quality evidence).We found no trials that compared a screening hysteroscopy versus no hysteroscopy before IUI. At present, there is no high-quality evidence to support the routine use of hysteroscopy as a screening tool in the general population of subfertile women with a normal ultrasound or hysterosalpingogram in the basic fertility work-up for improving reproductive success rates.In women undergoing IVF, low-quality evidence, including all of the studies reporting these outcomes, suggests that performing a screening hysteroscopy before IVF may increase live birth and clinical pregnancy rates. However, pooled results from the only two trials with a low risk of bias did not show a benefit of screening hysteroscopy before IVF.Since the studies showing an effect are those with unclear allocation concealment, we are uncertain whether a routine screening hysteroscopy increases live birth and clinical pregnancy, be it for all women, or those with two or more failed IVF attempts. There is insufficient data to draw conclusions about the safety of screening hysteroscopy.

Preconceptional thyrotropin level in euthyroid women is inversely associated with the live birth rate in first in vitro fertilization cycle.

Thyroid disorders have been associated with adverse reproductive outcome. Whether the preconceptional level of thyrotropin (TSH) in euthyroid women impacts on in vitro fertilization (IVF) outcome has been debated. This study reports the outcome of first IVF cycle in euthyroid women in relation to TSH level. A retrospective study was conducted in women referred for fertility treatment in the period 1 January 2012 until 31 March 2014. Among the exclusion criteria were thyroid medication at referral and comorbidities. TSH was measured as part of the fertility workup, and women were followed until pregnancy loss or live birth. Outcome as well as patient characteristics were prospectively collected from a treatment database. A total of 623 euthyroid women underwent their first IVF cycle. The live birth rate was 27.0% (n=168). Comparing women with a preconceptional TSH level above vs below 2.5mIU/L, we found lower odds for clinical pregnancy (adjusted odds ratio [aOR] 0.52; 95% CI 0.29-0.95), and lower odds for live birth (aOR 0.53; 95% CI 0.29-0.99). A preconceptional TSH level >2.5mIU/L was associated with lower odds for clinical pregnancy and live birth in euthyroid healthy women undergoing first IVF cycle.

Tubal flushing with oil- or water-based contrast medium: can we identify markers that indicate treatment benefit?

STUDY QUESTIONCan we identify patient characteristics that distinguish which ovulatory infertile women undergoing hysterosalpingography (HSG) benefit more or less from flushing with oil-based contrast medium compared to water-based contrast medium?SUMMARY ANSWERIn ovulatory infertile women, HSG with oil-based contrast medium resulted in higher 6-month ongoing pregnancy and live birth rates as compared to HSG with water-based contrast medium and this treatment effect was independent of characteristics of the couple.WHAT IS KNOWN ALREADYWe recently showed that in infertile women undergoing HSG, flushing with oil-based contrast medium resulted in more ongoing pregnancies than flushing with water-based contrast medium.STUDY DESIGN, SIZE, DURATIONWe used data from our randomized clinical trial (RCT) in which 1,119 ovulatory infertile women undergoing HSG during fertility work-up were randomized for use of oil-based (N = 557) or water-based (N = 562) contrast medium.PARTICIPANTS/MATERIALS, SETTING, METHODSWe built logistic regression models to predict ongoing pregnancy and live birth (secondary outcome) as a function of the specific contrast, the specific marker, and marker-by-contrast-interaction. Markers considered were female age, maternal ethnicity, female smoking, body mass index (BMI), duration of infertility, infertility being primary or secondary, sperm quality, and previous appendectomy.MAIN RESULTS AND THE ROLE OF CHANCEThe 6-month ongoing pregnancy rates in the overall population were 39.7% after use of oil-based contrast versus 29.1% after use of water-based contrast medium [relative risk (RR), 1.37; 95% confidence interval (CI), 1.16–1.61; P < 0.001]. Among the studied baseline characteristics, BMI (P = 0.002) and semen volume (P = 0.02) were statistically significant prognosticators. The treatment effect of oil-based contrast was stronger in women with a BMI ≤30 kg/m2 [RR, 1.54; 95% CI, 1.23–1.92; P = 0.002], and in women whose partner had a semen volume >3 ml [RR, 1.77; 95% CI, 1.28–2.46; P = 0.02]. Also, in women who smoked, the treatment effect of flushing with oil was stronger, but this interaction did not reach statistical significance (P = 0.066). We found no positive effect of oil-based contrast in obese women. We found similar but weaker associations for live birth, which was probably due to lower number of events resulting in less power.LIMITATIONS, REASONS FOR CAUTIONThe RCT was restricted to infertile ovulatory women younger than 39 years of age without endocrinological disorders and at low risk for tubal pathology. Our results should not be generalized to infertile women who do not share these features.WIDER IMPLICATIONS OF THE FINDINGSAll infertile, ovulatory women younger than 39 years with a low risk for tubal pathology will benefit from an HSG with oil-based contrast; therefore, this should be offered to them after fertility work-up.STUDY FUNDING/COMPETING INTEREST(S)The original H2Oil RCT was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The study displayed in this paper was funded by an unconditional research grant from Guerbet. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). K.D. reports consultancy for Guerbet, during the conduct of the study, and also reports research grants from Guerbet. C.B.L. reports grants from Guerbet, during the conduct of the study, and grants from Ferring, grants from Merck, and personal fees from Ferring, outside the submitted work. P.H. reports grants from Guerbet, during the conduct of the study, and grants from Ferring and Merck, outside the submitted work. V.M. reports receiving travel and speakers fee as well as research grants from Guerbet. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, and Guerbet, and research grants from Guerbet and Merck. The other authors have no conflict of interest to declare.TRIAL REGISTRATION NUMBERNTR 3270 www.trialregister.nlTRIAL REGISTRATION DATE1 February 2012.DATE OF FIRST PATIENT’S ENROLMENT3 February 2012.

Combining individual Chlamydia trachomatis IgG antibodies MOMP, TARP, CPAF, OMP2, and HSP60 for tubal factor infertility prediction.

ProblemTubal factor infertility (TFI) is a severe complication of genital Chlamydia trachomatis infections. In fertility workup, chlamydia antibody test (CAT) is used to predict TFI. The predictive value for TFI of most commonly used CAT is moderate.Method of studyA total of 183 infertile Dutch Caucasian women were included in this study. All underwent tubal patency testing (hysterosalpingography [HSG] or laparoscopy). Cases had TFI, and controls had no TFI (ie normal findings during HSG or laparoscopy). TFI was categorized based on severity (TFI 1‐TFI 4). This study investigated the predictive values of major outer membrane protein (MOMP), translocated actin‐recruiting phosphoprotein (TARP), chlamydial protease‐like activity factor (CPAF), heat shock protein‐60 (HSP60) and outer membrane protein 2 (OMP2) for TFI. A predictive algorithm is developed to detect TFI with a high certainty based on combinations of antibody titres. Serum was tested with the Mikrogen recomLine immunoblot and quantified with the recomScan. A greedy algorithm that explores all possible antibody combinations was developed.ResultsSignificant differences in the distributions of antigen titres between cases and controls were observed for CPAF (P = 0.0021), HSP60 (P = 0.0061), MOMP (P = 0.0497) and OMP2 (P = 0.0016). Single antibodies could not discriminate between TFI and controls by themselves. The greedy algorithm performs better in specificity, positive predictive value (PPV), accuracy and clinical utility index than the original Mikrogen algorithm. CPAF combined with HSP60 identified 18.2% of TFI cases with 100% certainty. Most of the TFI 4 cases were identified with cut‐offs of CPAF > 10.7 or OMP2 > 3.9.ConclusionThis proof‐of‐principle study shows that combinations of antibodies in serum are predictive for TFI. A commercially available test can be adapted to predict TFI with a 100% specificity.

Consultation and treatment behaviour of infertile couples in China: a population-based study.

The prevalence of infertility in couples actively trying to conceive is 25%. What is the consultation-seeking behaviour, diagnosis and related treatment in infertile couples across China? Large cross-sectional population-based study in 2010-2011, in which 25,270 couples from eight provinces/municipalities in China were approached by a multistage stratified cluster sampling strategy. Among the 2680 couples reporting infertility, 1246 infertile couples consulted a fertility doctor. Age of the couple, man's body mass index and women's educational level were found to be associated with consultation behaviour. After the fertility work-up, diagnoses were tubal infertility (n=353, 28.3%), unexplained infertility (n=311, 25.0%), male infertility (n=234, 18.8%), ovulatory disorder (n=194, 15.6%) and endometriosis (n=34, 2.7%), while 8.6% (n=107) were not classified. Most couples received non-assisted reproductive technology (ART) fertility treatment (n=906, 89.3%), with a proportion using traditional Chinese medicine (TCM) (n=298, 29.4%). Intrauterine insemination (n=62, 6.1%) and IVF/intracytoplasmic sperm injection (n=57, 5.6%) were less frequent. Medical treatment and outcomes among five subtypes of infertility were also reported: about 30% of couples with unexplained infertility (n=94, 30.3%) or male infertility (n=67, 29.0%) used TCM to treat infertility. Apart from patients with endometriosis, of whom 20.6% (n=7) received ART, patients with other infertility subtypes rarely received ART. For subsequent fertility outcome, 94% of them did not achieve a pregnancy. The prevalence of infertility in China is high, but the uptake of treatment is relatively low.

Serum follistatin and its role in intracytoplasmic sperm injection outcomes

Background: progress in assisted reproductive technology (ART) has enabled the clinicians to treat many types of infertility. Objectives: The ultimate goal of all these procedures is to get a viable intrauterine pregnancy as a step to get a healthy baby. Intracytoplasmic sperm injection (ICSI) refers to the technique of assisted reproduction, including injecting a single sperm into the center (cytoplasm) of the egg. Materials and Methods: A prospective study included 45 women who were enrolled in ART programs in infertility center for in-vitro fertilization (IVF) in International Center/Kirkuk, Iraq. All women were subjected to the basic fertility workup at the infertility center which consists of history taking, physical examination, ovulation detection, evaluation of tubal patency, and uterine cavity. The average age of the included women ranged between 20 years and 42 years of age. All women were enrolled in short protocol type of IVF/ICSI cycle, and they had normal menstrual cycles. Serum samples were stored for estimation of follistatin level by ELISA technique and for estimation of luteinizing hormone, follicle-stimulating hormone, estrogen, and progesterone by VIDAS technique. Results: The present study showed that 31.1% of women underwent ICSI technique became pregnant and 68.9% were nonpregnant. The highest mean of age were recorded among pregnant women compared with nonpregnant women (32.21 ± 6.68 vs. 31.80 ± 5.38 years) although the result was nonsignificant (P > 0.05). The highest mean of body mass index were recorded among nonpregnant women compared with pregnant women (23.92 ± 1.55 vs. 25.36 ± 1.99 kg/m2); the result was significant. The study showed highest mean level of serum follistatin present in nonpregnant compared with pregnant women (0.75 ± 0.32 vs. 0.62 ± 0.24 ng/ml) although the result was nonsignificant (P > 0.05). Conclusions: There was no relation of serum follistatin with pregnancy after ICSI.

Is IUI with ovarian stimulation effective in couples with unexplained subfertility?

Does starting IUI with ovarian stimulation (IUI-OS) within 1.5 years after completion of the fertility workup increase ongoing pregnancy rates compared to expectant management in couples with unexplained subfertility? IUI-OS is associated with higher chances of ongoing pregnancy compared to expectant management in unexplained subfertile couples, specifically those with poor prognoses of natural conception, i.e. <15% over 6 months or <25% over 1 year. IUI-OS is often the first-line treatment for couples with unexplained subfertility. Two randomized controlled trials compared IUI-OS to expectant management using different thresholds for the prognosis of natural conception as inclusion criteria and found conflicting results. A cohort of couples with unexplained subfertility exposed to expectant management and IUI-OS offers an opportunity to determine the chances of conception after both strategies and to evaluate whether the effect of IUI-OS depends on a couple's prognosis of natural conception. A prospective cohort study on couples with unexplained or mild male subfertility who could start IUI-OS at any point after completion of the fertility workup, recruited in seven Dutch centres between January 2002 and February 2004. Decisions regarding treatment were subject to local protocols, the judgement of the clinician and the wishes of the couple. Couples with bilateral tubal occlusion, anovulation or a total motile sperm count <1 × 106 were excluded. Follow up was censored at the start of IVF, after the last IUI cycle or at last contact and truncated at a maximum of 1.5 years after the fertility workup. The endpoint was time to conception leading to an ongoing pregnancy. We used the sequential Cox approach comparing in each month ongoing pregnancy rates over the next 6 months of couples who started IUI-OS to couples who did not. We calculated the prognosis of natural conception for individual couples, updated this over consecutive failed cycles and evaluated whether prognosis modified the effect of starting IUI-OS. We corrected for known predictors of conception using inverse probability weighting. Data from 1896 couples were available. There were 800 couples whom had at least one IUI-OS cycle within 1.5 years post fertility workup of whom 142 couples conceived (rate: 0.50 per couple per year, median follow up 4 months). The median period between fertility workup completion and starting IUI-OS was 6.5 months. Out of 1096 untreated couples, 386 conceived naturally (rate: 0.31 per couple per year, median follow up 7 months). Starting IUI-OS was associated with a higher chance of ongoing pregnancy by a pooled, overall hazard ratio of 1.96 (95% CI: 1.47-2.62) compared to expectant management. The effect of treatment was modified by a couple's prognosis of achieving natural conception (P = 0.01), with poorer prognoses or additional failed natural cycles being associated with a stronger effect of treatment. The predicted 6-month ongoing pregnancy rate for a couple with a prognosis of 25% at completion of the fertility workup over the next six cycles (~40% over 1 year) was 25% (95% CI: 21-28%) for expectant management and 24% (95% CI: 9-36%) when starting IUI-OS directly. For a couple with a prognosis of 15% (25% over 1 year), these predicted rates were 17% (95% CI: 15-19%) for expectant management and 24% (95% CI: 15-32%) for starting IUI-OS. The effect estimates are based on a prospective cohort followed up for 1.5 years after completion of the fertility workup. Although we balanced the known predictors of conception between treated and untreated couples using inverse probability weighting, observational data may be subject to residual confounding. The results need to be confirmed in external datasets. These results explain the discrepancies between previous trials that compared IUI-OS to expectant management, but further studies are required to establish the threshold at which IUI-OS is (cost-)effective. This study was facilitated by (Grant 945/12/002) from ZonMW, The Netherlands Organization for Health Research and Development, The Hague, The Netherlands. B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck and Guerbet. S.B. reports acting as Editor-in-Chief of HROpen. The other authors have no conflicts of interest.

External validation of a dynamic prediction model for repeated predictions of natural conception over time.

How well does a previously developed dynamic prediction model perform in an external, geographical validation in terms of predicting the chances of natural conception at various points in time? The dynamic prediction model performs well in an external validation on a Scottish cohort. Prediction models provide information that can aid evidence-based management of unexplained subfertile couples. We developed a dynamic prediction model for natural conception (van Eekelen model) that is able to update predictions of natural conception when couples return to their clinician after a period of unsuccessful expectant management. It is not known how well this model performs in an external population. A record-linked registry study including the long-term follow-up of all couples who were considered unexplained subfertile following a fertility workup at a Scottish fertility clinic between 1998 and 2011. Couples with anovulation, uni/bilateral tubal occlusion, mild/severe endometriosis or impaired semen quality according to World Health Organization criteria were excluded. The endpoint was time to natural conception, leading to an ongoing pregnancy (defined as reaching a gestational age of at least 12 weeks). Follow-up was censored at the start of treatment, at the change of partner or at the end of study (31 March 2012). The performance of the van Eekelen model was evaluated in terms of calibration and discrimination at various points in time. Additionally, we assessed the clinical utility of the model in terms of the range of the calculated predictions. Of a total of 1203 couples with a median follow-up of 1 year and 3 months after the fertility workup, 398 (33%) couples conceived naturally leading to an ongoing pregnancy. Using the dynamic prediction model, the mean probability of natural conception over the course of the first year after the fertility workup was estimated at 25% (observed: 23%). After 0.5, 1 and 1.5 years of expectant management after the completion of the fertility workup, the average probability of conceiving naturally over the next year was estimated at 18% (observed: 15%), 14% (observed: 14%) and 12% (observed: 12%). Calibration plots showed good agreement between predicted chances and the observed fraction of ongoing pregnancy within risk groups. Discrimination was moderate with c statistics similar to those in the internal validation, ranging from 0.60 to 0.64. The range of predicted chances was sufficiently wide to distinguish between couples having a good and poor prognosis with a minimum of zero at all times and a maximum of 55% over the first year after the workup, which decreased to maxima of 43% after 0.5 years, 34% after 1 year and 29% after 1.5 years after the fertility workup. The model slightly overestimated the chances of conception by ~2-3% points on group level in the first-year post-fertility workup and after 0.5 years of expectant management, respectively. This is likely attributable to the fact that the exact dates of completion of the fertility workup for couples were missing and had to be estimated. The van Eekelen model is a valid and robust tool that is ready to use in clinical practice to counsel couples with unexplained subfertility on their individualized chances of natural conception at various points in time, notably when couples return to the clinic after a period of unsuccessful expectant management. This work was supported by a Chief Scientist Office postdoctoral training fellowship in health services research and health of the public research (ref PDF/12/06). There are no conflicts of interest.

It takes two to tango: couples’ long and expensive paths to varicocele repair

Since females traditionally drive a couple’s fertility workup, we characterized infertile couples requiring varicocelectomy and their delay in presentation to a male infertility clinic. Descriptive retrospective review of patients who underwent microsurgical varicocelectomy by two surgeons. Patients whose charts included partner histories were assessed for duration of attempting conception, prior workup, and prior use of assisted reproductive technology (ART). A student’s t test was used to compare total motile sperm counts between patients who used ART to those who did not. Time trying for conception was compared between those presenting with primary versus secondary infertility. A total of 376 patients were included in the study population. At presentation, the mean age was 34.6 (range 21 - 63) years for men, and 31.15 (range 19 - 43) years for women. On average, couples were trying for 22 (range 0 to 120) months prior to presenting for male evaluation. 86% (307/356) of couples presented with concerns for primary infertility while 14% (49/356) of couples presented for secondary infertility. Couples with primary infertility were trying for pregnancy for an average of 21 months, while couples with secondary infertility were trying for pregnancy for an average of 29 months prior to presentation for male workup. However this difference did not reach statistical significance (p=0.096). 59% (198/337) of couples were first seen by a gynecologist only, 24% (83/337) a reproductive endocrinologist (REI) only, 15% (50/337) presented without a female workup, and 2% (6) couples saw both a gynecologist and REI prior to presenting to a male infertility clinic. In total, 18% underwent ART prior to presentation [38/345 underwent intrauterine insemination (IUI) (range 1-10 cycles); 30/345 underwent in vitro fertilization (IVF) (1 to 4 cycles); 5/345 underwent both IUI and IVF] Couples who had undergone IUI or IVF had similar total motile sperm counts compared to others. The majority (72.3%) of females had no abnormality in their workup, making varicocele the only correctable factor for infertility. The female conditions diagnosed are in Table 1. Our findings show a significant delay in referral of infertile men requiring varicocelectomy. 18% of couples underwent IUI or IVF, a costly procedure, prior to having an inexpensive (<$1000) male workup (scrotal ultrasound, semen analysis, and hormone levels). In an era of medical cost containment, early referral to a male infertility specialist is imperative.Table 1Comorbidities and Results of Female Workup Prior to Seeing Male Fertility SpecialistComorbidity/Finding on WorkupIncidence (Total n=311)No Abnormality Found225 (72%)Ovulatory Factor/ Polycystic Ovarian Syndrome49 (15.7%)Tubal Factor17 (5.4%)Endometriosis13 (4.2%)Uterine Factor12 (3.9%)Cervical Factor3 (1.0%)Other/Unexplained1 (0.32%) Open table in a new tab

Comparison of the Mikrogen multi-target ELISA with the Mikrogen recomLine immunoblot for the detection of Chlamydia trachomatis IgG antibodies in serum in infertile women

ObjectivesChlamydia trachomatis (CT) IgG serology is used in many fertility clinics in order to estimate the risk for tubal factor infertility (TFI) in the fertility work-up. The predictive value for TFI of the currently used mono-target CT serology test should be improved. This study compares the performance of the new multi-target Mikrogen recomWell CT IgG ELISA with the Mikrogen recomLine CT immunoblot and visualizes distribution of individual antibodies in serum with the immunoblot in order to potentially improve the current CT IgG serology test that is clinically used. MethodsStudy population consisted of 183 Dutch Caucasian infertile women who underwent laparoscopy and/or hysterosalpingography. 48 women had TFI, 135 were controls. Serum was tested with Mikrogen CT IgG ELISA, which detects 3 CT IgG antibodies in one well, and Mikrogen CT immunoblot, which can individually detect 5 CT IgG antibodies. Tests were compared based on the results in general and in the case and control group also taking the individual antibodies into account. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), Kappa value and distribution of individual antibodies in positive samples were calculated. ResultsIn 183 patients 51% tested positive in the ELISA versus 35% in the immunoblot. 32% versus 65% tested negative. Difference between PPV was not statistically significant (33% and 39% respectively) and NPV in both tests was 81%. Difference in sensitivity and specificity was statistically significant, respectively 65% vs. 52% and 54% vs. 71%. Kappa was only 45%. 64.5% of samples that tested positive with ELISA were positive for at least 4 individual CT antibodies with the immunoblot. ConclusionThe concordance between CT ELISA and CT immunoblot is moderate. Due to separate criteria for positivity of both tests there is a significant difference in sensitivity and specificity. PPV and NPV, the most relevant characteristics for clinicians, of both tests did not differ significantly. The distribution of individual antibodies and the adjustment of the immunoblot algorithm will be further explored in the future in order to develop a potentially better prediction method for TFI with a higher clinical accuracy.

Klinefelter syndrome and fertility-Impact of X-chromosomal inheritance on spermatogenesis.

With the use of testicular sperm extraction (TESE), spermatozoa can be retrieved in about 30%-50% of men with Klinefelter syndrome (KS). The reason for the absence or presence of spermatozoa in half of the men with KS remains unknown. Therefore, the search for an objective marker for a positive prediction in finding spermatozoa is of significant clinical value to avoid unnecessary testicular biopsies in males with (mostly) low testicular volume and impaired testosterone. The objective of this study was to determine whether paternal or maternal inheritance of the additional X-chromosome can predict the absence or presence of spermatogenesis in men with KS. Men with KS who have had a testicular biopsy for diagnostic fertility workup TESE were eligible for inclusion. Buccal swabs from nine KS patients and parents (trios) were taken to compare X-chromosomal inheritance to determine the parental origin of both X-chromosomes in the males with KS. Spermatozoa were found in TESE biopsies 8 of 35 (23%) patients after performing a unilateral or bilateral TESE. Different levels of spermatogenesis (from the only presence of spermatogonia, up to maturation arrest or hypospermatogenesis) appeared to be present in 19 of 35 (54%) men, meaning that the presence of spermatogenesis not always yields mature spermatozoa. From the nine KS-trios that were genetically analysed for X-chromosomal inheritance origin, no evidence of a correlation between the maternal or paternal origin of the additional X-chromosome and the presence of spermatogenesis was found. In conclusion, the maternal or paternal origin of the additional X-chromosome in men with KS does not predict the presence or absence of spermatogenesis.