STUDY QUESTION:Does the chance of pregnancy keep improving with increasing number of oocytes, or can you collect too many? SUMMARY ANSWER:Clinical pregnancy (CP) and live birth (LB) rates per embryo transfer varied from 10.2 and 9.2% following one oocyte collected to 37.7 and 31.3% when >16 oocytes were collected. Regression modelling indicated success rates increased or at least stayed the same with number of oocytes collected. WHAT IS KNOWN ALREADY:It has been suggested that if >15 oocytes are collected, the success rate for fresh embryo transfers decreases. As this is counterintuitive, as more oocytes should result in more embryos, with a better choice of quality embryos, we decided to analyse the recent experience in a busy IVF unit. STUDY DESIGN, SIZE DURATION:A retrospective analysis of clinical pregnancy and live birth outcome, with respect to number of oocytes collected at Monash IVF for the 2-year period between August 2010 and July 2012, where patients under the age of 45 years underwent a fresh embryo transfer. This included 7697 stimulated cycles for IVF and ICSI. PARTICIPANT/MATERIALS, SETTING, METHODS:Statistical analysis involved data tables and graphs comparing oocyte number with outcome. Results of women who had their first oocyte collection with an embryo transfer within the reference period were analysed by logistic regression analysis including other covariates that might influence pregnancy outcome. Analysis was also carried out of all the 7679 oocyte collections undertaken, resulting in fresh embryo transfers by generalized estimating equations to allow for the within subject correlation in outcomes for repeated treatments. MAIN RESULTS AND THE ROLE OF CHANCE:The number of oocytes collected varied from 1 to 48. Clinical pregnancy and live birth rates per embryo transfer varied from 10.2 and 9.2% when only one oocyte was collected to 37.7 and 31.3% when >16 oocytes were collected. Regression modelling indicated success rates increased or at least stayed the same or with the number of oocytes collected. The percentage of women with embryos cryopreserved increased from under 20% with <4 oocytes collected to over 70% with >16 oocytes collected. There was a slight increase (from 18 to 22%) in oocyte immaturity and a more marked increase (from 0 to 3%) in cancelling fresh transfers to prevent Ovarian Hyperstimulation Syndrome (OHSS) with increase in number of oocytes collected above 16. The results of this study suggest that you cannot collect too many oocytes as both clinical pregnancy and live birth rates do not decrease with high numbers of oocytes collected. However, once >15 oocytes are collected, everything gets quite uncertain. LIMITATIONS, REASONS FOR CAUTION:As the data become sparse above 15 oocytes, we could not demonstrate a significant increase in pregnancy rates above this number. Larger studies would be required to answer the question whether there is a plateau, or rates continue to increase. The negative of aggressive stimulation to produce many oocytes is that the risk of OHSS increases, and this is the most serious complication of ovarian stimulation. STUDY FUNDING/COMPLETING OF INTERESTS:No funding was required. There is no conflict of interest, except that G.K., V.M. and C.M. are shareholders in Monash IVF Pty Ltd.

study question: Does the chance of pregnancy keep improving with increasing number of oocytes, or can you collect too many? summaryanswer: Clinical pregnancy (CP) and live birth (LB) rates per embryo transfer varied from 10.2 and 9.2% following one oocyte collected to 37.7 and 31.3% when .16 oocytes were collected. Regression modelling indicated success rates increased or at least stayed the same with number of oocytes collected. what is known already: It has been suggested that if .15 oocytes are collected, the success rate for fresh embryo transfers decreases. As this is counterintuitive, as more oocytes should result in more embryos, with a better choice of quality embryos, we decided to analyse the recent experience in a busy IVF unit. study design, size duration: A retrospective analysis of clinical pregnancy and live birth outcome, with respect to number of oocytes collected at Monash IVF for the 2-year period between August 2010 and July 2012, where patients under the age of 45 years underwent a fresh embryo transfer. This included 7697 stimulated cycles for IVF and ICSI. participant/materials, setting, methods: Statistical analysis involved data tables and graphs comparing oocyte number with outcome. Results of women who had their first oocyte collection with an embryo transfer within the reference period were analysed by logistic regression analysis including other covariates that might influence pregnancy outcome. Analysis was also carried out of all the 7679 oocyte collections undertaken, resulting in fresh embryo transfers by generalized estimating equations to allow for the within subject correlation in outcomes for repeated treatments. main results and the role of chance: The number of oocytes collected varied from 1 to 48. Clinical pregnancy and live birth rates per embryo transfer varied from 10.2 and 9.2% when only one oocyte was collected to 37.7 and 31.3% when .16 oocytes were collected. Regression modelling indicated success rates increased or at least stayed the same or with the number of oocytes collected. The percentage of women with embryos cryopreserved increased from under 20% with ,4 oocytes collected to over 70% with .16 oocytes collected. There was a slight increase (from 18 to 22%) in oocyte immaturity and a more marked increase (from 0 to 3%) in cancelling fresh transfers to prevent Ovarian Hyperstimulation Syndrome (OHSS) with increase in number of oocytes collected above 16. The results of this study suggest that you cannot collect too many oocytes as both clinical pregnancy and live birth rates do not decrease with high numbers of oocytes collected. However, once .15 oocytes are collected, everything gets quite uncertain. limitations, reasons for caution: Asthe data become sparse above 15 oocytes, wecould not demonstratea significant increase in pregnancy rates above this number. Larger studies would be required to answer the question whether there is a plateau, or rates continue to increase. The negative of aggressive stimulation to produce many oocytes is that the risk of OHSS increases, and this is the most serious complication of ovarian stimulation. study funding/completing of interest(s): No funding was required. There is no conflict of interest, except that G.K., V.M. and C.M. are shareholders in Monash IVF Pty Ltd.

Objective: To determine association between defective protein kinases C (PKC) and A (PKA) and disordered zona pellucida (ZP)induced acrosome reaction (DZPIAR) in normozoospermic infertile men with normal sperm-ZP binding.Design: Sperm from DZPIAR infertile men were treated without (control) or with (test) phorbol myristate acetate (PMA, PKC activator) or dibutyryl cyclic AMP (dbcAMP, PKA activator) under in vitro standard culture condition. The ZP-induced AR was assessed and compared between control and test.Setting: Public and private hospital-based clinical assisted reproduction technology (ART) centers.Patient(s): A total of 51 DZPIAR infertile men were involved in this study.Intervention(s): None.Main Outcomes Measure(s): Sperm-ZP binding and the ZP-induced IAR.Result(s): Both PMA and dbcAMP enhanced ZP-induced AR up to a normal level (>= 25%) in some subjects with DZPIAR: 29 (57%) with PMA and 27 (53%) with dbcAMP. Overall 35 (69%) had the ZP-induced AR enhanced to normal by PMA or dbcAMP but 16 (31%) had little or no response to either agent. Fourteen men responded to the two activators differently: 8 effective only with PMA and 6 effective only with dbcAMP.Conclusion(s): Defective upstream of PKC and PKA pathways are highly associated with disordered ZPIAR in normozoospermic infertile men with normal sperm-ZP binding. (Fertil Steril (R) 2013;99:86-91. (C) 2013 by American Society for Reproductive Medicine.)

A common defect encountered in the spermatozoa of male infertility patients is an idiopathic failure of sperm-egg recognition. In order to resolve the molecular basis of this condition we have compared the proteomic profiles of spermatozoa exhibiting an impaired capacity for sperm-egg recognition with normal cells using label free mass spectrometry (MS)-based quantification. This analysis indicated that impaired sperm-zona binding was associated with reduced expression of the molecular chaperone, heat shock 70 kDa protein 2 (HSPA2), from the sperm proteome. Western blot analysis confirmed this observation in independent patients and demonstrated that the defect did not extend to other members of the HSP70 family. HSPA2 was present in the acrosomal domain of human spermatozoa as a major component of 5 large molecular mass complexes, the most dominant of which was found to contain HSPA2 in close association with just two other proteins, sperm adhesion molecule 1 (SPAM1) and arylsulfatase A (ARSA), both of which that have previously been implicated in sperm-egg interaction. The interaction between SPAM1, ARSA and HSPA2 in a multimeric complex mediating sperm-egg interaction, coupled with the complete failure of this process when HSPA2 is depleted in infertile patients, provides new insights into the mechanisms by which sperm function is impaired in cases of male infertility.

A new Assisted Reproductive Treatment Act was passed in Victoria on December 2008 and came into effect on 1 January 2010. The new legislation changed who was eligible for assisted reproductive technology (ART) and the types of services that clinics could provide. This article reports on interviews with service providers in Victoria who experience first hand the impact of legislation on clinical practice and patients, as well as regulators who are able to provide insight into the values underpinning the regulatory framework. The new legislation was viewed by all participants as an improvement on the old Act because of the removal of discriminatory and ambiguous aspects. The authors argue that while some of the details of the legislation have changed, the underlying principles and the framework have not.

The aim of this study was to compare sperm velocity, hyperactivation, zona pellucida (ZP) binding and ZP-induced acrosome reaction (AR) between Quinn’s advantage fertilization (QAF), human tubal fluid (HTF) and Ham’s F10 media. Semen samples were obtained from normozoospermic men and motile spermatozoa were prepared by gradient centrifugation (PureSperm). Unfertilized oocytes from clinical IVF were used for spermatozoa–oocyte interaction tests. Sperm velocity and hyperactivation were assessed using a Hamilton-Thorn motility analyser. When media were supplemented with human albumin, sperm motility and velocity and sperm binding were not significantly different between QAF and HTF. However, ZP-induced AR was significantly higher with QAF than HTF (42±22 versus 21±18, P<0.001). Sperm velocity, hyperactivation and sperm binding were also significantly higher in QAF than Ham’s F10 media. Supplementation of media with either human serum or human albumin showed no difference in effect on all sperm test results. In conclusion, QAF medium significantly enhances ZP-induced AR which is essential for sperm penetration. Thus QAF appears to be a better medium than HTF for sperm fertilizing ability in conventional IVF.The aim of this study was to compare sperm velocity, hyperactivated motility, sperm binding and zona pellucida (ZP)-induced acrosome reaction (AR) between Quinn’s advantage fertilization (QAF) and human tubal fluid (HTF) and Ham’s F10 media. Semen samples were obtained from men with normal semen analysis results and all test results were compared in paired control samples between different media. When media were supplemented with human albumin, sperm motility, velocity and sperm binding were not significantly different between QAF and HTF. However, ZP-induced AR was significantly higher with QAF than HTF. Sperm velocity, hyperactivated motility and sperm binding were all significantly higher in QAF than Ham’s F10 media. Supplementation with either human serum or human albumin in media had no different effects on all sperm test results. In conclusion, Quinn’s advantage fertilization medium significantly enhances ZP-induced AR, which is essential for sperm penetration. Thus QAF appears to be a better medium than HTF for sperm fertilizing ability in conventional IVF.

This study was to compare the outcomes of conventional (scientist-selected sperm) intracytoplasmic sperm injection (ICSI) and a modified ICSI using zona pellucida (ZP)-bound sperm. Although with 39 couples in each group there was no statistical significance in fertilization, embryo development, implantation, and fetal heart clinical pregnancy rates, the higher implantation and clinical pregnancy rates with ZP-bound sperm encourages further evaluation with larger numbers of subjects using sibling oocytes to determine if the ZP-bound sperm are biologically and functionally superior.

The paper by Lu et al. 1 “A survey on the status of semen analysis in 118 laboratories in China” provides a major review of the current methods of semen analysis in mainland China. It involved a 36-item questionnaire completed by technicians in 118 of a possible 145 potential semen laboratories. Recruitment for the study was via contacts developed at Chinese Andrology meetings and training sessions between 2005 and 2007. It is not stated how comprehensive this strategy would be for accessing all semen laboratories in China. About half the participating laboratories were in general hospitals and the others in hospitals with academic affiliations or family planning institutes. Some who did not complete the questionnaire were found to be not involved in semen analysis or their institution did not have a semen laboratory and thus the impressive response rate is probably even higher–a notable characteristic of Chinese medicine! The results led the authors to call for better standardization of semen analysis.

Objective: To determine whether adverse perinatal outcomes are increased in subfertile women.Design: Cohort study.Setting: Two tertiary assisted reproductive technologies (ART) centers; Victorian births register.Patient(s): Records of women who registered with the clinics (1991-2000), but did not have an infant using ART, were linked to the birth register (1991-2004) to identify singleton non-ART births within 5 years of registration (N = 2171). Controls, matched by maternal age and year of infant's birth, were selected randomly from birth records (N = 4363).Interventions: None.Main Outcome Measure(s): Adverse obstetric and perinatal outcomes.Result(s): After adjusting for confounders, compared with controls, subfertile women had increased odds of hypertension or preeclampsia (adjusted odds ratio [OR] 1.29, 1.02-1.61), antepartum hemorrhage (adjusted OR 1.41, 1.05-1.89), perinatal death (adjusted OR 2.19, 1.10-4.36), low birth weight (adjusted OR 1.44, 1.11-1.85), preterm birth <37 weeks (adjusted OR 1.32, 1.05-1.67) or <31 weeks (adjusted OR 2.37, 1.35-4.13), and cesarean delivery (adjusted OR 1.56, 1.37-1.77). There was weak evidence for increased birth defects (adjusted OR 1.30, 0.98-1.72) and gestational diabetes (adjusted OR 1.25, 0.96-1.63). No increased risk was found for prelabor rupture of membranes, small for gestational age, or postpartum hemorrhage.Conclusion(s): Subfertile women with singleton births are at increased risk of several adverse outcomes. These risks should be considered during their antenatal care and when analyzing adverse effects of ART. (Fertil Steril (R) 2010;94:2674-9. (C) 2010 by American Society for Reproductive Medicine.)

BACKGROUND:The aim of this study was to describe the perceptions of infertile men regarding the impact of infertility on their intimate relationships, their experience of treatment and their sources of information and support. METHODS:A cross-sectional survey of a consecutive cohort of men diagnosed 5 years earlier as infertile at Melbourne IVF and the Royal Women's Hospital Reproductive Services, Melbourne was conducted. Study-specific questions assessed the impact of male factor infertility on the intimate relationships, their perceived quality of infertility-related health care and their preferred sources of infertility-related information and personal support and the effectiveness of these. RESULTS:The response rate was 41% (112/276). Male factor infertility was reported to have had a negative impact on the intimate partner relationship by 25% of men, and 32% reported a negative effect on their sexual satisfaction. Satisfaction with medical care and clinic information was high and not influenced by the outcome of the treatment. Clinic-provided information and discussion with clinic staff were the most strongly preferred sources of information, and the partner and clinic staff were the most valued sources of personal support. Very few men found support groups useful and less than half confided in friends. CONCLUSIONS:The findings suggest that for a significant subgroup of men, male factor infertility affects their intimate relationship negatively. Wider sources of social support are not used by infertile men as they rely predominantly on clinic-provided information and support. This indicates that psychologically informed supportive clinical care is particularly important for men diagnosed as infertile.

BACKGROUND:The reasons for increased birth defect prevalence following in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are largely unknown. Classification of birth defects by pathology rather than organ system, and examination of the role of embryo freezing and thawing may provide clues to the mechanisms involved. This study aimed to investigate these two factors.METHOD:Data on 6946 IVF or ICSI singleton pregnancies were linked to perinatal outcomes obtained from population-based data sets on births and birth defects occurring between 1991 and 2004 in Victoria, Australia. These were compared with 20,838 outcomes for singleton births in the same population, conceived without IVF or ICSI. Birth defects were classified according to pathogenesis.RESULTS:Overall, birth defects were increased after IVF or ICSI [adjusted odds ratio (OR) 1.36; 95% CI: 1.19-1.55] relative to controls. There was no strong evidence of risk differences between IVF and ICSI or between fresh and thawed embryo transfer. However, a specific group, blastogenesis birth defects, were markedly increased [adjusted OR 2.80, 95% CI: 1.63-4.81], with the increase relative to the controls being significant for fresh embryo transfer (adjusted OR 3.65; 95% CI: 2.02-6.59) but not for thawed embryo transfer (adjusted OR 1.60; 95% CI: 0.69-3.69).CONCLUSION:Our findings suggest that there is a specific risk of blastogenesis birth defects arising very early in pregnancy after IVF or ICSI and that this risk may be lower with use of frozen-thawed embryo transfer.

The anti-acrosin monoclonal antibody AcrC5F10 inhibited proacrosin activation, proacrosin-human zona pellucida glycoprotein A (ZPA) binding, and the zona pellucida (ZP)-induced acrosome reaction of the ZP-bound spermatozoa but had no significant effect on sperm-ZP binding. These results suggest that proacrosin-acrosin may play an important role in the ZP-induced acrosome reaction of spermatozoa after primary binding to the ZP. (Fertil Steril (R) 2010;93:2456-9. (C) 2010 by American Society for Reproductive Medicine.)

BACKGROUNDSemen quality is taken as a surrogate measure of male fecundity in clinical andrology, male fertility, reproductive toxicology, epidemiology and pregnancy risk assessments. Reference intervals for values of semen parameters from a fertile population could provide data from which prognosis of fertility or diagnosis of infertility can be extrapolated.METHODSSemen samples from over 4500 men in 14 countries on four continents were obtained from retrospective and prospective analyses on fertile men, men of unknown fertility status and men selected as normozoospermic. Men whose partners had a time-to-pregnancy (TTP) of < or =12 months were chosen as individuals to provide reference distributions for semen parameters. Distributions were also generated for a population assumed to represent the general population.RESULTSThe following one-sided lower reference limits, the fifth centiles (with 95th percent confidence intervals), were generated from men whose partners had TTP < or = 12 months: semen volume, 1.5 ml (1.4-1.7); total sperm number, 39 million per ejaculate (33-46); sperm concentration, 15 million per ml (12-16); vitality, 58% live (55-63); progressive motility, 32% (31-34); total (progressive + non-progressive) motility, 40% (38-42); morphologically normal forms, 4.0% (3.0-4.0). Semen quality of the reference population was superior to that of the men from the general population and normozoospermic men.CONCLUSIONSThe data represent sound reference distributions of semen characteristics of fertile men in a number of countries. They provide an appropriate tool in conjunction with clinical data to evaluate a patient's semen quality and prospects for fertility.

Objective: To investigate attitudes toward parenthood, long-term life satisfaction, and health and well-being in men diagnosed as infertile.Design: A cross-sectional survey of a cohort of men 5 years after diagnosis of infertility.Setting: The andrology clinic at the Royal Women's Hospital Reproductive Services, Melbourne Australia.Patient(s): All men diagnosed at this center as infertile in 2001 and 2002.Intervention(s): None.Main Outcome Measure(s): Attitudes to parenthood (Meaning of Parenthood), quality of intimate relationship (Intimate Bonds Measure), personality characteristics (Vulnerable Personality Style Questionnaire), life satisfaction (Satisfaction with Life Scale), and self-rated physical health (Physical Component Summary of SF-12 [PCS-12]) and relationship with mental health (Mental Component Summary of SF12 [MCS-12]).Result(s): A total of 112 (41%) of 276 men completed the survey. Of these, 96% had pursued infertility treatment and 87% had become fathers. Only 10% thought that fertility confirmed by fatherhood reflected masculinity, and 84% desired parenthood as much as their partners did. When all other factors were controlled for, men who had not become fathers had poorer mental health (MCS-12 score = 43.9 +/- 9.9) than those who were fathers (MCS-12 score = 49.25 +/- 8.7).Conclusion(s): Clinical practice should not presume that infertile men conflate fertility and masculinity, are less distressed than women about the potential loss of parenthood, or adjust more readily to childlessness, which appear to be inaccurate but widespread stereotypes. (Fertil Steril(R) 2010;94:574-80. (C) 2010 by American Society for Reproductive Medicine.)

The aim of this study was to determine the relationship between seminal zinc concentration and spermatozoa-zona pellucida (ZP) binding and the ZP-induced acrosome reaction (ZPIAR) in subfertile men. Semen analyses and seminal zinc concentration assessments were carried out according to the World Health Organization manual for 458 subfertile men. A spermatozoa-ZP interaction test was carried out by incubating 2 x 10(6) motile spermatozoa with a group of four unfertilized oocytes obtained from a clinical in vitro fertilization programme. After 2 h of incubation, the number of spermatozoa bound per ZP and the ZPIAR of ZP-bound spermatozoa were examined. The effect of adding 0.5 mmol L(-1) zinc to the media on the ZPIAR of spermatozoa from normozoospermic men was also tested in vitro. Seminal zinc concentration positively correlated with sperm count and duration of abstinence, but negatively correlated with semen volume. On analysis of data from all participants, both spermatozoa-ZP binding and the ZPIAR were significantly correlated with sperm motility and normal morphology, but not with seminal zinc concentration. However, in men with normozoospermic semen, the seminal zinc concentration was significantly higher in men with defective ZPIAR (< 16%) than in those with normal ZPIAR (>or= 16%) (P < 0.01). The addition of 0.5 mmol L(-1) zinc to the culture media had no effect on spermatozoa-ZP binding, but significantly reduced the ZPIAR in vitro (P < 0.001). In conclusion, seminal zinc concentration is correlated with sperm count and the duration of abstinence in subfertile men. In men with normozoospermic semen, high seminal zinc concentration may have an adverse effect on the ZPIAR.