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Objective: This study aimed to evaluate the risk of endometrial carcinoma and atypical endometrial hyperplasia in asymptomatic postmenopausal women concerning the endometrial thickness measured by stratified threshold categories used for performing subsequent endometrial sampling and histologic evaluation., Data Sources: MEDLINE, Scopus, ClinicalTrials.gov, SciELO, Embase, the Cochrane Central Register of Controlled Trials, LILACS, conference proceedings, and international controlled trials registries were searched without temporal, geographic, or language restrictions., Study Eligibility Criteria: Studies were selected if they had a crossover design evaluating the risk of atypical endometrial hyperplasia and endometrial carcinoma in postmenopausal asymptomatic women and calculated the diagnostic accuracy of transvaginal ultrasonography thresholds (at least 3.0 mm) confirmed by histopathologic diagnosis., Methods: This was a systematic review and diagnostic test accuracy meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy and Synthesizing Evidence from Diagnostic Accuracy Tests guidelines. Endometrial thickness thresholds were grouped as follows: from 3.0 to 5.9 mm; between 6.0 and 9.9 mm; between 10.0 and 13.9 mm; and ≥14.0 mm. Quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. Publication bias was quantified using the Deek funnel plot test. Coprimary outcomes were the risk of atypical endometrial hyperplasia or endometrial carcinoma according to the endometrial thickness and diagnostic accuracy of each threshold group., Results: A total of 18 studies provided the data of 10,334 women who were all included in the final analysis. Overall, at an endometrial thickness threshold of at least 3.0 mm, the risk of atypical endometrial hyperplasia or endometrial carcinoma was increased 3-fold relative to women below the cutoff (relative risk, 3.77; 95% confidence interval, 2.26-6.32; I 2 =74%). Similar degrees of risk were reported for thresholds between 3.0 and 5.9 mm (relative risk, 5.08; 95% confidence interval, 2.26-11.41; I 2 =0%), 6.0 and 9.9 mm (relative risk, 4.34; 95% confidence interval, 1.68-11.23; I 2 =0%), 10.0 and 13.9 mm (relative risk, 4.11; 95% confidence interval, 1.55-10.87; I 2 =86%), and ≥14.0 mm (relative risk, 2.53; 95% confidence interval, 1.04-6.16; I 2 =78%) with no significant difference among subgroups (P=.885). Regarding diagnostic accuracy, the pooled sensitivity decreased from thresholds below 5.9 mm (relative risk, 0.81; 95% confidence interval, 0.49-0.85) to above 14.0 mm (relative risk, 0.28; 95% confidence interval, 0.18-0.40). Furthermore, the specificity increased from 0.70 (95% confidence interval, 0.61-0.78) for endometrial thickness between 3.0 and 5.9 mm to 0.86 (95% confidence interval, 0.71-0.94) when the endometrial thickness is ≥14.0 mm. For 3.0 to 5.9 mm and 10.0 to 13.9 mm thresholds, the highest diagnostic odds ratios of 10 (95% confidence interval, 3-41) and 11 (95% confidence interval, 2-49), with areas under the curve of 0.81 (95% confidence interval, 0.77-0.84) and 0.82 (95% confidence interval, 0.79-0.86), respectively, were retrieved. The summary point analysis revealed that the 3.0 to 5.9 mm cutoff point was placed higher in the summary receiver operator curve space than the other subgroups, indicating increased endometrial carcinoma or atypical endometrial hyperplasia diagnosis using these cutoffs., Conclusion: Both low and high endometrial thickness thresholds in postmenopausal asymptomatic women seem equally effective in detecting endometrial carcinoma and atypical endometrial hyperplasia. However, although using a 3.0 to 5.9 mm cutoff results in a lower specificity, the offsetting improvement in sensitivity may justify using this cutoff for further endometrial evaluation in patients with suspected endometrial malignancy., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Research Question: The semen harbours a diverse range of microorganisms. The origin of the seminal microbes, however, has not yet been established. Do testicular spermatozoa harbour microbes and could they potentially contribute to the seminal microbiome composition?, Design: The study included 24 samples, comprising a total of 307 testicular maturing spermatozoa. A high-throughput sequencing method targeting V3 and V4 regions of 16S rRNA gene was applied. A series of negative controls together with stringent in-silico decontamination methods were analysed., Results: Between 50 and 70% of all the detected bacterial reads accounted for contamination in the testicular sperm samples. After stringent decontamination, Blautia (P = 0.04), Cellulosibacter (P = 0.02), Clostridium XIVa (P = 0.01), Clostridium XIVb (P = 0.04), Clostridium XVIII (P = 0.02), Collinsella (P = 0.005), Prevotella (P = 0.04), Prolixibacter (P = 0.02), Robinsoniella (P = 0.04), and Wandonia (P = 0.04) genera demonstrated statistically significant abundance among immature spermatozoa., Conclusions: Our results indicate that the human testicle harbours potential bacterial signature, though in a low-biomass, and could contribute to the seminal microbiome composition. Further, applying stringent decontamination methods is crucial for analysing microbiome in low-biomass site., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The current pandemic of Coronavirus Disease 2019 (COVID-19) has focused the attention of medical-care providers away from non-life-threatening diseases, including infertility. Although infertility does not jeopardize the physical survival of infertile couples, it does jeopardize their future quality of life. Human infertility can be caused by a number of factors, some of which are age-dependent, and their effects may become irreversible if appropriate measures are not taken in time to prevent irreversible childlessness. Accordingly, each case of infertility should be evaluated comprehensively to establish its position of priority. Assisted reproductive technology (ART) makes it possible to separate fertilization and pregnancy in time. Whereas pregnant women infected with coronavirus may have an increased risk of adverse neonatal outcomes, gametes do not transmit COVID-19. Thus, performing ovarian stimulation and fertilization without delay, freezing the resulting embryos and delaying embryo transfer until the end of the pandemic appears to be the best strategy at present., (Copyright © 2020 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Research Question: This study aimed to identify women with IVF failure associated with low serum progesterone levels after embryo transfer in HCG-triggered cycles and to evaluate the effects of gonadotrophin-releasing hormone (GnRH) agonist, administered after embryo transfer, on serum progesterone and pregnancy outcomes in these cases., Design: Fifty women who failed to achieve an ongoing clinical pregnancy and had abnormally low luteal-phase serum progesterone concentrations in their first IVF attempt were assigned to two matched groups in their subsequent attempt. Twenty-five women were treated with the original protocol plus14 daily injections of GnRH agonist, beginning on the day of oocyte recovery, in their second IVF attempt (group 1). These women were matched to 25 women with the same characteristics and outcomes in their first IVF attempt who underwent the second IVF attempt without the use of GnRH agonist after embryo transfer (group 2). In both groups, the two sequential attempts were compared for serum progesterone concentration 14 days after oocyte recovery and pregnancy outcome., Results: The patients in group 1 had significantly higher progesterone levels 14 days after oocyte recovery in the second attempt compared with the first attempt (P < 0.001), and 12 (48%) of them achieved clinical pregnancy and birth. No significant differences in pregnancy outcome or in the serum progesterone concentration were observed between the first and the second attempt in group 2., Conclusions: In patients with luteal phase deficiency, the administration of GnRH agonist after embryo transfer increases serum progesterone concentration and improves the chance of pregnancy and birth., (Copyright © 2019 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Italian legislation regarding reproductive medicine limits the number of embryos transferred per attempt to three. Thus, in order to achieve pregnancy, more IVF cycles may be required, generating a need for methods of ovarian stimulation with fewer side effects. The gonadotrophin-releasing hormone (GnRH) antagonists have several advantages in this respect, but there is a debate regarding a possible lower pregnancy rate from resulting cycles. This study evaluated the clinical applicability of GnRH antagonists for ovarian stimulation in young women undergoing intracytoplasmic sperm injection (ICSI) in which only three oocytes can be fertilized. The 200 women treated with GnRH antagonist had a significantly shorter stimulation and lower gonadotrophin consumption, oestradiol concentration, total and mature oocyte recovery as compared with 200 matched controls treated with GnRH agonist. No differences were found between the groups in the number of normal zygotes, total cleaved, transferred and high quality embryos, or in the clinical outcomes. Thus, the previously reported lower pregnancy rate in GnRH antagonist cycles may be related to the oocyte characteristics. Finally, under conditions of oocyte number restriction, the GnRH antagonist-based cycles may be proposed as an efficacious, safe and minimally invasive alternative to GnRH agonist in a standard long protocol.

Previous studies have shown that repeated intracytoplasmic sperm injection failures can be associated with sperm DNA damage. This paper reviews the current understanding of the mechanism of sperm DNA damage, discusses different diagnostic methods and their threshold values to discriminate between good- and poor-prognosis patients, and outlines the currently available treatment options. A rational approach to the interpretation of sperm DNA fragmentation data and to the choice of the optimal treatment method is suggested.

Previous studies have shown that repeated intracytoplasmic sperm injection (ICSI) failures can be caused by a paternal effect. Other studies have suggested that ICSI results are compromised if morphologically abnormal spermatozoa are injected into oocytes. This study was undertaken to evaluate the usefulness of a high-magnification optical system to select spermatozoa to be used for ICSI (high-magnification ICSI) in couples with repeated conventional ICSI failures. Couples with two or more previous conventional ICSI failures underwent an additional conventional ICSI attempt, followed by a high-magnification ICSI attempt. The outcomes of the two sequential attempts were compared. In 72 of these patients, sperm DNA integrity was assessed. In the whole group of 125 couples with repeated ICSI failures, high-magnification ICSI improved clinical outcomes (pregnancy, implantation, delivery and birth rates) without affecting biological outcomes (fertilization and cleavage rates, embryo morphology). The improvement of clinical ICSI outcomes was evident both in patients with an elevated degree of sperm DNA fragmentation and in those with normal sperm DNA status. It is concluded that high-magnification ICSI improves clinical outcomes in couples with previous repeated conventional ICSI failures.

Recombinant FSH (r-FSH) used for ovarian stimulation can currently be self-administered either by a conventional syringe or by a pen device. This randomized controlled trial compares the efficacy and convenience of a new, more sophisticated and fully automated injection device (Softinject(trade mark)) with the conventional syringe for r-FSH self-administration. A total of 300 women needing ovarian stimulation for IVF/intracytoplasmic sperm injection were randomized to the automated injector or the conventional syringe group. Patients of both groups had ovarian stimulation with follitropin alpha after pituitary desensitization with a gonadotrophin-releasing hormone agonist. State anxiety score, overall pain score and pregnancy rate were chosen as the main outcome measures. Patients in the automated injector group showed lower state anxiety (P < 0.01) and overall pain (P < 0.01) scores and a comparable pregnancy rate per started cycle as compared with the conventional syringe group. They needed lower doses of r-FSH (P < 0.05) and their stimulation was shorter (P < 0.05). It is concluded that the use of a fully automated injector for r-FSH self-administration reduces pain and stress as compared with the conventional syringe. This device can be used for any subcutaneously administered drug employed in ovarian stimulation.

Cell divisions in the human preimplantation embryo can be compromised by deficiencies in sperm nuclear genome or sperm-derived developmentally relevant cytoplasmic factors, oocyte activating substance and centriole. Sperm nuclear deficiencies are usually not detected before the 8-cell stage of embryo development, when a major expression of sperm-derived genes has begun. Sperm cytoplasmic deficiencies can be detected as early as the 1-cell zygote and then throughout the preimplantation development. The terms 'late paternal effect' and 'early paternal effect' have been suggested to denote these two pathological conditions. The late paternal effect is associated with an increased incidence of sperm DNA fragmentation. No association with sperm DNA damage has been found for the early paternal effect. The diagnosis of the late paternal effect is thus based on the examination of sperm DNA integrity, which should be performed in cases of repeated assisted reproduction failure even if morphologically normal embryos result from fertilization with the patient's spermatozoa. The only element leading to the diagnosis of the early paternal effect is poor zygote and embryo morphology and low cleavage speed. The absence of increased sperm DNA damage does not exclude the presence of this pathology. ICSI with testicular spermatozoa has recently been shown to be an efficient treatment for the late paternal effect. The use of oral antioxidant treatment in this indication has also given promising results.

In spite of several past attempts at defining the point at which conception can be considered completed, resulting in the formation of an embryo, the existing definitions are still contradictory. In the absence of clear terminology, the application of laws aimed at the protection of early human life may have inadequate consequences for the efficacy of the current techniques of human infertility treatment. In this paper biological arguments are revisited, suggesting that the only point at which a clear demarcation line between what is and what is still not an embryo can be drawn is the moment of nuclear syngamy at the outset of the first cleavage division. The term 'zygote' is suggested to denote entities composed of spermatozoon and oocyte components before nuclear syngamy. It is suggested that the current embryo protection laws should not concern the zygote stage: at this stage, the main features that are said, in documents issued by different ethical and legal authorities, to characterize the early human embryo, namely the inseparable union of the male and female contribution, cell division and an autonomous control over cell division, are still not present. This reasoning strictly applies to embryos of biparental (paternal and maternal contribution) origin and cannot be extrapolated to embryos created by cell nuclear transfer (cloning). The application of embryo protection laws from the nuclear syngamy stage onwards can regulate embryo and embryo-derived stem cell research while still preserving the current high standard and efficacy of infertility treatment, which is of immediate interest to millions of infertile couples throughout the world.

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

The X-linked dominant form of Charcot-Marie-Tooth syndrome (CMTX) is a clinically and genetically heterogeneous hereditary disorder of the peripheral nerves caused by mutations in the GJB1 gene that encodes a gap junction protein named connexin 32 (Cx32). Clinically, CMTX is characterized by peripheral motor and sensory deficit with muscle atrophy. A couple with a previous history of pregnancy termination after being diagnosed positive for CMTX by chorionic villus sampling, was referred for preimplantation genetic diagnosis (PGD). The female partner carried the causative H94Q, characterized by a C-->G substitution in codon 94 of exon 2 of the GJB1 gene. Embryos obtained after intracytoplasmic sperm injection (ICSI) were evaluated for the presence of the mother's mutation using polymerase chain reaction (PCR), followed by mutation analysis performed using the minisequencing method. Amelogenin sequences on the X and Y chromosomes were also co-amplified to provide a correlation between embryo gender and mutation presence. A single PGD cycle was performed, involving nine fertilized oocytes, five of which developed into good quality embryos useful for biopsy. Two unaffected embryos were transferred, resulting in a singleton pregnancy followed by the birth of a healthy female.

Previous studies have suggested that LH, in addition to its well-known effects on the ovary, may exert direct effects on the uterus. This study evaluated the effects of mid-cycle administration of human chorionic gonadotrophin (HCG), which signals through the LH receptor, on endometrial thickness and uterine receptivity in two groups of women lacking ovarian activity and receiving embryos from an oocyte donation programme. Patients in one group still had ovulatory cycles, but their ovarian function was suppressed by pituitary down-regulation with a gonadotrophin-releasing hormone (GnRH) agonist in the embryo transfer cycle, resulting in low endogenous LH concentrations. Patients in the other group were menopausal women whose pituitary function was not down-regulated in the embryo transfer cycle and whose endogenous LH concentrations were thus high. Patients in each of the two groups were randomized into two subgroups. Patients in one subgroup were given 5000 IU of HCG 2 days before oocyte recovery in the corresponding donor. Patients in the other subgroup received placebo at the same time. Oocytes from each donor were randomly distributed between one patient from the HCG subgroup and one patient from the placebo subgroup in each patient group. Endometrial growth and secretory transformation were stimulated by sequential treatment with oestradiol valerate and progesterone. In women with low endogenous LH receiving placebo, endometrial thickness stopped increasing at the beginning of secretory transformation. Mid-cycle HCG administration resulted in a continuous increase in endometrial thickness through this period, improved the implantation rate after embryo transfer in these women (30.6 versus 20.7%) and augmented the number of multiple pregnancies. No similar stagnation of endometrial thickness and no effects of mid-cycle HCG administration on endometrial thickness, the implantation rate and the number of multiple pregnancies were found in women with high endogenous LH. It is concluded that endometrial maturation is disturbed in women with low endogenous LH but can be rescued by mid-cycle stimulation of LH receptor with exogenous HCG in the absence of ovarian activity.

Oocyte donation is the only method of treating female sterility caused by complete absence of oocytes, with the loss of genetic motherhood. Genetic fatherhood of males with complete absence of spermatozoa can only be restored by assisted reproduction treatment if sperm precursor cells belonging to the male germline can still be recovered from the testis. Otherwise, sperm donation is the only available solution. Somatic nucleus haploidization after injection into previously enucleated donor oocytes (diploid-to-haploid reduction) might enable the reconstruction of new oocytes carrying the complete nuclear genome of female patients lacking their own oocytes. Such newly formed oocytes could subsequently be fertilized by spermatozoa from the patient's husband. In cases of male infertility with complete absence of the germline, the patient's somatic cell nuclei could be injected into the oocytes without previous enucleation, and somatic nucleus haploidization would occur in the presence of the original female nucleus (triploid-to-diploid reduction), hopefully leading to the formation of a diploid embryo. Both interventions differ substantially from cloning because embryos are formed by syngamy with the male and female genomes originating from the two genetic parents, as in natural fertilization. Ultrastructural remodelling of mouse somatic cell nucleoli can be achieved in enucleated metaphase II mouse oocytes. Haploidization has also been attempted with Sertoli cells and with fibroblasts, both of which are also available in male patients. Experiments are currently under way to assess the regularity of chromatid segregation during somatic nucleus haploidization.

The only assisted reproduction treatment now available for women with ovarian failure or irreparable oocyte defects is oocyte donation. However, some women experience psychological barriers to the recourse to donor oocytes, related to the lack of contribution of their proper genes to the progeny. A pilot study in humans suggests that this problem may be overcome by the development of techniques for haploidization of somatic cell nuclei, allowing the formation of new oocytes bearing the complete nuclear genome of the patient. Somatic cell nuclei were obtained from cumulus cells of a patient who failed to produce fertilizable oocytes and were transferred into enucleated oocytes (ooplasts) from a donor. Out of six ooplasts injected with the somatic cell nuclei and fertilized with spermatozoa from the patient's husband, signs of haploidization were detected in three oocytes, two of which subsequently started embryonic development and were cryopreserved for eventual future transfer to the genetic mother. These data show that human oocytes can be used for both reprogramming and haploidization of somatic cell nuclei, allowing reconstruction of genetically own oocytes for patients without, or with seriously disturbed, ovarian function.

Assisted reproductive techniques and the science of embryology have advanced rapidly over the last decades. The fact that social and moral objectives vary from country to country has resulted in differences not only in legislation, but also in the definition of embryological terms. Among the latest additions to the field has been nuclear transfer technology, which has led to concerns about the possibilities of human cloning. These facts call for a review of gametogenesis and early embryogenesis. The aim of the present paper is to initiate a discussion on terminology with a view to reaching a consensus. As a starting point definitions are proposed for the most important terms.

Progesterone has previously been shown to exert non-genomic effects on human spermatozoa by opening plasma membrane ion channels and by stimulating protein tyrosine phosphorylation. Here we examined how these two activities are influenced by 11-hydroxyl substitution of the steroid molecule either in the alpha- or in the beta-configuration. Both the 11alpha-OH and the 11beta-OH derivatives of progesterone were more effective than progesterone in stimulating tyrosine phosphorylation, although 11alpha-OH-progesterone was a markedly weaker Ca(2+)-influx inducing agonist than the other two steroids. In Ca(2+)-containing medium, the agonist activity of the 11alpha-OH derivative was weaker than that of the 11beta-OH derivative, and it was completely abolished by genistein, whereas that of progesterone and its 11beta-OH derivative was inhibited only partly by this drug. In contrast, when applied in Ca(2+)-free medium, the 11alpha-OH derivative was the strongest of the three agonists tested, and the effects of all the three steroids were completely abolished by genistein. These data show that the structural motifs of steroid molecules that are responsible for the stimulation of tyrosine phosphorylation are different from those mediating the steroid action on Ca2+ influx through plasma membrane channels. The synthesis of selective agonists of both activities may lead to the development of new pharmacological agents to be used in the treatment of steroid-dependent pathologies., (Copyright 1999 Academic Press.)

Signal transduction pathways regulate various aspects of mammalian sperm function. When human sperm were incubated in a medium supporting capacitation, proteins became tyrosine-phosphorylated in a time-dependent manner. This phosphorylation was inhibited by genistein, a protein tyrosine kinase inhibitor. Phosphorylation was also reduced when sperm were incubated either in the presence of increasing concentrations of extracellular Ca2+ or in a medium containing the Ca2+ ionophore A23187. This Ca2+-induced dephosphorylation was calmodulin-dependent, suggesting that calcineurin was involved. In this regard, the calcineurin inhibitor deltamethrin inhibited the Ca2+ ionophore-induced dephosphorylation. A limited number of Mr 80,000-105,000 polypeptides were the most prominent phosphotyrosine-containing proteins present in human sperm. Unlike mouse sperm, which contains a tyrosine-phosphorylated isoform of hexokinase, a phosphotyrosine-containing hexokinase in human sperm was not detected. Most of the tyrosine-phosphorylated proteins were Triton X-100-insoluble and were localized to the principal piece of the flagellum, the region where the cytoskeletal fibrous sheath is found. Prominent phosphotyrosine-containing proteins of Mr 82,000 and 97,000 were identified as the human homologues of mouse sperm AKAP82, the major fibrous sheath protein, and pro-AKAP82, its precursor polypeptide, respectively. These proteins are A Kinase Anchor Proteins, polypeptides that sequester protein kinase A to subcellular locations. Taken together, these results suggest that protein tyrosine phosphorylation may be part of a signal transduction cascade(s) regulating events pertaining to capacitation and/or motility in mammalian sperm and that an interrelationship between tyrosine kinase and cAMP signaling pathways exists in these cells.

It is known that steroids can produce nongenomic effects on cells, such as opening of ionic channels, membrane receptor aggregation or changes in protein phosphorylation status. However, it is not known whether these different effects, when occurring concomitantly, are linked by a causal relationship or whether they are triggered independently by the steroid ligand. Here we show that progesterone opens a plasma membrane Ca2+ channel and activates a protein tyrosine kinase of human spermatozoa independently of each other because, on the one hand, tyrosine kinase inhibition does not affect the progesterone-induced Ca2+ influx and, on the other hand, the absence of extracellular Ca2+ does not preclude tyrosine-kinase-mediated progesterone-induced acrosomal exocytosis. These data suggest that steroids interact with multireceptor systems on the surface of responsive cells.