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Cyclophosphamide (CP) could cause severe gonadotoxicity via imbalanced activation of primordial follicles through PI3K/AKT/mTOR activation. Whether metformin, a widely prescribed anti-diabetes agent with mTOR inhibitory effect, could preserve ovarian function against CP toxicity is unknown. Female C57BL/6 mice were randomized into seven groups (n = 11), including control, CP-alone, CP + metformin, CP + sirolimus or everolimus, metformin-alone and sirolimus-alone groups. The duration of pharmaceutical treatment was 4 weeks. CP treatment significantly impaired ovarian function and fertility in mice. CP + metformin treatment significantly attenuated the gonadotoxicity comparing to CP-alone treatment (primordial follicle count: 17.6 ± 4.2 versus 10.3 ± 2.7 follicles/high-power field; P = 0.027). CP + metformin treatment also tended to increase antral follicular count (5.4 ± 1.1 versus 2.5 ± 1.6 follicles/section), serum AMH levels (4.6 ± 1.2 versus 2.0 ± 0.8 ng/ml) and the litter size (4.2 ± 1.3 versus 1.5 ± 1.0 mice per pregnancy), compared with CP-alone group. Expression of phospho-mTOR and the number of TUNEL-positive granulosa cells increased after CP treatment and decreased in the CP + metformin groups, suggesting the mTOR inhibitory and anti-apoptotic effects of metformin. In in-vitro granulosa cell experiments, the anti-apoptotic effect of metformin was blocked after inhibiting p53 or p21 function, and the expression of p53 mRNA was blocked with AMPK inhibitor, suggesting that the anti-apoptotic effect was AMPK/p53/p21-mediated. In conclusion, concurrent metformin treatment during CP therapy could significantly preserve ovarian function and fertility and could be a promising novel fertility preserving agent during chemotherapy. The relatively acceptable cost and well-established long-term safety profiles of this old drug might prompt its further clinical application at a faster pace.

Background/Purpose: The long-acting corifollitropin alfa is comparable to FSH in terms of pregnancy outcomes in normal responders and poor responders. Corifollitropin alfa has never been studied in polycystic ovary syndrome (PCOS) patients because of concerns of excessive ovarian stimulation and ovarian hyperstimulation syndrome (OHSS). The purpose of the study was to evaluate if corifollitropin alfa can be used in PCOS patients. Methods: Forty PCOS patients who were going to undergo in vitro fertilization were enrolled in this study. A single injection of corifollitropin alfa was administered on cycle day 2 or day 3. From stimulation day 8 onwards, daily FSH was administered until the day of final oocyte maturation. Cetrorelix was administered from stimulation day 5 to prevent premature LH surge. Final oocyte maturation was triggered by: acetate. All embryos were cryopreserved and replaced in subsequent cycles. Results: All 40 patients were subjected to oocyte retrieval, and none developed moderate or severe ovarian hyperstimulation syndrome (0%, 95% CI 0–0.088). For each patient, an average of 23.4 (±7.4; 95% CI 21.0–25.7) oocytes were retrieved and a mean of 11.7 (±6.4; 95% CI 9.6–13.8) embryos were frozen. Mean serum estradiol level on the day of GnRHa triggering was 7829.9 pg/ml (±3297; 95% CI 6775–8885). The cumulated ongoing pregnancy rate after 3 frozen-thawed embryo transfers was 75.0% (95% CI 61.6%–88.4%). Conclusion: The results suggest that corifollitropin alfa/GnRH antagonist protocol can be used in PCOS patients, in combination with GnRHa triggering and embryo cryopreservation. Keywords: Corifollitropin alfa, Cryopreservation, GnRH agonist, Polycystic ovary syndrome

Serum anti-Mullerian hormone (AMH) is a predictor of the pregnancy outcome in assisted reproductive technology (ART) cycles, particularly for older women. This study attempts to elucidate the effect of serum AMH on follicular hormone profiles and implantation outcome of the ensuing embryos in ART cycles. A total of 412 patients undergoing ART cycles at a private infertility center were included and 780 follicular fluid samples were collected. Levels of follicular hormones, including FSH, LH, inhibin B, AMH, estradiol, progesterone, and androstenedione were measured. The implantation outcome of the ensuing embryos was traced as a main outcome measure. We demonstrated that the follicular levels of estradiol, progesterone, and androstenedione were considerably similar, but the overall implantation rates increased as the serum AMH increased. Logistic regression analysis revealed that the best predictor for embryo implantation was follicular FSH (>9.64mIU/mL, odds ratio [OR] 0.9). Furthermore, serum AMH (Spearman's rho=-0.352) and female age (rho=0.369) are correlated with follicular FSH levels in those follicles. In conclusion, the serum AMH might affect follicular hormone profiles by interaction with gonadotrophin rather than with steroidogenesis. The follicular FSH levels are correlated with the implantation potential of the ensuing embryos.

Study question Can the use of whole-exome sequencing (WES) together with single nucleotide polymorphism (SNP) array help to identify novel causative genes of isolated Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome? Summary answer OR4M2 (olfactory receptor, family 4, subfamily M, member 2) and PDE11A (phosphodiesterase 11A) gene loss-of-function variants as well as deletions at 15q11.2, 19q13.31, 1p36.21, and 1q44 were identified as possible commonly altered regions in patients with type 1 MRKH. What is known already The isolated form of Mullerian aplasia is the most common subtype of MRKH syndrome, which invariably leads to difficulties producing offspring in affected women. However, there is little information currently available to allow for genetic testing and counseling to be performed for those affected by this syndrome. Study design, size and duration This was a case-series genetic study. A total of seven consecutive unrelated women with type 1 MRKH were enrolled. The enrollment and experimental procedures were performed over a 2-year period. Participants/materials, setting, methods Whole exome-targeted next-generation sequencing and SNP array (Affymetrix Genome-Wide Human SNP Array 6.0) were performed on the first five unrelated women with type 1 MRKH syndrome. The data were combined, and the '3-hit principal' was applied on a genome-wide scale to search for the common causative genes. Quantitative PCR (qPCR) and Sanger sequencing were used to validate the identified genomic copy number losses and variants. Replication tests using direct Sanger sequencing and qPCR were performed on the remaining two women with type 1 MRKH syndrome to support the credibility of the potential candidate genes and deletions. Main results and the role of chance A total of 3443 damaging variants based on WES were shown to intersect with 1336 copy number variations (deletions) derived from the SNP array. Four highly recurrent deletions at 15q11.2 (80%), 19q13.31 (40%), 1p36.21 (40%) and 1q44 (40%) were identified in the first five women with type 1 MRKH syndrome and were considered to be novel candidate aberrations. A previously reported 1q21.1 deletion was also recurrent in two of the first five women with type 1 MRKH syndrome. The 1q44 and 19q13.31 deletions were present in at least one of the two additional patients. Damaging variants were detected in HNRNPCL1 (heterogeneous nuclear ribonucleoprotein C-like 1), OR2T2 (olfactory receptor, family 2, subfamily T, member 2), OR4M2, ZNF816 (zinc finger protein 816), and PDE11A in several of the initial five patients. Among these, the damaging variants of OR4M2 (located at 15q11.2) and PDE11A were found in at least one of the two additional patients with type 1 MRKH. Limitations, reasons for caution In this study, we only searched for the deletions or damaging variants causing loss-of-function of genes in at least three of the initial five patients (3-hit criteria). Therefore, the study was designed to only detect common causative genes. Genomic duplications and/or rare individual mutations that may have also contributed to MRKH syndrome were not investigated. Wider implications of the findings This study demonstrated the feasibility of the use of combined data from both WES and SNP arrays for the identification of possible common causative genetic aberrations in patients with type 1 MRKH syndrome on a genome-wide scale. Further validation of our found causative genes is required before applying on genetic testing and counseling. Study funding/competing interests The study was supported by grants from the National Science Council of Taiwan (NSC98-2314-B002-105-MY3 and NSC 100-2314-B002-027-MY3). The funding sources had no involvement in the design or analysis of the study. The authors have no competing interests to declare. Trial registration number Not applicable.

Previous studies indicated that progesterone can be withdrawn at the time of the first positive β-hCG test without compromising the clinical pregnancy outcome in normal ovarian responder. However, the effect of early stop of progesterone supplementation for patients with poor ovarian response (POR) has not been investigated. This study retrospectively collected data from patients with POR in 156 IVF/ICSI fresh embryo transfer (ET) cycles in single tertiary center from January 2010 to June 2016. All the patients met ESHRE consensus, the Bologna criteria, of POR and had hCG injection for luteal phase support (LPS) on day 2, 5 and 8 after ovum pick-up. The pregnant patients were divided into two groups: early stop group represented those who stopped LPS from day of positive pregnancy test; control group represented those who kept progesterone supplementation till gestational age of 9 weeks. There were no significant differences in age, BMI, parity, hormone data, number of follicles>10(mm), endometrial thickness and number of embryos transferred between the two groups. After adjustment for possible confounders with multivariate logistic regression analysis, the clinical pregnancy rates (55.0% vs. 57.1%, P = 0.35), ongoing pregnancy rates (47.0% vs. 46.4%, P = 0.66), miscarriage rates (34.0% vs. 26.7%, P = 0.66) and live-birth rates (44.0% vs. 46.4%, P = 0.41) were not statistically different between early stop group and the control group. Our study indicates that early stop of progesterone supplementation on the day of positive pregnancy test for patients of POR using hCG as LPS in fresh ET cycles does not affect pregnancy outcome.

Background/Purpose: The freeze-all strategy in high responders is considered to be a safe and effective strategy for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment; however, the cumulative pregnancy outcomes have not been established. Methods: A retrospective, single-center cohort study was conducted and 1311 high-responder patients (>20 oocytes retrieved and/or a serum estradiol level > 3000 pg/ml on the triggering day) were recruited from 2006 to 2015. The study group (n = 351) underwent the freeze-all strategy with subsequent thawed embryo transfer (ET), and the control group (n = 960) received fresh-cycle ET and subsequent thawed ET if needed. A case-control matching analysis was performed to match the two groups for the number of retrieved oocytes. The primary outcomes were the ongoing pregnancy rate (OPR) of the first ET cycle and the cumulative OPR. Results: After matching, there was a significantly higher OPR in the first ET cycle (49.5% vs. 32.2%, p

Iron is an essential nutrient that may exert toxic effects when it accumulates in tissues. Little is known regarding its effects on gonadal function. Both Fe2+ and Fe3+ could be released from iron deposition. We employed mouse nonluteinized granulosa cell for in vitro studies and human ovarian tissues for Prussian blue and immunohistochemical staining to identify the iron deposition and effect in vivo. After treatment with FeSO4-7H2O or FeCl3 in granulosa cell cultured with follicle-stimulating hormone (FSH) for 48 h, we found that Fe2+ significantly suppressed FSH-induced granulosa cell proliferation and arrested the cell cycle at the G2/M phase by cell proliferation assay and flow cytometry. Fe2+ significantly increased intracellular reactive oxygen species (ROS) and ferritin levels of mouse granulosa cells. The increases in p21 and p53 messenger RNA and protein expression facilitated by Fe2+ treatment in mouse granulosa cells were significantly suppressed by separate treatments with p53 small interfering RNA and p38 mitogen-activated protein kinase (MAPK) inhibitors. An ROS inhibitor downregulated Fe2+-induced increases in p38MAPK expression in mouse granulosa cells. Quantitative analysis of immunohistochemical staining revealed that human ovarian tissue sections with positive Prussian blue staining had lower levels of proliferating cell nuclear antigen expression, but higher levels of p21, p53, and CDC25C expression than those with negative Prussian blue staining. Conclusively, Fe2+ could directly arrest the cell cycle and inhibit granulosa cell proliferation by regulating the ROS-mediated p38MAPK/p53/p21 pathway. Therefore, iron can directly affect female gonadal function.

Objectives Conotruncal heart defects (CTD) are associated with del22q11.2 syndrome, which is often diagnosed by fluorescence in-situ hybridization (FISH). However, in those negative for del22q11.2 on FISH, the etiology is usually obscure. We aimed to use high-resolution array comparative genomic hybridization (array CGH) to clarify the underlying genetic causes in these cases. Methods In this retrospective study, fetal samples of amniocytes or fibroblasts, taken either for prenatal diagnosis by amniocentesis or for postnatal survey after termination of pregnancy, were obtained from 45 fetuses with CTD and were investigated by cytogenetic analysis including karyotyping and FISH for del22q11.2 syndrome. Eight fetuses with no findings on karyotyping and FISH were investigated further by array CGH, real-time quantitative polymerase chain reaction (qPCR) and Sanger sequencing of TBX1. Results Array CGH revealed that three of the eight fetuses carried submicroscopic genomic imbalances. Of these, two cases showed similar small microdeletions/duplications in 22q11.2 (one 0.85 kb microdeletion and one 8.51 kb microduplication). The minimal shared region spanned exon 2 of TBX1, a candidate gene responsible for cardiovascular defects in del22q11.2 syndrome. In all eight cases, the array CGH results were confirmed by qPCR, and Sanger sequencing did not detect other molecular pathologies. Conclusion Our findings indicate an association between TBX1 variations and fetal CTD. The results also demonstrate the power of array CGH to further scrutinize the critical gene(s) of del22q11.2 syndrome responsible for heart defects. Array CGH apparently has diagnostic sensitivity superior to that of FISH in fetuses with CTD associated with del22q11.2 (and dup22q11.2) syndrome. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Previous studies reported that patients with endometriosis had excess nitric oxide (NO) in the reproductive tract and poor embryo development in IVF cycles. This study aims to elucidate the effects of NO on early embryo development. Zygotes from superovulated B6CBF1 mice were cultured to blastocysts in a variety of media. Sodium nitroprusside (SNP) and NG-nitro-L-arginine (LNA) were added to the culture medium as a NO donor and a NO synthase inhibitor, respectively. The localization and fluorescence intensity of S-nitrosylated (SNO) proteins within 2-cell stage embryos were analyzed with confocal microscopy. Apoptosis and ATP production in the blastocysts were measured. Subsequent to NO exposure, the SNO proteins mainly colocalized with the mitochondria and endoplasmic reticulum and the intensity of SNO proteins increased. The addition of a quanylate cyclase inhibitor and a cyclic GMP mimic agent induced nonsignificant changes in SNO proteins, whereas addition of a superoxide scavenger or a reduced form of glutathione rescued the embryos from the effects of NO. However, superoxide scavenger supplementation resulted in decreased blastocyst ATP production. Elevated NO exerts deleterious effects on embryo development, possibly through protein S-nitrosylation in the mitochondria and endoplasmic reticulum. Including glutathione as a component in the culture medium might counteract this effect.

Study question What is the value of a new strategy for preimplantation genetic diagnosis (PGD) of monogenic diseases: blastocyst biopsy, cryopreservation and thawed embryo transfer? Summary answer This strategy is highly effective for PGD of monogenic diseases and merits wide use. What is known already PGD of monogenic diseases is conventionally performed on 6- to 8-cell embryos with fresh transfer. The diagnostic time is restricted and is subjected to amplification failure and allele drop-out (ADO). Study design, size, duration This is a prospective observational cohort study. A total of 33 couples were included from November 2008 to January 2012. Participants/materials, setting, methods A cohort of 33 couples who were carriers of monogenic diseases underwent a total of 40 oocyte pick-up (OPU) cycles, with subsequent blastocyst biopsy, vitrification and thawed embryo transfer. DNA analysis was performed by whole genome amplification using multiple displacement amplification followed by real-time PCR and mini-sequencing. Main results and the role of chance The diagnostic rate was 90% with 5% amplification failure and 5% ADO. The survival rate of vitrified blastocysts was 94%. Amongst 33 couples, 24 ongoing pregnancies were achieved (60% per OPU cycle) with an implantation rate of 50%. All of the genotyping results of prenatal diagnosis were consistent with those of PGD. There was no severe or late ovarian hyperstimulation syndrome (OHSS) and no hospitalization. Limitations, reasons for caution The participants are limited to the carriers of monogenic diseases. Wider implications of the findings This strategy achieves high rates of genotyping success, survival after warming and pregnancy. Cryopreservation of blastocysts after biopsy permits sufficient time for transportation of specimens and molecular diagnosis. In particular, cryopreservation of biopsied embryos without fresh transfer is an important strategy to prevent OHSS and circumvent a suboptimal endometrium in high responders. Study funding/competing interest(s) This study is financially supported by the National Science Council of Taiwan (grants NSC 96-2628-B-002-063-MY3, NSC 98-2314-B-002-088-MY3 and 98-FTN13). No competing interests are declared.

The inflammatory cytokine IL-6 is related to ovarian hyperstimulation syndrome (OHSS), although the functional role of IL-6 in OHSS remains largely unknown.A key feature of the IL-6 response is that its regulation is dependent on IL-6 trans-signaling via soluble IL-6 receptor-α (sIL-6Rα). The objective of the study was to elucidate the mechanistic role of IL-6 trans-signaling in the vascular leakage that underlies the pathophysiology of OHSS.Ovarian endothelial cells (ECs) and granulosa-lutein cells were obtained from women undergoing in vitro fertilization. OHSS was induced in mice by administering gonadotropins for 2 days followed by human chorionic gonadotropin. The functional role of IL-6 trans-signaling in OHSS was verified using the designer cytokines Hyper IL-6 and sgp130-Fc.The follicular fluid levels of sIL-6Rα were elevated in women at high risk for OHSS. In the murine OHSS model, stimulation with gonadotropins significantly induces ovarian IL-6 and sIL-6Rα expression. In vitro, FSH induces de novo sIL-6Rα synthesis in granulosa-lutein cells through a protein kinase C-dependent pathway. In addition, sIL-6Rα was released by leukocytes in the presence of conditioned medium from human chorionic gonadotropin-treated granulosa-lutein cells. Ovarian ECs responded to the IL-6Rα-IL-6 complex (Hyper IL-6) but not to IL-6 alone. With activation of signal transducer and activator of transcription 3 (STAT3) and ERK, Hyper IL-6 increased vascular endothelial growth factor expression and the vascular permeability of ECs. Selective blockade of IL-6 trans-signaling by sgp130-Fc significantly inhibited vascular endothelial growth factor expression and prevented OHSS in mice.IL-6 trans-signaling is activated during the ovarian stimulation process. Our findings provide insight into the biologic effects of IL-6 trans-signaling in OHSS and highlight that IL-6 trans-signaling can induce vascular leakage in this disease.

An endometrial polyp is a frequently encountered abnormality of the uterine cavity that may interfere with normal embryo implantation. In this case-control study, we enrolled 56 women in whom endometrial polyps were incidentally diagnosed by transvaginal ultrasound and office hysteroscopy during IVF (Group 1), and 112 age-matched IVF controls randomly selected from the same time period (group 2). Cryopreserved embryos were transferred in group 1 whereas fresh embryos were transferred in group 2, which is a limitation of the study. Hysteroscopic polypectomy was carried out for those in group 1, followed by vitrified-warmed embryo transfer 1-7 months later. Results revealed that the clinical pregnancy rate was higher in group 1 than in group 2 (63% versus 41%, P = 0.009), but the embryo implantation rates were not different between the two groups (26% versus 20%). In group 1, pregnancy rates (64%, 69%, and 53% respectively) and embryo implantation rates (30%, 24%, and 23%, respectively) were similar among women that received vitrified-warmed embryo transfer at 1, 2, and 3 months or over after hysteroscopic polypectomy. We conclude that, for women with endometrial polyps incidentally diagnosed during IVF, pregnancy outcomes are not compromised after hysteroscopic polypectomy followed by vitrified-warmed embryo transfer.

Ovarian hyperstimulation syndrome is a relatively common complication of ovarian stimulation and can be life-threatening. The pathophysiology of ovarian hyperstimulation syndrome is characterised by increased capillary permeability, leading to leakage of fluid from the vascular compartment, with third space fluid accumulation and intravascular dehydration. The combined use of a gonadotrophin-releasing hormone antagonist protocol with gonadotrophin-releasing hormone agonist triggering and oocyte and embryo freezing has considerable promise in preventing ovarian hyperstimulation syndrome. Women with severe ovarian hyperstimulation syndrome require hospitalisation for more careful monitoring and treatment. Transvaginal paracentesis can be used as an outpatient treatment to prevent the need for hospitalisation. The inhibition of vascular permeability seems to be a novel therapeutic approach to preventing and treating ovarian hyperstimulation syndrome.

What is the role of myostatin and its relationship with obesity, androgens and follistatin levels in women with polycystic ovary syndrome (PCOS)? SUMMARY ANSWERS: The myostatin level was positively correlated to the risk of abdominal obesity, but negatively associated with circulating levels of dehydroepiandrosterone sulfate (DHEAS) and follistatin in women with PCOS.Myostatin is a well-known negative regulator of skeletal muscle and is involved in metabolism; however, little is known about the role of myostatin in women with PCOS. In this study, we found that the myostatin level was positively related to the risk of abdominal obesity, but negatively related to the circulating levels of DHEAS and follistatin in women with PCOS. Such a relationship might imply a potential regulatory role of androgens and follistatin in the metabolism of skeletal muscle in women with PCOS.A cross-sectional case-control study.A total of 239 untreated, consecutive women with PCOS and 38 healthy volunteer women without PCOS were enrolled and studied in a tertiary medical center.Myostatin level was higher in women with PCOS than those without PCOS (16.6±15.6 and 14.2±9.7, P=0.025), but were not significantly different between non-obese women with and without PCOS after considering the effect of obesity (P=0.09). Stepwise multivariate regression analysis in women revealed that only the presence of PCOS (β=0.256, P=0.0001), total testosterone (β=0.159, P=0.031), DHEAS (β=-0.188, P=0.0003) and follistatin (β=-0.171, P=0.0001) levels were left in the final model and were significantly related to the myostatin level after considering all the explanatory variables. By using stepwise multivariate regression analysis, the total testosterone levels (β=0.196, P=0.003) were positively, but the DHEAS (β=-0.196, P0.0001) and follistatin (β=-0.151, P=0.0001) levels were negatively, related to myostatin levels in women with PCOS after adjustment for age, anthropometric measurements, insulin sensitivity index and hormonal profiles. The high myostatin level was associated with the increased risk of abdominal obesity after further adjusting the androgens and follistatin levels in women with PCOS.This study is a cross-sectional case-control design, and therefore, cannot answer the cause-effect relationship among the androgens, follistatin and myostatin levels. The small sample size and non-obese control group may also limit the application of the conclusion of the present study to general population other than women with PCOS. In addition, lack of data regarding muscle mass is another limitation in this study that prevents clarification of the relationship between myostatin, lean mass and obesity and therefore restricts the clinical application of the results.Future studies to investigate the efficacy of exercise and lifestyle modification in treating women with PCOS should consider the myostatin, follistatin and androgen levels as well as the effect of muscle mass and BMI.This study was supported by grants NSC97-2314-B002-079-MY3, NSC98-2314-B002-105-MY3 and NSC 100-2314-B002-027-MY3 from the National Science Council of Taiwan. There is no competing interest declared in this study.

�Preimplantation genetic diagnosis (PGD) is gradually widely used in prevention of gene diseases and chromosomal abnormalities. Much improvement has been achieved in biopsy technique and molecular diagnosis. Blastocyst biopsy can increase diagnostic accuracy and reduce allele dropout. It is cost-effective and currently plays an important role. Whole genome amplification permits subsequent individual detection of multiple gene loci and screening all 23 pairs of chromosomes. For PGD of chromosomal translocation, fluorescence in-situ hybridization (FISH) is traditionally used, but with technical difficulty. Array comparative genomic hybridization (CGH) can detect translocation and 23 pairs of chro mosomes that may replace FISH. Single nucleotide polymorphisms array with haplotyping can further distinguish between normal chromosomes and balanced translocation. PGD may shorten time to conceive and reduce miscarriage for patients with chromosomal translocation. PGD has a potential value for mitochondrial diseases. Preimplantation genetic haplotyping has been applied for unknown mutation sites of single gene disease. Preimplantation genetic screening (PGS) using limited FISH probes in the cleavage-stage embryo did not increase live birth rates for patients with advanced maternal age, unexplained recurrent abortions, and repeated implantation failure. Polar body and blastocyst biopsy may circumvent the problem of mosaicism. PGS using blastocyst biopsy and array CGH is encouraging and merit further studies. Cryopreservation of biopsied blastocysts instead of fresh transfer permits sufficient time for transportation and genetic analysis. Cryopreserva tion of embryos may avoid ovarian hyperstimulation syndrome and possible suboptimal endometrium.

Background/Purpose An increasing number of human immunodeficiency virus-1 (HIV-l)-discordant couples in Taiwan have been seeking fertility help. We conducted the first clinical trial in Taiwan of assisted reproductive technology (ART) using sperm washing and viral load measurement. Methods From 2005 to 2009, we performed 22 ART cycles on 14 HIV-1-discordant couples. The sperm washing involved density gradient centrifugation followed by swim-up method. HIV-1 RNA was checked by real-time reverse transcription-polymerase chain reaction with a sensitivity of 40 copies/mL. In addition, we enrolled two other groups of ART recipients using frozen sperm to compare the clinical outcomes. Results There were five pregnancies in the fresh cycles (23.8%) of HIV-1-discordant couples and the cumulative pregnancy per couple was 42.9% (6/14). The data were comparable with normal controls and testicular sperm extraction/microscopic epididymal sperm aspiration groups. The nine babies and the 14 women in this study showed no seroconversion. Conclusion The preliminary data showed good ART results in HIV-1-discordant couples. Fertility services should not be withheld from individuals with HIV-1, although larger series are needed to reach conclusions about safety.

This paper proposes a solution, called the Translator approach, to allow two different earthquake engineering hybrid simulation environments to communicate and collaborate with each other for a distributed hybrid simulation with minimal modification needed in either environment. By using a Translator module that is designed and implemented to translate messages between the two environments, all the software modules of the two environments can remain intact but exchange messages for simulation collaboration. A distributed hybrid simulation across a US system called UI-SimCor and a Taiwanese system called NCREE-ISEEdb was conducted to validate the approach and demonstrate the feasibility of the Translator approach. In addition, the impact of the Translator module on the runtime efficiency of the simulation was investigated and found to be minimal (about 3% time increase).

with transfusion-dependent b-thalassaemia, the serum AMH level was significantly inversely related to the ferritin level, but not related to the presence of hypogonadotrophic hypogonadism, diabetes and haematological phenotypes. The serum ferritin level was positively associated with advanced age and the presence of hypogonadotrophic hypogonadism in the study participants. However, the inverse relationship between AMH and ferritin still exists after further adjustment for advanced age in women with transfusion-dependent b-thalassaemia. Conclusions The present study indicates that the serum AMH levels in women with transfusion-dependent b-thalassaemia are lower when compared with normal healthy women of a similar age, and are significantly negatively correlated with their serum ferritin levels. This implies that ovarian function might be impaired by the chronic iron overload status in women with transfusion-dependent b-thalassaemia.

Summary Objective Pregnancies with extremely preterm premature rupture of membranes (EPPROM), especially before 20 weeks of gestation, are usually considered to be a termination of pregnancy. By improvement of obstetric and neonatal care, we can prolong the pregnancy across the threshold of survival by aggressive tocolysis. Case Report Using intrauterine insemination, a 32-year-old woman became pregnant with twins (first pregnancy). Threatened abortion occured since 9 weeks of gestation and EPPROM of the upper twin was noted at 18 weeks. Massive vaginal bleeding and vigorous uterine contractions occurred at 22 weeks. Poor control of preterm labor occurred using ritodrine and MgSO 4 . Atosiban was applied to calm uterine activities. After discontinuation of atosiban at 30 weeks, the uterine contractions became severe again and an emergency cesarean section was performed to deliver two live, premature babies weighing 1,518 g and 830 g, respectively. Twin A was healthy, weighing 2,030 g at 35 days after birth and subsequently discharged. The smaller twin B was dependent on continuous positive airway pressure and died of pulmonary infection 120 days after birth. Conclusion Comparing to other tocolytic agents, Atosiban has few side effects and assisted in prolonging a pregnancy involving twins that experienced EPPROM.

Summary Objective Intact amniotic membranes may serve to protect the extremely fragile preterm infant from some of the mechanical forces caused by strong uterine contraction. This article introduces the technique of “en caul” cesarean delivery and reviews the experience of the National Taiwan University Hospital. Materials and Methods This is a prospective study carried out to perform the “en caul” cesarean delivery for early preterm labors between October 2007 and December 2008. Cases were included if the estimated birth weight was below 1,500 g or gestational age was = 32 weeks. Results Twenty women including four twin pregnancies were included, and 23 neonates were born with intact membranes. Preterm labor was indicated in 16 cases, and nine of the cases were due to severe hypertensive disorders during pregnancy. Except in the case of placenta accreta, all underwent lower transverse uterine incision without wound extension. One fetus died after 3 days due to sepsis and the mortality rate was 4.3%. A total of 15 babies had an Apgar score at 5 minutes of more than seven. The value of first arterial pH was 7.278 ± 0.117 and hemoglobin was 16.1 ± 2.1 g/dL. The corrected post-menstrual age at discharge was 277.75 ± 38.56 days. Conclusion Cesarean delivery en caul is an effective and easy technique for extremely preterm fetuses to protect them from pressure trauma and also results in less uterine injury.

In this double-blind, double-dummy, randomized, equivalence trial (Ensure), 396 women weighing 60kg or less who underwent controlled ovarian stimulation prior to IVF or intracytoplasmic sperm injection were randomized in a 2:1 ratio to a single dose of 100mug corifollitropin alfa or daily 150IU recombinant FSH (rFSH) for the first 7days of stimulation in a gonadotrophin-releasing hormone antagonist protocol. The mean +/- SD number of oocytes retrieved per started cycle was 13.3 +/- 7.3 for corifollitropin alfa versus 10.6 +/- 5.9 for rFSH. The estimated treatment difference of +2.5 oocytes (95% CI 1.2-3.9) in favour of corifollitropin alfa (P0.001) was well within the predefined equivalence margin. The median (range) duration of stimulation was 9 (6-15) days in both groups. In 32.8% of the patients, one injection of corifollitropin alfa was sufficient to reach the human chorionic gonadotrophin criterion. The incidence of moderate and severe ovarian hyperstimulation syndrome was 3.4% for corifollitropin alfa and 1.6% for rFSH. A dose of 100mug corifollitropin alfa offers a simplified treatment option for potential normal responder patients with a lower body weight.

Sixty-one patients with gonadal dysgenesis were grouped under chromosomally incompetent ovarian failure (CIOF) and chromosomally competent ovarian failure (CCOF) according to their karyotypes. Forty-one patients (67.2%) belong to CIOF, including: 12 cases (19.7%) with 45X; 22 cases (36.1%) with 45X/46XX; One case (1.6%) with 45X/46XX/47XXX; One case (1.6%) with 46X, i (Xq); 4 cases (6.6%) with 45X/46XY and one case (1.6%) with 46XY/47XYY. Twenty patients (32.8%) belong to CCOF including 16 cases (26.2%) with 46XX and 4 cases (6.6%) with 46XY. Various degree of phenotypic expression in different chromosomal complements were noted. Patients without X chromosome material were more likely to have complete picture of the Turner stigmata. Cases with mosaic pattern such as 45X/46XX retained some degree of fertility, prenatal genetic counselling should be advised in these cases because their progeny had higher incidence of chromosomal anomalies. As high incidence of germ cell tumors may arise from streak gonads of individuals with a Y chromosome, bilateral gonadectomy should be performed in every case as soon as possible if the diagnosis was confirmed.

Preimplantation genetic diagnosis (PGD) is employed increasingly to allow transfer of embryos to the uterus in assisted reproduction procedures. There are three stages of biopsy: polar bodies, one or two blastomeres from the cleavage-stage embryos, and trophectoderm cells (∼5 cells) from the blastocyst-stage embryos. Validation of polymerase chain reaction (PCR)-based assays are challenging because only limited genetic material can be obtained for PGD. In the current study, we modified a valid single-cell PCR protocol for PGD using real-time PCR assay with fluorescence resonance energy transfer (FRET) hybridization probes followed by melting curve analysis. We optimized and clinically applied the protocol, permitting molecular genetic analysis to amplify a specific region on the beta-globin (HBB) gene for a couple, carriers of two mutations: c.-78A>G and c.52A>T. Among a total of eight embryos obtained after ovarian stimulation, a single blastomere per embryo at the six- to eight-cell stage was biopsied. This PGD method showed that four embryos were unaffected, two embryos were selected for transfer, and one pregnancy was achieved. Finally, a healthy male baby was delivered at 38 weeks’ gestation. The results obtained using the new method, FRET hybridization probes, were compared with findings using an existing method, primer extension minisequencing.

BACKGROUND: Follistatin levels have recently been considered as a marker for inflammation. Our objective was to evaluate the level of circulating follistatin and high-sensitivity C-reactive protein (hsCRP) in women with polycystic ovary syndrome (PCOS) after oral contraceptive (OC) treatment. METHODS: A total of 56 Taiwanese women with PCOS were enrolled in this prospective observational study in which they were treated for 3 months with OCs (ethinyl estradiol-cyproterone acetate). Blood samples were taken at baseline after treatment during the withdrawal bleed. Body mass index (BMI) lipid profiles plasma follistatin hsCRP fasting glucose insulin for the homeostasis model assessment of insulin resistance (HOMA-IR) and hormone profiles were measured and analyzed. RESULTS: Total testosterone free androgen index (FAI) dehydroepiandrosterone sulfate (DHEAS) follicle-stimulating hormone (FSH) luteinizing hormone (LH) and estradiol levels were significantly lower but total cholesterol low-density lipoprotein cholesterol (LDL-C) high-density lipoprotein cholesterol (HDL-C) triglycerides circulating follistatin and hsCRP were significantly higher than baseline in women with PCOS after treatment with OCs. An elevation of fasting insulin HOMA-IR and hsCRP after OC treatment was more evident in non-obese than obese women whereas the elevation of follistatin was significant in both obese and non-obese women. Follistatin and hsCRP levels all showed significant correlations with each other at baseline and after treatment. The differences in follistatin and hsCRP levels from baseline to after OC treatment were significantly associated with the difference in triglyceride levels. CONCLUSIONS: Both hsCRP and follistatin levels increase after OC treatment in women with PCOS. Follistatin seems more sensitive than hsCRP alone to represent the aggravated low-grade inflammatory status after OC treatment in obese and non-obese women with PCOS.