Dissertations / Theses on the topic 'In-vitro fertilisation (IVF)'

This study was designed to investigate the emotional, marital and sexual functioning of female infertility patients and their male partners, to examine factors influencing psychological functioning, and to assess ways that patients cope with their infertility. Patients attending one of two London clinics for in vitro fertilisation (IVF) or donor insemination (DI) treatment were assessed prior to treatment and approximately 9 months later. At initial assessment, fifty-nine women were interviewed and completed self-report questionnaires assessing state and trait anxiety, depression, sex role, marital and sexual functioning and strategies used to cope with infertility. Thirty-four of their partners also completed questionnaires. Prior to treatment, participants experienced high levels of anxiety, but not depression. They did not have significant levels of marital or sexual problems. High levels of avoidance coping were associated with higher levels of anxiety and depression, but coping strategies were not related to marital or sexual functioning. More female participants were classified as having feminine sex roles in comparison with the general population. High levels of masculinity were associated with lower anxiety but not depression for both men and women. Female IVF patients had higher trait anxiety than female DI patients, but there were no other differences in psychological functioning between the treatment groups. In terms of factors influencing emotional functioning, avoidance coping was a consistent predictor of anxiety and depression in both women and men. The response to follow up was poor: only 46% of female participants completed assessments. For most participants, treatment was unsuccessful. There was a strong relationship between functioning at initial and follow up assessment for these patients. Couples who undergo IVF and DI are a select group of patients: although anxious prior to treatment their emotional functioning is generally good. Reasons for these findings are discussed and proposals for interventions to reduce anxiety and enable appropriate coping strategies are made.

We aimed to prospectively investigate the paternal antigen-induced cytokine secretion by peripheral blood mononuclear cells (PBMCs) in response to hormone treatment in women undergoing in vitro fertilisation (IVF) and to examine the predictive value of the cytokine secretion profile in the outcome of IVF treatment, in a pilot study. Twenty-five women were included and IVF treatment was successful for six and unsuccessful for 19 women. Blood samples were collected before IVF treatment, on four occasions during IVF and four weeks after embryo transfer. The numbers of Th1-, Th2- and Th17-associated cytokine-secreting cells and cytokine levels in cell supernatants were analysed by enzyme-linked immunospot-forming (ELISpot), enzyme-linked immune-sorbent (ELISA) or Luminex assay. None of the cytokines (IFN-γ, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17, TNF and GM-CSF) had any predictive value regarding IVF outcome. The majority of the cytokines reached their peak levels at ovum pick-up, suggesting an enhancing influence of the hormonal stimulation. Pregnancy was associated with a high number of IL-4-, IL-5- and IL-13-secreting cells four weeks after ET. In conclusion, the results do not support our hypothesis of a more pronounced peripheral Th1 and Th17 deviation towards paternal antigens in infertile women with an unsuccessful IVF outcome, although this is based on a small number of observations. A larger study is required to confirm this conclusion. Higher numbers of Th2-associated cytokine-secreting cells in pregnant women four weeks after ET do corroborate the hypothesis of a Th2 deviation during pregnancy.

Since the advent of IVF (in vitro fertilisation) and assisted reproductive technologies (ART), several million babies have been born worldwide. However, reports link in vitro techniques with adverse short and long-term health outcomes. Using a mouse model, we have investigated the effect of IVF and culture on blastocyst development and cell number and on postnatal health of offspring. To explore the effect of different durations of embryo culture after IVF (as used commonly in clinical practice) and to evaluate the effect of embryo transfer itself plus the need for different controls, five treatment groups were generated as follow, each comprising 8-13 litters. NM (natural mating control, no ART treatment, non-superovulated); IV-ET-2Cell (2-cell embryos derived in vivo from superovulated (SO) mothers and immediately transferred (ET) to pseudo-pregnant recipients); IV-ET-BL (blastocysts derived in vivo from SO mothers and immediate ET); IVF-ET-2cell (2-cell embryos generated by IVF from SO mothers, short culture and ET); IVF-ET-BL (blastocysts generated by IVF from SO mothers, long culture and ET). Offspring were weighed weekly, systolic blood pressure (SBP) taken at weeks 9, 15, 21 and LIFE (average), and glucose tolerance test (GTT) carried out prior to culling for organ collection at week 27. Serum glucose, insulin concentration and the G:I ratio were calculated, with serum and lung angiotensin converting enzyme (ACE) levels determined after collection and storage of serum and lungs following culling; with random effects regression statistical analysis used to assess independence of litter size and maternal origin. IVF blastocysts after prolonged culture developed slower and comprised reduced trophectoderm and ICM cell numbers compared with in vivo generated blastocysts (P < 0.05; n= 50-87 per treatment; differential nuclear labelling). Offspring from IV-ET-2Cell (n= 57), IV-ET-BL (n= 47), IVF-ET-2Cell (n= 75) and IVF-ET-BL (n= 42) groups compared with NM controls (n=80), showed increased body weight, increased SBP, impaired GGT and abnormal organ:body weight ratios in both sexes (P < 0.05), independent of litter size. At weeks 15, 21 and LIFE, SBP for IVF-ET-BL males was increased compared with IV-ET-BL males (P= 0.003, 0.014 and 0.001, respectively). At weeks 15, 21 and LIFE, IVF-ET-BL males had increased SBP compared with IVF-ET-2Cell males (P=0.032, 0.034 and 0.017, respectively). In addition, offspring from the IVF-ET-BL group had a significant increase in serum and lung ACE activity compared with the NM group (P= 0.034), (P= 0.019) respectively. Offspring from IVF-ET-BL group also had a significant increase in lung ACE activity compared with IV-ET-BL group (P=0.042), although, serum ACE activity tended to be higher than IV-ET-BL, but this did not reach statistical significance (ʈ =0.070). Selected correlations show that SBP at 21 weeks in male offspring from IVF-ET-BL were positively correlated with body weight at 9 weeks (ʈ =0.051), at 15 weeks (P=0.018) and at 21 weeks (P=0.016) with R2 values of 0.046, 0.09 and 0.09 respectively. SBP at 21 weeks and LIFE were also positively correlated with lung ACE activity 0.002 and 0.009 respectively. However, glucoseconcentration 2 hours after glucose injection and the AUC (area under curve) in the male IVF-ET-BL group was reduced compared with IVF-ET-2Cell males (P= 0.03, 0.003, respectively). In males, IV-ET-2Cell, IVF-ET-2Cell and IV-ET-BL offspring all demonstrate low G:I ratios in comparison to NM mice (P=0.005, P=0.001 and P=0.038; respectively). Selected correlations demonstrate that there is a relationship between weight and AUC, in which weight is positively correlated with AUC measurements in NM (P=0.001), IV-ET-2Cell (P=0.000), IVF-ET-2Cell (P=0.046), IV-ET-BL (P=0.013) and IVF-ET-BL offspring (P=0.002), with R2 values of 0.2, 0.29, 0.13, 0.26 and 0.2, respectively. Male IVF-ET-BL heart:body weight ratio was increased and liver:body weight ratio reduced compared with IVF-ET-2Cell males (P=0.019, 0.023, respectively). No differences were evident between the four treatments groups for females. Our results suggest that reproductive treatments affect the development and potential of preimplantation embryos, influencing postnatal development and physiology compared with undisturbed reproduction. In particular, prolonged embryo culture (from 2-Cell to blastocyst), with normalised SO, IVF and ET, may adversely affect male offspring cardiovascular health, but improve the metabolic profile, compared with short culture (ET at 2-cell stage). However, female health is less sensitive.

Die GnRH-Agonisten-Applikation zur Downregulation vor IvF ist "gold standard", überwiegend im sogenannten langen Protokoll. Die Behandlung soll den vorzeitigen LH-Anstieg mit vorzeitiger Ovulation verhindern. Die unerwünschten Wirkungen sind dosisabhängig und rechtfertigen die Suche nach der optimal niedrigen Dosis des GnRH-Agonisten. Mit dieser Fragestellung wurde eine prospektive randomisierte Dosisfindungsstudie durchgeführt. 200 sterile Frauen zwischen 18 und 38 Jahren erhielten vor der IvF-Behandlung im langen Protokoll die Standarddosis von 4,12 mg Triptorelinazetat-Depot (1 Amp. i.m. = Gruppe B: n = 100) versus 2,1 mg Triptorelinazetat Depot (1/2 Amp. i.m = Gruppe A. n = 100) zur Downregulation. Folgende Parameter wurden bestimmt: E2, LH, Progesteron. Die Behandlungsergebnisse wurden korreliert mittels der Anzahl der gewonnenen Oocyten, der fertilisierten Oocyten, der transferierten Embryonen und der Schwangerschaftsraten pro Embryotransfer. Abgebrochene IvF-Zyklen wurden einzeln analysiert. Bezüglich der Hormonwerte waren beide Gruppen ohne signifikanten Unterschied. In der Gruppe der Patientinnen mit der halbierten Dosis (A) kam es nur in einem Fall zu einer vorzeitigen Luteinisierung, in der Standartdosisgruppe (B) in keinem Fall. Wegen low response wurde in Gruppe A in 5 Fällen die Therapie abgebrochen, versus 3 Fälle in Gruppe B (ns). Ebenfalls vergleichbar war das IvF-outcome, nur die ET-Rate pro begonnener Stimulation zeigte einen signifikanten Unterschied: 88 % (A) versus 96 % (B), p
The GnRH agonist application for the downregulation prior to IVF is 'gold standard', mainly in the so-called long protocol. This should avoid premature ovulations. The dose-dependent, undesired effects justify the search for the optimal low dose of the GnRH agonist. A prospective randomised dose-finding study was carried out in this respect. Among 200 sterile women (18 and 38 years) for the planned IVF and/or IVF / ICSI treatment in the long protocol, n = 100 in group A received 2.1 mg Triptorelinacetate depot (1/2 amp., i.m.) and n = 100 in group B the standard dose of 4.12 mg (1 amp., i.m.) for the downregulation. The hormone values E2, LH, progesterone were determined. The treatment results were compared by means of the number and quality of the oocoytes, the embryo transfers and the pregnancy rates. Cancelled IVF cycles were analysed. With respect to the hormone values, neither of the two groups showed significant differences. A premature luteinization occurred in group A (reduced dose) in only one case; in the standard dose of group B, none occurred. Due to the low response, the therapy was cancelled in 5 cases in group A, in comparison to 3 cases in group B (ns). The IVF outcome showed a comparable result. The only significant difference was the ET rate per started stimulation (p

Objectives: To determine the effect of female and male cigarette smoking, caffeine and alcohol consumption, stress and indicators of dietary status on the clinical outcomes of NF treatment. Design: Prospective cohort study. Setting: PIVET Medical Centre, Perth, Western Australia. Patients: Of 351 couples who commenced IVF treatment at PIVET Medical Centre between January 1997 and August 1998, 281 females and 247 males participated in this study, generating participation rates of 80.1% and 70.4%, respectively. Main Outcome Measures: Multivariate methods of data analyses were used to control for patient and treatment variables in the examination of the effect of lifestyle factors on the following clinical outcomes: 1) number of oocytes retrieved by transvaginal oocyte aspiration (oocyte production), 2) fertilisation, measured as the number of oocytes fertilised weighted by the number of oocytes inseminated, 3) B-hCG pregnancy, 16 days post-embryo transfer, and 4) <12 week pregnancy loss following confirmation of B-hCG pregnancy. As a measure of ovarian reserve, serum basal FSH levels were also investigated as a dependent variable. Lifestyle factors included years of cigarette smoking (smoke years), tobacco, alcohol, caffeine and fruit and vegetable consumption, and stress from daily living and NF treatment. Results: Daily stress, tobacco consumption and smoke years were the female lifestyle factors shown to have a significant effect on NF treatment. Oocyte production decreased with increasing levels of daily stress (P=0.039). However, female patients with high daily stress levels experienced higher than average rates of fertilisation in vitro (P=0.0059) and pregnancy (P--0.0207). Smoke years had an adverse effect on ovarian reserve (P=0.035), which in turn, compromised oocyte production.Female smoke years was negatively associated with rates of fertilisation (P<0.0001), and this effect was exacerbated by cigarette smoking at the time of treatment (P=0.0187). Of the male lifestyle factors, caffeine, alcohol and fruit and vegetable consumption and IVF stress affected fertilisation in vitro. Fertilisation increased with alcohol consumption (P<0.0001), and with fruit and vegetable consumption (P<0.0001). A significant interaction term between these two factors (P=0.0144) implied a threshold of benefit from the combined effect of the consumption of alcohol and fruit and vegetables. Caffeine consumption negated the beneficial effect of alcohol consumption, as shown by a significant interaction term between alcohol consumption and caffeine consumption (P=0.0007). Male stress from NF treatment had an adverse effect on rates of fertilisation in vitro (P<0.0001). Cigarette smoking by the male partner increased the likelihood of the female partner experiencing a <12 week pregnancy loss (P=0.0084). Conclusions: In meeting with its principal objective, this study has demonstrated that specific lifestyle factors impact on the clinical outcomes of IVF treatment. It confirms the findings from former studies, namely the adverse effect of female smoking on ovarian reserve, and daily stress on ovulation. Moreover, this study has identified numerous new and unexpected relationships. Of note, the positive effect of male alcohol consumption on fertilisation in vitro and the elevated risk of early pregnancy loss associated with male smoking. This study has paved the way for future research into the identification of specific mechanisms of effect, including those suggested.

Objectives: To determine the effect of female and male cigarette smoking, caffeine and alcohol consumption, stress and indicators of dietary status on the clinical outcomes of NF treatment. Design: Prospective cohort study. Setting: PIVET Medical Centre, Perth, Western Australia. Patients: Of 351 couples who commenced IVF treatment at PIVET Medical Centre between January 1997 and August 1998, 281 females and 247 males participated in this study, generating participation rates of 80.1% and 70.4%, respectively. Main Outcome Measures: Multivariate methods of data analyses were used to control for patient and treatment variables in the examination of the effect of lifestyle factors on the following clinical outcomes: 1) number of oocytes retrieved by transvaginal oocyte aspiration (oocyte production), 2) fertilisation, measured as the number of oocytes fertilised weighted by the number of oocytes inseminated, 3) B-hCG pregnancy, 16 days post-embryo transfer, and 4) <12 week pregnancy loss following confirmation of B-hCG pregnancy. As a measure of ovarian reserve, serum basal FSH levels were also investigated as a dependent variable. Lifestyle factors included years of cigarette smoking (smoke years), tobacco, alcohol, caffeine and fruit and vegetable consumption, and stress from daily living and NF treatment. Results: Daily stress, tobacco consumption and smoke years were the female lifestyle factors shown to have a significant effect on NF treatment. Oocyte production decreased with increasing levels of daily stress (P=0.039). However, female patients with high daily stress levels experienced higher than average rates of fertilisation in vitro (P=0.0059) and pregnancy (P--0.0207). Smoke years had an adverse effect on ovarian reserve (P=0.035), which in turn, compromised oocyte production.
Female smoke years was negatively associated with rates of fertilisation (P<0.0001), and this effect was exacerbated by cigarette smoking at the time of treatment (P=0.0187). Of the male lifestyle factors, caffeine, alcohol and fruit and vegetable consumption and IVF stress affected fertilisation in vitro. Fertilisation increased with alcohol consumption (P<0.0001), and with fruit and vegetable consumption (P<0.0001). A significant interaction term between these two factors (P=0.0144) implied a threshold of benefit from the combined effect of the consumption of alcohol and fruit and vegetables. Caffeine consumption negated the beneficial effect of alcohol consumption, as shown by a significant interaction term between alcohol consumption and caffeine consumption (P=0.0007). Male stress from NF treatment had an adverse effect on rates of fertilisation in vitro (P<0.0001). Cigarette smoking by the male partner increased the likelihood of the female partner experiencing a <12 week pregnancy loss (P=0.0084). Conclusions: In meeting with its principal objective, this study has demonstrated that specific lifestyle factors impact on the clinical outcomes of IVF treatment. It confirms the findings from former studies, namely the adverse effect of female smoking on ovarian reserve, and daily stress on ovulation. Moreover, this study has identified numerous new and unexpected relationships. Of note, the positive effect of male alcohol consumption on fertilisation in vitro and the elevated risk of early pregnancy loss associated with male smoking. This study has paved the way for future research into the identification of specific mechanisms of effect, including those suggested.

Abstract Fertility declines with advancing age and the number of couples seeking infertility treatment at an older age is constantly increasing. A top quality embryo is believed to have the highest potential for implantation and development into a child. A better understanding of the relative importance of patient and treatment characteristics and of embryo quality could help to optimise the existing therapeutic schemes and the safety of in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI). In this work, databases of five Finnish infertility clinics were studied retrospectively. Data on treatments performed in the years 1994–2005 were collected. A total of 19,000 treatment cycles were analysed. Special attention was paid to the relative significance of the transfer of top quality embryos with regards to pregnancy, miscarriage, live birth and cost of treatment in the general IVF/ICSI patient population and in groups with expected poor outcome. The results showed that the transfer of a top quality embryo is associated with a better chance of pregnancy and live birth. However, it does not diminish the probability of miscarriage. Both low and high BMI increase the miscarriage rate. Advancing age and a positive history of previous miscarriages are also associated with a higher probability of miscarriage. In addition, the need for hormonal substitution in cases of frozen-embryo transfer is a risk factor of miscarriage, probably because of suboptimal endometrial function. Since the transfer of several embryos leads to multiple pregnancies, which are associated with a high risk of maternal and fetal complications, elective single embryo transfer (eSET) of a top quality embryo allows all additional good quality embryos to be frozen and transferred later in frozen-thawed embryo transfer cycles. The present work demonstrates that eSET is a safe treatment strategy at least until the age of 40. However, it might not be performed in women with fewer than four collected oocytes, since the prognosis might remain poor even if the response is improved in a following cycle. When eSET is applied routinely and on a large scale, it diminishes treatment costs while increasing the number of deliveries occurring at term, making IVF/ICSI at the same time safer and more affordable even to patients without access to reimbursed IVF treatment.

Background: This thesis is based on a randomised controlled trial comparing the effectiveness of intrauterine insemination (IUI) plus Controlled Ovarian Hyperstimulation (COH) versus in vitro fertilisation (IVF) as the first line treatment option for couples with unexplained subfertility. Subfertility of a couple is classed as unexplained when they fail to conceive after one year of regular unprotected intercourse and when all the standard investigations for ovulation, tubal patency and semen analysis have been found to be normal. It affects 30-40% of couples. The age-old methods of treating these couples have included the empirical use of clomiphene or gonadotrophins to correct any possible subtle defects in ovulation with or without IUI (to overcome any existing cervical barrier to natural conception) or IVF. However, the best treatment options for these couples have yet to be determined. The matter has been made even more controversial by the issue of NICE (National Institute for Health and Care Excellence) guidelines in the UK that suggest IUI be abandoned completely for these women in favour of IVF after 2 years of expectant management. A systematic review of the available literature comparing IUI + COH versus IVF for unexplained subfertility revealed limited numbers of available studies and high clinical and statistical heterogeneity among them. An online survey was also conducted among fertility specialists to establish the general consensus regarding management of such couples. The results revealed a lack of agreement among fertility specialists with regards to the first line treatment of couples with unexplained subfertility. The mixed 8 response to this survey demonstrated the ongoing dilemma among practitioners, much of which was due to the lack of robust evidence. A randomised controlled trial was then designed to examine the effectiveness of COH with gonadotrophins + IUI versus IVF as the first line approach to the treatment of unexplained subfertility (Figure 1). This was the first UK-based randomised controlled trial comparing these two first-line management options for unexplained subfertility.

This study, investigating 263 women undergoing trans-vaginal oocyte retrieval for in vitro fertilisation (IVF) found that microorganisms colonising follicular fluid contributed to adverse IVF (pre-implantation) and pregnancy (post-implantation) outcomes including poor quality embryos, failed pregnancy and early pregnancy loss (< 37 weeks gestation). Some microorganisms also showed in vitro growth patterns in liquid media that appeared to be enhanced by the hormonal stimulation protocol used for oocyte retrieval. Elaborated cytokines within follicular fluid were also associated with adverse IVF outcomes. This study is imperative because infertility affects 16% of the human population and the numbers of couples needing assistance continues to increase. Despite significant improvements in the technical aspects of assisted reproductive technologies (ART), the live birth rate has not increased proportionally. Overt genital tract infection has been associated with both infertility and adverse pregnancy outcomes (including miscarriage and preterm birth) as a direct result of the infection or the host response to it. Importantly, once inflammation had become established, medical treatment often failed to prevent these significant adverse outcomes. Current evaluations of fertility focus on the ovary as a site of steroid hormone production and ovulation. However, infertility as a result of subclinical colonisation of the ovary has not been reported. Furthermore, identification of the microorganisms present in follicular fluid and the local cytokine profile may provide clinicians with an early indication of the prognosis for IVF treatment in infertile couples, thus allowing antimicrobial treatment and/or counselling about possible IVF failure. During an IVF cycle, multiple oocytes undergo maturation in vivo in response to hormonal hyperstimulation. Oocytes for in vitro insemination are collected trans-vaginally. The follicular fluid that bathes the maturing oocyte in vivo, usually is discarded as part of the IVF procedure, but provides a unique opportunity to investigate microbial causes of adverse IVF outcomes. Some previous studies have identified follicular fluid markers that predict IVF pregnancy outcomes. However, there have not been any detailed microbiological studies of follicular fluid. For this current study, paired follicular fluid and vaginal secretion samples were collected from women undergoing IVF cycles to determine whether microorganisms in follicular fluid were associated with adverse IVF outcomes. Microorganisms in follicular fluid were regarded as either "colonisers" or "contaminants"; colonisers, if they were unique to the follicular fluid sample, and contaminants if the same microorganisms were detected in the vaginal and follicular fluid samples indicating that the follicular fluid was merely contaminated during the oocyte retrieval process. Quite unexpectedly, by these criteria, we found that follicular fluid from approximately 30% of all subjects was colonised with bacteria. Fertile and infertile women with colonised follicular fluid had decreased embryo transfer rates and decreased pregnancy rates compared to women with contaminated follicular fluids. The observation that follicular fluid was not always sterile, but contained a diverse range of microorganisms, is novel. Many of the microorganisms we detected in follicular fluid are known opportunistic pathogens that have been detected in upper genital tract infections and are associated with adverse pregnancy outcomes. Bacteria were able to survive for at least 28 weeks in vitro, in cultures of follicular fluid. Within 10 days of establishing these in vitro cultures, several species (Lactobacillus spp., Bifidobacterium spp., Propionibacterium spp., Streptococcus spp. and Salmonella entericus) had formed biofilms. Biofilms play a major role in microbial pathogenicity and persistence. The propensity of microbial species to form biofilms in follicular fluid suggests that successful treatment of these infections with antimicrobials may be difficult. Bifidobacterium spp. grew, in liquid media, only if concentrations of oestradiol and progesterone were similar to those achieved in vivo during an IVF cycle. In contrast, the growth of Streptococcus agalactiae and Escherichia coli was inhibited or abolished by the addition of these hormones to culture medium. These data suggest that the likelihood of microorganisms colonising follicular fluid and the species of bacteria involved is influenced by the stage of the menstrual cycle and, in the case of IVF, the nature and dose of steroid hormones administered for the maturation of multiple oocytes in vivo. Our findings indicate that the elevated levels of steroid hormones during an IVF cycle may influence the microbial growth within follicular fluid, suggesting that the treatment itself will impact on the microflora present in the female upper genital tract during pre-conception and early post-conception phases of the cycle. The effect of the host immune response on colonising bacteria and on the outcomes of IVF also was investigated. White blood cells reportedly compose between 5% and 15% of the cell population in follicular fluid. The follicular membrane is semi-permeable and cells are actively recruited as part of the normal menstrual cycle and in response to microorganisms. A previous study investigated follicular fluid cytokines from infertile women and fertile oocyte donors undergoing IVF, and concluded that there were no significant differences in the cytokine concentrations between the two groups. However, other studies have reported differences in the follicular fluid cytokine levels associated with infertile women with endometriosis or polycystic ovary syndrome. In this study, elevated levels of interleukin (IL)-1 á, IL-1 â and vascular endothelial growth factor (VEGF) in vaginal fluid were associated with successful fertilisation, which may be useful marker for successful fertilisation outcomes for women trying to conceive naturally or prior to oocyte retrieval for IVF. Elevated levels of IL-6, IL-12p40, granulocyte colony stimulating factor (GCSF) and interferon-gamma (IFN ã) in follicular fluid were associated with successful embryo transfer. Elevated levels of pro-inflammatory IL-18 and decreased levels of anti-inflammatory IL-10 were identified in follicular fluid from women with idiopathic infertility. Successful fertilisation and implantation is dependent on a controlled pro-inflammatory environment, involving active recruitment of pro-inflammatory mediators to the genital tract as part of the menstrual cycle and early pregnancy. However, ongoing pregnancy requires an enhanced anti-inflammatory environment to ensure that the maternal immune system does not reject the semi-allergenic foetus. The pro-inflammatory skew in the follicular fluid of women with idiopathic infertility, correlates with normal rates of fertilisation, embryo discard and embryo transfer, observed for this cohort, which were similar to the outcomes observed for fertile women. However, their pregnancy rate was reduced compared to fertile women. An altered local immune response in follicular fluid may provide a means of explaining infertility in this cohort, previously defined as 'idiopathic'. This study has found that microorganisms colonising follicular fluid may have contributed to adverse IVF and pregnancy outcomes. Follicular fluid bathes the cumulus oocyte complex during the in vivo maturation process, and microorganisms in the fluid, their metabolic products or the local immune response to these microorganisms may result in damage to the oocytes, degradation of the cumulus or contamination of the IVF culture system. Previous studies that have discounted bacterial contamination of follicular fluid as a cause of adverse IVF outcomes failed to distinguish between bacteria that were introduced into the follicular fluid at the time of trans-vaginal oocyte retrieval and those that colonised the follicular fluid. Those bacteria that had colonised the fluid may have had time to form biofilms and to elicit a local immune response. Failure to draw this distinction has previously prevented consideration of bacterial colonisation of follicular fluid as a cause of adverse IVF outcomes. Several observations arising from this study are of significance to IVF programs. Follicular fluid is not always sterile and colonisation of follicular fluid is a cause of adverse IVF and pregnancy outcomes. Hormonal stimulation associated with IVF may influence whether follicular fluid is colonised and enhance the growth of specific species of bacteria within follicular fluid. Bacteria in follicular fluid may form biofilms and literature has reported that this may influence their susceptibility to antibiotics. Monitoring the levels of selected cytokines within vaginal secretions may inform fertilisation outcomes. This study has identified novel factors contributing to adverse IVF outcomes and that are most likely to affect also natural conception outcomes. Early intervention, possibly using antimicrobial or immunological therapies may reduce the need for ART and improve reproductive health outcomes for all women.

Gamete donors are actively searched by companies dedicated to assisted reproduction in the Spanish State, and advertising is not only legal but rather common. This thesis provides an overview of the main themes that arise from the analysis of mostly visual materials used to promote ovum donation in public spaces in Barcelona, and critically links them to current debates in intersectional feminist cultural studies of technoscience, bodily theory and visual studies. Conceptual and affective tensions between characterisations of women’s bodies, reproductive function and desires are identified and brought forward in terms that imply tropes of sacralisation, reification of cells/organs/tissues, and fragmentation of the bodily reality. It is argued that egg donation advertisements use an imagery that deeply connects with practices well rooted in Western biomedical traditions when it comes to female bodies, physiology and reproductive function, and that such practices are to be understood against the backdrop of neoliberalism. The analysis supports the idea that the publicity discourse of the assisted reproduction industry in Spain actively engages in a legitimation of the desire of biological parenthood as a right, in ways that value lives conceived in different circumstances and geopolitical contexts in radically different ways, and that can be interpreted as paving the way to prosurrogacy and/or eugenic positions. Future research is encouraged and directed towards exploring issues of agency, particularly in vulnerable groups such as migrant, poor, uneducated or racialised women. Further research is needed in order to build the foundations of a feminist ethical reflection on reproductive technologies and particularly of ovum donation.

Cette thèse porte sur l'étude du comportement hydrodynamique d'un embryon lors de la procédure de transfert suivant la fécondation in-vitro. Un couple sur six fait l'expérience de problèmes d'infertilité. Aujourd'hui 5 millions de nourrissons sont nés depuis la première fécondation in-vitro en 1978. En 2009, 1.5 millions de cycles de Procréation Médicalement Assistée étaient débutés, donnant ainsi naissance à350 000 nourrissons de par le monde. Le nombre de cycle est en constante augmentation de 5 à 10 % par an et le nombre de cycle de PMA pourrait être proche de 4 millions à l'horizon 2020. Bien que l'étape de fertilisation soit maintenant bien maitrisée avec 80% de réussite, l'étape finale du transfert d'embryon dans la cavité intra-utérine reste une étape critique puisque seulement 25% des cycles mènent à une grossesse viable. Bien que chaque cycle soit couteux, aucun protocole spécifique, optimisé, et indépendant de l'opérateur n'a encore été mis au point. Dans cette thèse, nous nous proposons de démontrer dans un premier temps l'intérêt et la faisabilité d'une approche de bio ingénierie. En effet, bien que l'issue de transfert dépende de nombreux facteurs chimiques et physiologiques, cette étape cruciale peut aussi être étudiée d'un point de vue mécanique des fluides. Cette étape peut être décomposée en plusieurs sous-étapes : l'introduction du cathéter dans la cavité intra utérine, l'injection du fluide medium contenant un ou plusieurs embryons, et le retrait du cathéter. On peut dégager plusieurs paramètres d'importance comme la viscosité des fluides, la vitesse d'injection, la vitesse de retrait du cathéter, le schéma de chargement du cathéter, et les géométries de la cavité et du cathéter. Dans une deuxième partie, nous nous intéressons à la structure des écoulements de fluides intra-uterins au moment de l'injection. L'influence des paramètres constitutifs d'importance est étudiée grâce à un code de calcul résolvant les équations de Navier-Stokes dans une géométrie tri-dimensionnelle idéalisée. Une étude des trajectographies potentielles des embryons est également réalisée et mis en relation directe avec les zones d'implantation optimales et à risques. A l'issue de ces calculs, nous sommes en mesure de proposer des recommandations à l'usage des cliniciens pratiquant le transfert d'embryon. La dernière partie de la thèse est une ouverture vers les méthodes numériquesnécessaires à l'appréhension des phénomènes d'interaction fluide/structure à l'échelle de l'embryon. L'embryon est en effet soumis à des contraintes potentiellement destructrices au moment du transfert qu'il ne nous est pas possible de définir précisément _à l'_échelle de l'utérus. Dans l'optique du développement d'un modèle mécanique d'un blastocyste pour déterminer les paramètres procéduraux minimisant les contraintes, nous présentons l'implémentation de deux méthodes numériques de type Eulerienne-Eulerienne. La première est une méthode level-set dans un code en volumes finis et bénéficiant de raffinement de maillage automatique. La seconde concerne une méthode phase-field basée sur un formalisme éléments finis de type Galerkin discontinu
This thesis focuses on the study of the hydrodynamic behavior of an embryo during the transfer process following the in vitro fertilization. Worldwide, one in six couples experiences infertility problems. Today, 5 millions babies are born from an in-vitro fertilization since the first one in 1978. In 2009, 1.5 millions Assisted Reproductive Technology cycles have been started, resulting in 350 000 births. The total number of cycles per year is constantly increasing (from 5 to 10 %), and the number of ART cycles is believed to reach 4 millions per year in 2020. Although the fertilization step is now fairly mastered with a 80% success rate, the final stage consisting in the embryo transfer into the uterine cavity remains a critical step, since only 25% of the cycles lead to a live birth. Even though every cycle is expensive, no specific, optimized and operator-independent protocol has been developed yet. In this thesis, we first demonstrate the interest and the feasibility of a bio-engineering approach. Indeed, although the issue of the transfer depends on numerous chemical and physiological factors, this crucial step can also be studied from a fluid mechanical point of view. This step can be divided in several sub-steps : introduction of the catheter in the intra-uterine cavity, injection of the medium fluid containing one or several embryos, and the withdrawal of the catheter. One can identify several important parameters such as fluids viscosity, injections speeds, catheter withdrawal speed, catheter loading scheme and the geometries of the uterine cavity and the catheter. In a second part, we focus on the fluid ow patterns inside the uterine cavity during the injection. The influence of the system parameters is studied thanks to a computational solving of the Navier-Stokes equations in an idealized three-dimensional uterine cavity. A study of the potential trajectories of the embryos is also conducted and confronted against the location of optimal implantation zones but also risky zones. As the outcome of these computations, we are able to propose recommendations for physicians practicing embryo transfers. In the last part of the thesis, we discuss numerical methods for the fluid{structure interaction study of embryo transfer. The embryo is indeed submitted to potentially destructive stress constraints at injection time that we are not capable of defining precisely at the scale of the uterine cavity. With the aim of developing a mechanical model for the blastocyst to determine system parameters minimizing the constraints, we present the implementation of two Eulerian numerical methods. The first one is a fluid-structure level set method in a finite volume code benefiting from an automatic mesh refinement feature. The second one addresses a phase field method based on a Discontinuous Galerkin finite element formalism

In vitro fertilisation (IVF) has been widely used to treat infertility since 1978. Worldwide, there are over 5 million children who have been born following assisted reproduction, mostly by IVF. However, the long term health implications of IVF are unknown. This thesis focuses on the metabolic risks of IVF in adult humans and mouse offspring. A suboptimal in vivo environment during pregnancy, and the early postnatal period, predisposes offspring to chronic diseases later in life. Preimplantation embryos are also sensitive to adverse environmental insults in vivo or in vitro. Emerging evidence suggests that IVF children may be at an increased risk of developing metabolic and cardiovascular diseases. However, it is unclear if increased risk is related to the underlying genetics of the parents, environmental factors, or the treatment procedures per se which include both ovarian stimulation and embryo culture. This is the first study to show that IVF adult humans were insulin resistant, by using gold standard assessment hyperinsulinemic-euglycemic clamp, compared to BMI and aged matched naturally conceived individuals after 3 days of a baseline energy balanced diet (30% fat), and that they tended to be more susceptible to the metabolic consequences of 3 days of high-fat overfeeding (+1250 kcal/day, 45% fat) as evidenced by a greater increase in systolic blood pressure. To separate out potential genetic and environmental confounders as well as the effects of ovarian stimulation versus embryo culture, we developed an IVF mouse model using inbred C57BL/6J mice. Here, we examined glucose metabolism in adult offspring conceived by natural conception (NC), by ovarian stimulation alone (OS) or by IVF, and then fed a chow or high-fat diet (60% fat) for 8 weeks. Our data suggest it is the process of IVF itself that contributes to impaired glucose metabolism in the adult mouse, which was more prominent in males. Moreover, we show that ovarian stimulation impairs fetal growth, and also results in glucose intolerance in offspring, which was unmasked by a high-fat diet in adult females. This study suggests that ovarian stimulation alone and IVF may program distinct metabolic effects in the offspring, but that high fat diet may be required to uncover these differences. Our data shows that the preimplantation period is a critical stage for development and later adult health. The mechanisms underlying these differences are unclear, but may involve epigenetic modifications and/or changes in mitochondrial numbers and function. We initially examined whether altered DNA methylation and expression of key genes PPARGC1A and IGF2 occurs in peripheral insulin sensitive tissues of morbidly obese individuals with or without type 2 diabetes. Our data showed that obese patients with and without type 2 diabetes displayed tissue specific DNA methylation of PPARGC1A and IGF2, highlighting the importance of measuring individual tissues in this response in humans and controlling for adiposity. Whether these alternations are evident in IVF conceived adults requires further study. In conclusion, this study highlights an increased risk of developing type 2 diabetes and cardiovascular disease in IVF offspring later in life in an obesogenic environment.
Thesis (Ph.D.) -- University of Adelaide, School of Paediatrics and Reproductive Health, 2014

The role oxygen plays in the developing ovarian follicle is of interest not only to the field of developmental biology but also to in-vitro fertilisation (IVF) technologists, as oxygenation of the oocyte is considered to be a potential determinant of oocyte competence. Oxygen transport through the developing ovarian follicle, and practical aspects of the analysis of oxygen in human follicular fluid were investigated in this work. Mathematical modelling of oxygen transport in the pre-antral, and antrallpreovulatory follicle revealed a number of interesting findings, Contrary to previous conclusions (Gosden & Byatt-Smith, 1986), oxygen can reach the oocyte in the small pre-antral follicle. Improved estimates of diffusion coefficients through the granulosa cell layer and the inclusion of fluid voidage in this layer showed that oxygen can also reach the oocyte in large pre-antral follicles. The amount of oxygen that reaches the oocyte in the pre-antral follicle is a function of its size and degree of vascularisation. Symmetrically distributed vascularisation is superior in achieving a well oxygenated follicle. However, the large pre-antral follicle will eventually reach a size beyond which it cannot grow without anoxic regions developing. The size at which this occurs is consistent with the size at which antrum formation is observed in human follicles. The model predicts that the follicle can avoid an anoxic state through antrum formation, and shows that the follicle develops in a way that is consistent with overcoming mass transport limitations. The oxygen status of the follicle during the antrallpre-ovulatory phase of growth requires that the volume of granulosa cells be balanced by the volume of follicular fluid. Further predictions suggest that oocyte respiration becomes sub-maximal at follicular fluid volumes below approximately 4m1, vascularisation levels below 38%, or fluid i dissolved oxygen levels below 5.1 ~01%. These values are consistent with observations in the literature. It was also shown that the measurement of follicular fluid dissolved oxygen levels could provide a simple measure of the respiratory status of the oocyte, and this may be superior to the measurement of follicular vascularisation which requires knowledge of more parameters. Methodology for the analysis of follicular fluid oxygen solubility and diffusivity was developed using a Clark oxygen electrode. Analysis of these parameters showed that they are similar to human plasma, and allowed the predictive uncertainty of the model to be reduced. Experimental studies into the effects of IVF aspiration on follicular fluid were carried out. Aspiration results in significant changes in the properties of follicular fluid. Dissolved oxygen levels rose 5 * 2 vol%, pH increased by 0.04 * 0.01 pH units, and temperature dropped by 7.7 * 1.3 "C. Mathematical modelling of blood contaminated follicular fluid also showed that contamination results in significant changes in the dissolved oxygen of the fluid. This suggests that if the composition of follicular fluid is to be determined (particularly dissolved oxygen), sampling andlor measurement of fluid must take place before the collection vial of the aspiration kit, and blood contamination must be eliminated. Based on this result, the design and testing of devices capable of reliable sampling andlor rneasurement of oxygen levels of follicular fluid was considered. This presents a continuing challenge, including the integration of routine follicular fluid oxygen measurement into clinical practice.