Platelet-activating factor significantly enhances intrauterine insemination pregnancy rates in non-male factor infertility

Transcription

1 FERTILITY AND STERILITY VOL. 82, NO. 1, JULY 2004 Copyright 2004 America Society for Reproductive Medicie Published by Elsevier Ic. Prited o acid-free paper i U.S.A. Platelet-activatig factor sigificatly ehaces itrauterie isemiatio pregacy rates i o-male factor ifertility William E. Roudebush, Ph.D., Adrew A. Toledo, M.D., Hilto I. Kort, M.D., Dorothy Mitchell-Leef, M.D., Carlee W. Elser, M.D., ad Joe B. Massey, M.D. Reproductive Biology Associates, Atlata, Georgia Objective: To determie the efficacy of treatig seme specimes with platelet-activatig factor () before IUI. Desig: Prospective radomized double-blided study of treatmet of sperm for patiets with a history of ifertility udergoig IUI. Settig: Private ifertility ceter. Itervetio(s): Patiets had ovulatio iductio therapy with clomiphee citrate (CC) or goadotropi, two IUIs per moth with treatmet. Mai Outcome Measure(s): Cliical pregacy rates. Result(s): There was a sigificat differece i IUI pregacy rates per cycle betwee cotrol (10/56; 17.9%) ad (14/47; 29.8%) treatmet groups i the ormal male study arm. There was a sigificat differece i cumulative IUI pregacy rates betwee cotrol (10/35; 28.6%) ad (14/26; 53.9%) patiet groups i the ormal male study arm. There was o sigificat differece i IUI pregacy rates per cycle betwee cotrol (12/124; 9.7%) ad (14/119; 11.8%) treatmet groups i the male factor study arm. There was o sigificat differece i cumulative IUI pregacy rates betwee cotrol (12/46; 26.1%) ad (14/38; 36.8%) patiet groups i the male factor study arm. There was a sigificat differece i overall cumulative IUI pregacy rates betwee cotrol (21/81; 25.9%) ad (27/64; 42.2%) patiet groups. Coclusio(s): The iclusio of ito the IUI sperm wash procedure sigificatly improves pregacy rates. However, the sigificat improvemet ca oly be show to affect me presetig with ormal seme parameters. (Fertil Steril 2004;82: by America Society for Reproductive Medicie.) Key Words: Platelet-activatig factor, itrauterie isemiatio, sperm, pregacy Received August 11, 2003; revised ad accepted November 25, Preseted i part (O-222) at the 58th Aual Meetig of the America Society for Reproductive Medicie, Seattle, WA, October 12 17, Reprits requests: William E. Roudebush, Ph.D., Reproductive Biology Associates, 1150 Lake Hear Drive, Suite 400, Atlata, Georgia (FAX: ; roudebush@ rba-olie.com) /04/$30.00 doi: /j.fertstert I may ceters drug-iduced ovulatio iductio followed by itrauterie isemiatio (IUI) has become stadard therapy for otubal factor-related ifertility. The iitial treatmet for ifertile couples is IUI ad is commoly used (1). The success of IUI is depedet o the ovulatio iductio regime (2), as well as semial parameters (3). Cumulative pregacy rates for three cycles have approached those of a sigle IVF treatmet whe goadotropis are combied with IUI (4). Commoly, because of lower patiet costs, complexity ad risks of high order multiple pregacy (i.e., triplets or more), clomiphee citrate (CC) is iitially used. I our ceter the typical treatmet regime ivolves three CC/ IUI cycles followed by goadotropi/iui for up to three cycles. Failed IUI therapy subsequetly results i cosideratio of IVF therapy. Silverberg et al. (5) have show that two IUI procedures per cycle have improved pregacy rates, although this cotiues to be cotroversial (6). Male fertility requires productio of a adequate umber of morphologically ormal sperm with sufficiet motility ad the ability to udergo capacitatio ad the acrosome reactio to peetrate the oocyte s cumulus oophorus ad zoa pellucida for fertilizatio. Defects i ay of these ecessary evets may lead to subfertility or ifertility. Recetly, for example, chromati itegrity of sperm was foud to be related to IUI pregacy rates (7). 52

2 A umber of edogeous biochemical factors have bee attributed to regulate the fertility potetial of spermatozoa, for example, platelet-activatig factor (). Platelet-activatig factor is a uique ad ovel sigalig phospholipid that has pleiotropic biologic properties i additio to platelet activatio. Sice its discovery i the early 1970s this ovel compoud has bee implicated i a variety of reproductive fuctios icludig fertilizatio, implatatio, ad parturitio (8). The exact mechaism is ucertai, yet its importace i ormal fertility is sigificat. Platelet-activatig factor is preset i huma spermatozoa (9), ad its edogeous cotet has a sigificat ad positive relatioship with motility ad pregacy rate (10). Exogeous has bee used to stimulate huma sperm motility (11) ad IVF ad embryo developmet rates i rabbits (12). A prelimiary study (13) demostrated the improvemet of IUI pregacy rates after a short-term exposure of sperm to. I the preset study, our objective was to determie the effect of exogeous o IUI pregacy rates i couples presetig with ormal ad abormal seme aalyses. The study was a prospective radomized double-blided study of treatmet of sperm for patiets with a history of ifertility udergoig IUI. Patiets were radomized (blid umber draw from computer-geerated radom umber table) ito either receivig treatmet or servig as cotrols for up to three IUI cycles. Furthermore, couples were categorized ito either ormal or male factor groups. MATERIALS AND METHODS Study Populatio ad Maagemet Healthy, ifertile patiets with otubal factor ifertility were made aware of the study ad iformed of the study desig with the possibility of improved results based o a small cliical trial (13). The treatmet optio was ot made available outside the curret study. Possible risks were discussed ad iformed coset was obtaied uder guidelies approved by the Wester Istitutioal Review Board (Seattle, WA). Iclusio criteria were as follows: basal FSH level 15 miu/ml, evidece of a ormal uterie cavity, ad o cotraidicatio to pregacy. Ifertility diagoses icluded aovulatory, edometriosis, idiopathic, tubal (sigle or fibroids), cervical factor, ad male factor. Male factor ifertility patiets were classified as such if they failed to meet oe or more referece stadards (14). Couples were permitted to eter the study at ay poit i a series of IUI treatmets. Couples (ormal male ad male factor study groups) were radomized ito oe of two study groups (group 1, cotrol; group 2, ) from Jauary 2001 to December Oce patiets were assiged to the respective treatmet group, oly the RBA Adrology Laboratory staff was aware of assigmet. Patiets were subsequetly treated i each cosecutive cycle with the same regime (i.e., cotrol or augmeted). No cliical staff (physicia or urse) was iformed of assigmet util the study was completed. Cycle stimulatio was cotrolled by CC or goadotropis. I CC-cotrolled cycles, mg of CC was give for 5 cycle days. Timig of IUI was based o LH surge or ultrasoud-timed hcg admiistratio. I cycles maaged by goadotropis, stimulatios were started o cycle day 3 with IU daily (with dosages idividually titrated based o patiet age ad previous respose). Ultrasoud (oe to four ultrasoud follicular studies per IUI cycle) moitorig with E 2 (Access2, Beckma Coulter, Ic., Brea, CA) observatio was performed util the lead follicle was at least 18 mm i all but exceptioal cases. Preovulatory LH surge timig was moitored by urie LH levels. The IUI was performed hours ad agai i hours after hcg ijectio. Patiets takig CC who experieced a spotaeous LH surge had oly oe IUI performed 24 hours later. Seme Aalysis Seme specimes were permitted to liquefy for miutes at 37 C. Sperm cocetratio ad motility, before ad after treatmet, were evaluated by computer-assisted seme aalysis (IVOS v10.9i, Hamilto-Thore Research, Beverly, MA) operatig at a samplig frequecy of 60 Hz. All aalyses were performed usig MicroCell-20 Micro (Coceptio Techologies, Sa Diego, CA) coutig chambers. A total of five radom areas were selected ad evaluated by the IVOS system at 37 C. Seme Processig ad Exposure for IUI Group Seme specimes were processed (400 g; 12 miutes) through a 90% desity silae-coated silica suspesio (1:1; Promotor; CERES Fertility, Sa Diego, CA), washed with 4 ml of sperm wash medium (IVitroCare, Sa Diego, CA), cetrifuged (300 g; 8 miutes) ad resuspeded with 0.5 ml of PureSperm-Wash (Nidaco Iteratioal AB, Goteborg, Swede). Treatmet Group Seme specimes were processed (400 g; 12 miutes) through a 90% desity silae-coated silica suspesio (1:1; Promotor), resuspeded i 10 7 M i sperm wash medium (IVitroCare) ad icubated for 15 miutes at 37 C. After icubatio, sperm were washed (300 g; 8 miutes) free of ad resuspeded i 0.5 ml of PureSperm-Wash (Nidaco). IUI ad Pregacy Outcomes Washed sperm preparatios were isemiated with a IUI Catheter (Lifetek Medical, Ic., Portage, WI). Pregacy outcomes were determied first by -hcg serum levels (Access2, Beckma Coulter, Ic.) ad cofirmed by ultrasoography (fetal heartbeat a positive outcome). Sample Size ad Statistical Aalysis Power estimates based o published IUI pregacy rates (5% 16%) ad prelimiary data reveal that a miimal sample size of 83 IUI cycles per male factor ad 40 IUI cycles per ormal male treatmet group is required for alpha to equal FERTILITY & STERILITY 53

3 TABLE 1 Platelet activatig factor-itrauterie isemiatio patiet demographics. TABLE 3 Cumulative Platelet activatig factor-itrauterie pregacy rates per patiet. Demographic Patiet group Male age (y) Normal study arm, 36.4 ( 3.01);, 35.5 ( 4.02) Male factor study arm, 38.5 ( 6.01);, 36.0 ( 5.94) Female age (y) Normal study arm, 36.2 ( 4.16);, 35.9 ( 4.93) Male factor study arm, 35.8 ( 4.54);, 34.1 ( 4.40) Cycle stimulatio Clomiphee citrate 53 (32.1%) Goadotropi 112 (67.9%) Ifertility etiology (primary) Aovulatory 35 (24.1%) Edometriosis 12 (8.3%) Idiopathic 8 (5.5%) Tubal 2 (1.4%) Cervical factor 4 (2.8%) Male factor 84 (57.9%) Estradiol levels day of hcg mea ( SEM) (goadotropi cycles oly) 1, ( 150.9) ( 126.0) 0.05 ad to show a differece with 80% power (beta 0.80). A 50% icrease i pregacy rate after treatmet to the IUI protocol was used. Data were aalyzed by 2. Statistical calculatios were performed with SigmaStat for Widows, versio 2.03 (Jadel Scietific Corporatio, Sa Rafael, CA). RESULTS A prospective compariso of pregacy rates was performed after sperm treatmet with or without, at the time of seme washig just before IUI. Patiet demographics are preseted i Table 1. There were o sigificat differeces i patiet demographics betwee the pregat ad opregat groups or cotrol ad treatmet groups. A total of 165 patiets TABLE 2 Platelet activatig factor-itrauterie isemiatio pregacy rate per cycle. IUI cycle Normal male study arm 10/56 (17.9%) a 14/47 (29.8%) a Male factor study arm 12/124 (9.7%) 14/119 (11.8%) a Sigificatly differet, P.05. Overall 22/81 (27.2%) a Clomiphee citrate 11/31 (13.6%) Goadotropi 11/50 (22.0%) b 28/64 (43.8%) a Clomiphee citrate 8/22 (36.4%) Goadotropi 17/40 (52.5%) b Normal male study arm 10/35 (28.6%) c 14/26 (53.9%) c Male factor study arm 12/46 (26.1%) 14/38 (36.8%) a,b,c Similar superscripts are sigificatly differet, P.05. erolled i the study, of these 3 (1.8%) coverted to IVF ad 17 (10.3%) ever followed through with IUI therapy. Patiet pregacy rates are preseted i Table 2 (per cycle) ad Table 3 (cumulative). Cumulative IUI pregacy rate by umber of attempts accordig to treatmet group for all patiets (ormal ad male factor) are preseted i Figure 1. I couples presetig with ormal seme characteristics the cycle-specific pregacy rate was 29.8% (14/47) whe was used. This was sigificatly higher (P.05) whe compared with the cotrol (10/56; 17.9%). Cumulative pregacy rates were sigificatly higher (P.05) i the treatmet group (14/26; 53.90%) tha the cotrol group (10/35; 28.6%). There was o sigificat differece i IUI pregacy rates per cycle betwee cotrol (12/124; 9.7%) ad (14/119; 11.8%) treatmet groups i the male factor study arm. There was o sigificat differece i cumulative IUI pregacy rates betwee cotrol (12/46; 26.1%) ad (14/38; 36.8%) patiet groups i the male factor study arm. There was a sigificat differece (P.05) i overall cumulative IUI pregacy rates betwee cotrol (22/81; 27.2%) ad (28/64; 43.8%) patiet groups. TABLE 4 Platelet activatig factor-itrauterie isemiatio multiple pregacy rate. Twis 3/22 (13.6%) 5/28 (17.9%) Triplets 2/22 (9.1%) 0 (0.0%) Quadruplets 2/22 (9.1%) 2/28 (7.1%) Total multiple rate 7/22 (31.8%) 7/28 (25.0%) 54 Roudebush et al. Platelet-activatig factor ad IUI pregacy Vol. 82, No. 1, July 2004

4 FIGURE 1 Cumulative itrauterie isemiatio (IUI) pregacy rate by umber of attempts accordig to treatmet group for all patiets (ormal ad male factor). platelet-activatig factor. TABLE 5 Ogoig platelet activatig factor-itrauterie isemiatio pregacy rate. Stimulatio Pregacy rate Clomiphee citrate 12/31 (38.7%) Goadotropi 40/94 (42.6%) Overall 52/125 (41.6%) There was o sigificat differece i multiple pregacy rates betwee the cotrol ad treatmet groups (Table 4). DISCUSSION The iclusio of to IUI sperm wash procedure improves pregacy rates. However, this sigificat improvemet could oly be demostrated i cases where the seme aalysis was ormal. This cofirms our origial results demostratig the effectiveess of exogeous supplemetatio i a IUI program (13). Treatmet of sperm i male factor patiets with showed a icrease i pregacy rates, albeit ot statistically sigificat. It is possible that sperm i these idividuals are icapable of respodig to the exogeous due to poor receptor levels ad, or faulty receptors i the sperm (15). The atagoists will ihibit the motility, acrosome reactio ad hamster oocyte peetratio i exposed sperm, thus suggestig the presece of receptors for (16, 17). We have recetly reported o the presece ad distributio of the receptor i huma sperm (18) ad our prelimiary data demostrate that distributio of the receptor is sigificatly altered i abormal sperm (19). We have also discovered that receptor mrna expressio differs sigificatly betwee motile (high cotet) ad omotile (low cotet) sperm (15). I additio we have foud that sperm with abormal motility have differet receptor mrna sequeces (20). The plays a sigificat role i sperm fuctio ad has recetly bee reviewed (21). It may affect sperm motility ad fertilizatio through a receptor-mediated cotrol of itracellular calcium. The has bee show to augmet sperm capacitatio (22, 23). We believe that the beeficial effect of o IUI pregacy rates is due to bidig to its receptor o the cells surface, iitiatig itracellular calcium release, ehacig sperm capacitatio ad cell motility, thus ehacig fertilizatio rates. Sperm with defective or low umbers of receptor may ot respod to (edogeous or exogeous), thus havig poor motility (22). Additioal studies will elucidate the reproductive sigificace of activity ad s mechaism of actio i spermatozoa. Other possible factors may attribute to the high pregacy rates observed i this study. For example, i most cases we performed two IUI s per cycle, which has bee demostrated to improve pregacy outcome (5). Additioal cliical studies are warrated to further establish the use of therapy for patiet s udergoig IUI therapy for ifertility treatmet. I particular, larger umbers of male factor ifertility patiets will determie the sigificace of IUI therapy for these idividuals. To summarize, exposure of sperm to ca sigificatly icrease IUI pregacy rates. APPENDUM O February 10, 2003, we iitiated the routie washig of seme with before IUI. Our overall ogoig pregacy rate sice the is 41.6% ad is preseted i Table 5. Ackowledgmets: The authors express their sicere gratitude ad thaks to the staff ad physicias (Daiel Shapiro, M.D., David Keea, M.D., ad Scott Slayde, M.D.) at Reproductive Biology Associates for patiet recruitmet ad laboratory work without whose assistace would have made this study impossible. Refereces 1. Garceau L, Hederso J, Davis LJ, Petrou S, Hederso LR, McVeigh E, et al. Ecoomic implicatios of assisted reproductive techiques: a systematic review. Hum Reprod 2002;12: Ecochard R, Mathieu C, Royere D, Blache G, Rabilloud M, Czyba JC. A radomized prospective study comparig pregacy rates after clomiphee citrate ad huma meopausal goadotropi before itrauterie isemiatio. Fertil Steril 2000;73: Pasqualotto EB, Daitch JA, Hedi BN, Falcoe T, Thomas AJ, Nelso DR, et al. Relatioship to total motile sperm cout ad percetage motile sperm to successful pregacy rates followig itrauterie isemiatio. J Assisted Reprod Geetics 1999;16: FERTILITY & STERILITY 55

5 4. Matorras R, Diaz T, Corcostegui B, Ramo O, Pijoa JI, Rodriguez- Escudero FJ. Ovaria stimulatio i itrauterie isemiatio with door sperm: a radomized study comparig clomiphee citrate i fixed protocol versus highly purified uriary FSH. Hum Reprod 2002;8: Silverberg KM, Johso JV, Olive DL, Burs WN, Scheke RS. A prospective, radomized trial comparig two differet itrauterie isemiatio regimes i cotrolled ovaria hyperstimulatio cycles. Fertil Steril 1992;2: Catieau AE, Heiema MJ, Cohle BJ. Sigle versus double itrauterie isemiatio i stimulated cycles for subfertile couples: a systematic review based o a Cochrae review. Hum Reprod 2003;18: Dura EH, Morshedi M, Taylor S, Oehiger S. Sperm DNA quality predicts itrauterie isemiatio outcome: a prospective cohort study. Hum Reprod 2002;17: Harper MJK. Platelet-activatig factor: a paracrie factor i preimplatatio stages of developmet? Biol Reprod 1989;40: Mihas BS, Kumar R, Ricker DD, Robertso JL, Dodso MG. The presece of platelet activatig factor-like activity i huma spermatozoa. Fertil Steril 1991;55: Roudebush WE, Purell ET. Platelet-activatig factor cotet i huma spermatozoa: predictig pregacy outcome. Fertil Steril 2000;74: Ricker DD, Mihas BS, Kumar R, Robertso JL, Dodso MG. The effects of platelet activatig factor o the motility of huma spermatozoa. Fertil Steril 1989;52: Roudebush WE, Fukuda AI, Mihas BS. Ehaced embryo developmet of rabbit oocytes fertilized i vitro with platelet-activatig factor treated spermatozoa. J Assisted Reprod Geet 1993;10: Wild MD, Roudebush WE. Platelet-activatig factor improves itrauterie isemiatio outcome. Am J Obstet Gyecol 2001;184: WHO Laboratory Maual. The examiatio of huma seme ad sperm cervical mucus iteractio. 4th ed. Prepared by WHO Special Programme for Research Developmet ad Research Traiig i Huma Reproductio: Cambridge Uiversity Press, Cambridge, UK Purell ET, Roudebush WE. Platelet-activatig factor activity (ligad ad receptor trascript) cotet i sperm: motile versus omotile. I: Robaire E, Chemes H, Morales CR, eds. Adrology i the 21st cetury, Proceedigs of the VIIth Iteratioal Cogress of Adrology. Eglewood, NJ: Medimod Publishig Compay, Ic., 2001: Segoku K, Tamate K, Takaoka Y, Ishikawa M. Effects of plateletactivatig factor o huma sperm fuctio i vitro. Hum Reprod 1993;8: Mihas BS. Platelet-activatig factor treatmet of huma spermatozoa ehaces fertilizatio potetial. Am J Obstet Gyecol 1993;168: Reihardt JC, Cui X, Roudebush WE. Immuofluorescet evidece for the presece of the platelet-activatig factor receptor i huma spermatozoa. Fertil Steril 1999;71: Roudebush WE, Wild MD, Maguire EH. Platelet-activatig factor receptor expressio i huma spermatozoa: differeces i mrna cotet ad protei distributio betwee ormal ad abormal spermatozoa. Fertil Steril 2000;73: Roudebush WE, Mayorov V, Adkiso LR, Slayde SM, Shapiro DB, Elser CW, et al. Abormal sequece of the platelet-activatig factorreceptor i omotile spermatozoa. Fertil Steril 2002;76:P Levie AS, Kort HI, Toledo AA, Roudebush WE. A review of the effect of platelet-activatig factor o male reproductio ad sperm fuctio. J Adrol 2002;23: Wu C, Stojaov T, Chami O, Ishii S, Shimizu T, Li A, et al. Evidece for the autocrie iductio of capacitatio of mammalia spermatozoa. J Biol Chem 2001;276: Toledo AA, Mitchell-Leef D, Elser CW, Slayde SM, Roudebush WE. Fertilizatio potetial of huma sperm is correlated with edogeous platelet-activatig factor cotet. J Assist Reprod Geet 2003; 20: Roudebush et al. Platelet-activatig factor ad IUI pregacy Vol. 82, No. 1, July 2004