A number of non-invasive methods have been proposed to evaluate embryo viability in human in-vitro fertilization programmes. In addition to biochemical analyses, a common method for the selection of embryos prior to transfer involves assessment of embryo quality and morphology. We propose a new method to evaluate embryo viability based on the timing of the first cell division. Fertilized embryos that had cleaved to the 2-cell stage 25 h post-insemination were designated as 'early cleavage' embryos while the others that had not yet reached the 2-cell stage were designated as 'no early cleavage'. In all cases the early cleavage embryos were transferred when available. Early cleavage was observed in 27 (18.9%) of the 143 cycles assessed. There were significantly (chi2 = 4.0; P = 0.04) more clinical pregnancies in the early cleavage group, 9/27 (33.3%), compared with the no early cleavage group, 17/116 (14.7%). No difference was found when comparing key parameters (age, stimulation protocol and semen characteristics) of couples belonging to both groups, pointing to an intrinsic property or factor(s) within the early cleaving embryos. We propose 'early cleavage' as a simple and effective non-invasive method for selection and evaluation of embryos prior to transfer.

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Kim Dickson and colleagues analyze the progress made by 13 priority countries toward scale-up of medical male circumcision programs, finding that the most successful programs involve country ownership of the program and have sustained leadership at all levels.

ObjectivesTo compare rates of unintended pregnancy, method continuation and reasons for removal among women using the 52-mg levonorgestrel (daily release 20 microg) levonorgestrel IUD (LNG-IUD) or the copper T 380 A (TCu380A) intrauterine device.Study designThis was an open-label 7-year randomized controlled trial in 20 centres, 11 of which in China. Data on 1884 women with interval insertion of the LNG-IUD and 1871 of the TCu380A were analysed using life tables with 30-day intervals and Cox proportional hazards models.ResultsThe cumulative 7-year pregnancy rate of the LNG-IUD was 0.5 (standard error 0.2) per 100, significantly lower than 2.5 (0.4) per 100 of the TCu380A, cumulative method discontinuation rates at 7 years were 70.6 (1.2) and 40.8 (1.3) per 100, respectively. Dominant reasons for discontinuing the LNG-IUD were amenorrhea (26.1 [1.3] per 100) and reduced bleeding (12.5 [1.1] per 100), particularly in Chinese women and, for the TCu380A, increased bleeding (9.9 [0.9] per 100), especially among non-Chinese women. Removal rates for pain were similar for the two intrauterine devices (IUDs). Cumulative rates of removal for symptoms compatible with hormonal side effects were 5.7 (0.7) and 0.4 (0.2) per 100 for the LNG-IUD and TCu380A, respectively, and cumulative losses to follow-up at 7 years were 26.0 (1.4) and 36.9 (1.3) per 100, respectively.ConclusionThe LNG-IUD and the TCu380A have very high contraceptive efficacy, with the LNG-IUD significantly higher than the TCu380A. Overall rates of IUD removals were higher among LNG-IUD users than TCu380A users. Removals for amenorrhea appeared culturally associated.ImplicationsThe 52-mg LNG-IUD and the TCu380A have very high contraceptive efficacy through 7 years. As an IUD, the unique side effects of the LNG-IUD are reduced bleeding, amenorrhea and symptoms compatible with hormonal contraceptives.

BackgroundHuman immunodeficiency virus (HIV)–infected pregnant women increasingly receive antiretroviral therapy (ART) to prevent mother-to-child transmission (PMTCT). Studies suggest HIV-exposed uninfected (HEU) children face higher mortality than HIV-unexposed children, but most evidence relates to the pre-ART era, breastfeeding of limited duration, and considerable maternal mortality. Maternal ART and prolonged breastfeeding while on ART may improve survival, although this has not been reliably quantified.MethodsIndividual data on 19 219 HEU children from 21 PMTCT trials/cohorts undertaken from 1995 to 2015 in Africa and Asia were pooled to estimate the association between 24-month mortality and maternal/infant factors, using random-effects Cox proportional hazards models. Adjusted attributable fractions of risks computed using the predict function in the R package “frailtypack” were used to estimate the relative contribution of risk factors to overall mortality.ResultsCumulative incidence of death was 5.5% (95% confidence interval, 5.1–5.9) by age 24 months. Low birth weight (LBW <2500 g, adjusted hazard ratio (aHR, 2.9), no breastfeeding (aHR, 2.5), and maternal death (aHR, 11.1) were significantly associated with increased mortality. Maternal ART (aHR, 0.5) was significantly associated with lower mortality. At the population level, LBW accounted for 16.2% of 24-month mortality, never breastfeeding for 10.8%, mother not receiving ART for 45.6%, and maternal death for 4.3%; combined, these factors explained 63.6% of deaths by age 24 months.ConclusionsSurvival of HEU children could be substantially improved if public health practices provided all HIV-infected mothers with ART and supported optimal infant feeding and care for LBW neonates.

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Complete avoidance of breast-feeding is the surest way to avoid mother-to-child transmission (MTCT) of HIV through breast-feeding, but replacement feeding exposes infants, especially those born in developing countries, to the risk of other infectious diseases with consequent increase in morbidity and mortality. One study has suggested that exclusive breast-feeding during the first months of life carries a lower risk of HIV transmission than when other foods are given in addition to breast milk. Other studies have provided limited data on the risks of HIV transmission according to different patterns of breast-feeding, but studies have used different definitions of breast-feeding patterns and have analysed their data with adjustment on different risk factors. This hampers our ability to understand the mechanisms underlying HIV transmission through breast milk and the risks associated with different infant feeding practices. Consequently it is difficult to determine the best interventions to reduce the risk of transmission and the development of optimal policies. In collaboration with research teams involved with infant feeding research, the World Health Organization has developed a tool to assist studies on MTCTto collect information in a standardized manner, using common definitions and terms. The purpose is to facilitate comparisons between studies and the quantification of the risks of transmission according to various feeding patterns, after adjusting for potential confounding variables. The tool includes a core questionnaire to record infant feeding practices and other key information on the mother's and the infant's health. It also provides guidance on methods of analysis and presentation of the complex data on infant feeding. The tool can be used in prospective research studies on MTCT prevention, as well as providing the framework to assess infant feeding patterns in intervention programmes, such as those providing intensive counselling to mothers on infant feeding. The tool will facilitate the compilation of information from these studies which will ultimately provide scientific basis for updating guidelines and policies on infant feeding by mothers infected with HIV.