The plasmid pGAD-PDC1 was made by replacing the 085-kb HindIII f

The plasmid pGAD-PDC1 was made by replacing the 0.85-kb HindIII fragment of pGAD GH (Clontech) with a PCR-amplified PDC1 open reading frame with HindIII linkers, Pexidartinib supplier and the 3.35-kb SphI fragment containing the ADH1 promoter-PDC1-ADH1 transcription termination sequence from pGAD-PDC1 was inserted into YIp5 at the unique SphI site. Then, the recombinant plasmid was linearized at the unique BglII site in PDC1 and transformed into YPH500. The PDC2 gene of the thus constructed strain NKC20 (LEU2::ADH1promoter-PDC1-ADH1termination in YPH500) was disrupted by

a PCR-directed integration method (Baudin et al., 1993) using HIS3 as a selectable marker. The newly constructed strain NKC21 (pdc2::HIS3 in NKC20) was a thiamin auxotroph, but grew normally in glucose medium containing thiamin. The mRNA levels of PHO3, THI20, and PDC5 in NKC21 were confirmed to be entirely depressed even under thiamin-deprived SRT1720 mw conditions (data not shown). To analyze the promoter activity of PDC5, all B593ΔX-derived plasmids were linearized with StuI to target integration to the ura3-52 locus and transformed

into YPH500. Single-copy integration was confirmed by restriction mapping of PCR-isolated fragments from the genomic DNA. Standard media and growth conditions for yeast cells were as described previously (Nosaka et al., 2005). Thiamin was added to the yeast minimal medium to a final concentration of 1 µM (high-thiamin medium) or 10 nM (low-thiamin medium). The concentration of the carbon source (glucose, raffinose, and galactose) was 2%. Yeast cultures (50 mL) were gently shaken with 1.5 mL of 36%

formaldehyde for 15 min at 30 °C, and the cross-linking reaction PAK6 was stopped with 2.5 mL of 2.5 M glycine. After two washes with cold PBS, the cells were suspended in 0.6 mL of lysis buffer (50 mM HEPES pH 7.5, 140 mM NaCl, 1% Triton X-100, 1 mM EDTA, and 0.1% sodium deoxycholate) containing 1 mM phenylmethylsulfonyl fluoride and 10 µL mL−1 protease inhibitor cocktail for Fungal and Yeast cells (Sigma), and lysed with glass beads in a bead beater (Biospec Products) by beating for three 60-s pulses with 5-min intervals on ice. After the lysate was drawn off the beads, the beads were again suspended with 0.6 mL of lysis buffer to recover the extracts. Then, the combined lysate was sonicated five times in ice-cold water using a Biorupter (Cosmo Bio, Tokyo) at 200 W for 30 s each time at 120-s intervals. Sonicated extracts were subsequently clarified by centrifugation. The lysate was divided into three fractions: the first and second (500 µL each) were used for immunoprecipitation, and the third (25 µL) was used as an input control.

In a more indirect way, the study of the multilayered

pro

In a more indirect way, the study of the multilayered

protective mechanisms also seems to lead to alterations in genetic expression. The earliest protective mechanisms that were studied included physical protection (typically by diffusion limitation/reduction) and physiological protection (through heterogeneous PF-02341066 price growth rates and nutrient concentrations within the biofilm). These mechanisms offer only transient protection (Cogan et al., 2005). Therefore, other mechanisms likely play a role. (3) What is the basis for biofilm persistence? Bacterial populations produce ‘persister’ cells that neither grow nor die in the presence of antibiotics. This phenomenon can lead to failure of antibiotic treatment in clinical situations. Persisters are different than drug-resistant mutants because their antibiotic tolerance is nonheritable and reversible (Lewis, 2007). These specialized cells, which are extremely tolerant to antibiotic application, can arise from a variety of

processes including gene expression, senescence, or niche expansion. Recent evidence indicates that this subpopulation may actively repress the expression of targets that are normally inhibited by antibiotics. This pathway is triggered in part by the SOS response and appears to involve toxin–antitoxin systems (Dorr et al., 2010; Kim & Wood, 2010). The process of persister cell formation has been incorporated into several mathematical models, sometimes indicating the predicted spatial location (Roberts & Stewart, 2005; Cogan, 2010), temporal find more stability (De Leenheer & Cogan, Progesterone 2009) or dynamic response to disinfection (Cogan, 2006). This is an area where the direct comparison of mathematical models and experimental studies has been explored helping to validate experimental hypotheses and suggest potential biological mechanisms (Balaban et al., 2004; Rotem et al., 2010). (4) How does the biofilm community contribute to ecological processes? The final question that

we will address is that of the developing ecology of the biofilm and its community. Understanding the phenotypic mosaic of developing biofilms is of importance in a variety of situations. For example, bioremediation often requires some control on the formation and elimination of an engineered biofilm. Also, biomineralization and other studies require detailed knowledge of the distribution of various species/phenotypes within the biofilm as well as their interactions. In general, ecological studies require the models to incorporate direct or indirect interaction between the biofilm components. In this way, the newest generation of models typically includes multiple species/phenotypes and often multiple substrates. It should be noted that the earliest models addressed some of these factors (Wanner & Gujer, 1986); however, based on the intermediate models it is clear that transport processes, mechanical structure, chemistry, and physics may be much more important than was initially assumed.

Such stringent conditions compromised signal intensities; however

Such stringent conditions compromised signal intensities; however, specific signals remained IDO inhibitor detectable at the highest stringency (at 75 °C hybridization) with negligible false negatives. These results suggest that, without any probe design or selection, genomic

fragments can provide a reasonable specificity for microbial diagnostics or species delineation by DNA–DNA similarities. Microarray-based technology, with its advantage of highly parallel detection, has been applied to both population profiling and to functional studies of complex microbial communities in the environment (Loy et al., 2002; Palmer et al., 2006; He et al., 2007; Iwai et al., 2008). Recent studies have used synthesized oligonucleotides as probes because of their flexibility in design and preparation, FK228 with intensive specificity evaluation applied to the probe design criteria (He et al., 2005). In addition, several studies have reported the

use of PCR-amplified genomic fragment sequences as probes. Such microarrays have been used for the detection of specific bacteria (Kim et al., 2004, 2005), species determination (Cho & Tiedje, 2001), and screening of environmental sequences related to a certain function within a community (Yokoi et al., 2007; Tobino et al., 2011). As the probes in these studies are randomly prepared by shotgun cloning of genomic DNAs, this kind of microarray is independent of sequence information found in public databases and hence offers unique potential for exploring unsequenced

microorganisms. Gemcitabine mw However, the specificity of genomic fragment probes has not been evaluated in detail. In this study, we prepared genomic fragment probes from pure cultures whose whole genome sequences are available and then evaluated hybridization specificity in terms of sequence similarity between probe and target. Genomic fragment probes were prepared from genomic DNAs of three Pseudomonas strains (Pseudomonas aeruginosa PAO1, Pseudomonas fluorescens Pf-5, and Pseudomonas putida KT2440) by shotgun cloning as described previously (Tobino et al., 2011). The probe set consisted of 167 fragment probes (55, 56, and 56 probes from PAO1, Pf-5, and KT2440, respectively) of ~ 2000 bp in length (Supporting Information, Table S1) and four control probes (see the figure legend of Fig. S1 for the preparation of control probes). Each fragment probe was spotted onto nylon membranes (5 ng per spot) in duplicate, and the spotted membranes were alkaline denatured, baked, and stored in a plastic bag until use (see Fig. S1 for probe layout). Genomic DNAs of pure cultures, plus control DNA (yeast gene ACT, included in the probe set as a positive control) were individually labeled with digoxigenin (DIG) by random priming according to the manufacturer’s instructions (DIG High Prime; Roche, Basel, Switzerland). Labeled products were sonicated to an average length of 400 bp.

Lopinavir/ritonavir was discontinued when the plasma viral load d

Lopinavir/ritonavir was discontinued when the plasma viral load dropped below 50 HIV-1 RNA copies/ml. After January 2008, zidovudine/lamuvidine

was replaced with tenofovir/emtricitabine (245/200 mg qd), and lopinavir/ritonavir tablets (600/150 mg bid) Hydroxychloroquine concentration replaced the capsules. Patients needed to have sufficient fluency in Dutch or English to complete a self-administered HRQL questionnaire. Recruitment of participants and the study design have been described previously [1, 11]. The study was approved by the Medical Ethics Committee of each participating site and written informed consent was obtained from all participants. Patients received a self-report questionnaire measuring HRQL when attending the out-patient clinic for the study visits at weeks

0, 8, 24, 36, 48, 60, 72, 84 and 96. The questionnaire consisted of two parts: the Medical Outcomes Study Health Survey for HIV (MOS-HIV) and a symptom checklist. The MOS-HIV is a widely used questionnaire comprising 10 subscales [12]. Physical health (PHS) and mental health summary (MHS) scores can be calculated on the basis of these subscale scores [13]. Higher scores indicate a better HRQL. The symptom checklist consisted of 14 items referring to symptoms related to PHI or to side effects of cART, i.e. difficulty with sleeping, lack of appetite, nausea, vomiting, diarrhoea, abdominal or stomach pain, fever, GDC-0199 mouse flu-like symptoms such as myalgia or chills, tingling of hands or feet, numb feeling in fingers or toes, dizziness,

itchiness and skin changes. These items were derived from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire – Core 30 and an HIV/AIDS-specific questionnaire [9]. The questions related to the experience of symptoms during the past week. Symptoms were scored on a four-point scale with the response categories ‘not at all’, ‘a little’, ‘quite a bit’, and ‘very much’. The four-point scale scores were linearly transformed to a scale of 0 to 100, with higher scores indicating more symptoms. We included patients who completed an HRQL questionnaire at baseline and at least one questionnaire during follow-up. Baseline characteristics Bortezomib manufacturer were compared using χ2 tests for categorical variables and general linear models or Kruskal–Wallis tests for continuous variables. Linear mixed effect models for repeated measurements were used to test for differences in MOS-HIV and symptoms scores during follow-up among the three groups, with baseline values included as a covariate. Model results were summarized by the estimated mean values during follow-up for the three groups, adjusted for baseline measurements. To investigate potential short-term toxicity of cART, we also compared the symptom scores among the three groups at week 8 using general linear models, with the baseline measurement included as a covariate.

broadinstituteorg, http://wwwgenomewustledu) G186A has four

broadinstitute.org, http://www.genome.wustl.edu). G186A has four chromosomes whereas G217B has only three (Steele et al., 1989). However, the total genome size of G217B is roughly 30% larger than G186A (41 megabases vs. 30.4 megabases, respectively) primarily due to repetitive DNA, which includes mobile DNA insertions, retrotransposons and multiple copies of a crypton (Goodwin et al., 2003). This suggests that the non-repetitive

‘core’ Histoplasma genome is roughly 26–28 megabases. Bioinformatics analyses of the sequence predicts that the Histoplasma genome encodes between 9000 and 10 000 genes (http://www.broadinstitute.org). Large regions of synteny exist between G186A and IDO inhibitor G217B and

much of the ‘extra’ DNA is located intergenically as clusters of repetitive sequence. Nucleotide sequence identity for homologous genes is roughly 97 ± 2% between G186A and G217B (J.A. Edwards and C.A. Rappleye, unpublished data) suggesting C59 wnt in vivo differential gene regulation, rather than amino acid change, is an important contributor to phenotypic differences between strains. Histoplasma capsulatum is a haploid organism and has a heterothallic mating system (Kwon-Chung, 1973). A mating type locus (MAT locus) is present in the genome and two MAT alleles are correlated with opposite mating types in clinical strains; G217B has the MAT1-1 allele whereas G186A has the MAT1-2 allele (Bubnick & Smulian, 2007). Some correlation exists between mating type and virulence. Considerable variation exists in the proportions of mating types (designated as + or −) in environmental sources of Histoplasma (Kwon-Chung et al., 1974; Gaur & Lichtwardt, 1980), however, in clinical samples – mating types predominate (Kwon-Chung et al., 1974, 1984). The significance of this correlation

is from presently unknown. Attempts to manipulate G186A and G217B in the lab have indicated differences in the efficiency of homologous recombination between the two strains. Whereas several gene deletion strains have been created through allelic replacement in the Panamanian background (G186A or G184A strains) (Woods et al., 1998; Sebghati et al., 2000; Tian & Shearer, 2002; Rappleye et al., 2004; Marion et al., 2006; Hwang et al., 2008; Hilty et al., 2011), only a limited number of gene knockout alleles exist in the NAm2 isolate G217B (Marion et al., 2006; Cooper & Woods, 2009). As a consequence, RNA interference (RNAi) has been adopted as a more practical means to deplete gene functions in Histoplasma (Rappleye et al., 2004) when efforts to delete genes through homologous recombination fail.

Baseline samples for CD4 cell count, VL and resistance should be

Baseline samples for CD4 cell count, VL and resistance should be taken. Treatment should be commenced immediately as per Recommendation 5.4.3 above. Triple therapy should be given to the neonate (see Section 8: Neonatal management). 5.5.1 Untreated women with a CD4 cell count ≥350 cells/μL and a VL <50 HIV RNA copies/mL (confirmed on a separate assay): Can be treated with zidovudine monotherapy

or with HAART (including abacavir/lamivudine/zidovudine). BTK inhibitor Grading: 1D Can aim for a vaginal delivery. Grading: 1C Should exclusively formula feed their infant. Grading: 1D Elite controllers are defined as the very small proportion of HIV-positive individuals who, without treatment, have undetectable HIV RNA in plasma as assessed by more than one different VL assay on more than one occasion. It is estimated that 1-in-300 HIV-positive individuals are elite controllers [95]. In the absence of data from RCTs on elite controllers, recommendations are based on RCT and observational data on all pregnant HIV-positive women. In the original zidovudine monotherapy study (ACTG 076) the transmission rate if maternal VL was <1000 HIV RNA copies/mL was 1% (range 0–7%) [16]. Treatment reduced transmission even among women with low or undetectable HIV VL, suggesting that the effects of treatment Ganetespib in vitro were not all related

to decreasing maternal viraemia but may also be related to reducing HIV in the genital tract and/or peri-exposure prophylaxis of the infant by placental transfer of zidovudine. A meta analysis of transmission outcomes in several major USA and European studies Immune system also demonstrated that an HIV VL <1000 HIV RNA copies/mL at delivery was associated with a relatively low risk of transmission and that ARV prophylaxis offered additional clinically significant protection [96]. Zidovudine has been shown to reduce cervicovaginal shedding of HIV [2] and there are no data to suggest that HAART is more effective than zidovudine at reducing cervicovaginal shedding in women with a plasma HIV

VL <50 copies/mL. Therefore, zidovudine monotherapy is an option in this setting. There are no data to support the use of intravenous zidovudine infusion during labour in elite controllers. HAART may provide more reassurance about prevention of MTCT but will also expose both mother and infant to more potential drug toxicities. The choice of HAART is as per Recommendation 5.3.3. Data on the mode of delivery in elite controllers are sparse and limited to case reports [97]. The benefits of PLCS at various levels of viraemia are discussed in Section 7.2 (Mode of delivery). There are no data to support the use of PLCS for PMTCT when the VL is <50 HIV RNA copies/mL in women on ART. The Writing Group therefore recommends vaginal delivery for all elite controllers on ART. 5.6.

Baseline samples for CD4 cell count, VL and resistance should be

Baseline samples for CD4 cell count, VL and resistance should be taken. Treatment should be commenced immediately as per Recommendation 5.4.3 above. Triple therapy should be given to the neonate (see Section 8: Neonatal management). 5.5.1 Untreated women with a CD4 cell count ≥350 cells/μL and a VL <50 HIV RNA copies/mL (confirmed on a separate assay): Can be treated with zidovudine monotherapy

or with HAART (including abacavir/lamivudine/zidovudine). E7080 purchase Grading: 1D Can aim for a vaginal delivery. Grading: 1C Should exclusively formula feed their infant. Grading: 1D Elite controllers are defined as the very small proportion of HIV-positive individuals who, without treatment, have undetectable HIV RNA in plasma as assessed by more than one different VL assay on more than one occasion. It is estimated that 1-in-300 HIV-positive individuals are elite controllers [95]. In the absence of data from RCTs on elite controllers, recommendations are based on RCT and observational data on all pregnant HIV-positive women. In the original zidovudine monotherapy study (ACTG 076) the transmission rate if maternal VL was <1000 HIV RNA copies/mL was 1% (range 0–7%) [16]. Treatment reduced transmission even among women with low or undetectable HIV VL, suggesting that the effects of treatment Sotrastaurin were not all related

to decreasing maternal viraemia but may also be related to reducing HIV in the genital tract and/or peri-exposure prophylaxis of the infant by placental transfer of zidovudine. A meta analysis of transmission outcomes in several major USA and European studies MG-132 mouse also demonstrated that an HIV VL <1000 HIV RNA copies/mL at delivery was associated with a relatively low risk of transmission and that ARV prophylaxis offered additional clinically significant protection [96]. Zidovudine has been shown to reduce cervicovaginal shedding of HIV [2] and there are no data to suggest that HAART is more effective than zidovudine at reducing cervicovaginal shedding in women with a plasma HIV

VL <50 copies/mL. Therefore, zidovudine monotherapy is an option in this setting. There are no data to support the use of intravenous zidovudine infusion during labour in elite controllers. HAART may provide more reassurance about prevention of MTCT but will also expose both mother and infant to more potential drug toxicities. The choice of HAART is as per Recommendation 5.3.3. Data on the mode of delivery in elite controllers are sparse and limited to case reports [97]. The benefits of PLCS at various levels of viraemia are discussed in Section 7.2 (Mode of delivery). There are no data to support the use of PLCS for PMTCT when the VL is <50 HIV RNA copies/mL in women on ART. The Writing Group therefore recommends vaginal delivery for all elite controllers on ART. 5.6.

poae DNA at lower concentrations, although a more sensitive rDNA-

poae DNA at lower concentrations, although a more sensitive rDNA-based TaqMan assay was applied. The differences obtained can PCI-32765 molecular weight most probably be explained by the increased amplification efficiency (98.5–99.8%) of the esyn1-based

TaqMan assay used in this study, which resulted in higher amplicon levels quantified in comparison with previous studies, where the amplification efficiency of the assay used was 91%. Additional qualitative PCR analyses with species-specific primers for F. avenaceum (Turner et al., 1998) and F. tricinctum (Kulik, 2008) were performed in order to detect the presence of F. avenaceum and F. tricinctum in the samples analyzed. The results showed that F. avenaceum was only present in all samples harvested in 2007 where higher amounts of enniatins were detected, while the presence of F. tricinctum was revealed in all samples analyzed (data not shown). These results support the previous results of the studies of Logrieco et al. (2002) and Jestoi et al. (2004a, b) showing that F. avenaceum is responsible to a large extent for the increase in the enniatins content in grain samples. It seems that F. poae and F. tricinctum are the most frequent contaminants of wheat with low enniatins levels, Lumacaftor ic50 even if environmental conditions did not promote the development of FHB. Although several studies demonstrated

correlations between Fusarium DNA and the mycotoxin concentration in cereal samples, it should not be assumed that the amount of genes of interest would in each case relate to the level of corresponding mycotoxins. Recent studies by Jurado et al. (2008) and Marín et al. (2010) demonstrated that the expression of genes involved in mycotoxin synthesis depends on different environmental factors. Additionally, the fungal strains can synthesize mycotoxins at different concentrations (Bakan et al., 2002). On the other hand, discrepancies between chemical and DNA-based methods may

result from the ability of plants to hide fungal toxins such as glucosides (Berthiller et al., 2005), although, to date, no glucosylation Coproporphyrinogen III oxidase or other conjugation process is known for enniatins. Yli-Mattila et al. (2006, 2008) found a correlation between the levels of F. avenaceum and F. poae DNA analyzed using the TaqMan assay and enniatins in highly contaminated barley grain samples, although the correlation was not confirmed in samples with lower amount of mycotoxins. Similarly, in our previous studies, no correlation was revealed between F. poae DNA and the levels of enniatins in asymptomatic wheat samples with very low levels of enniatins (Kulik & Jestoi, 2009). In this study, Pearson’s correlation analyses were used to determine whether the amounts of esyn1 genotypes were related to the total amount of enniatins. A significant positive correlation was found between the amount of F. avenaceum/F. tricinctum esyn1 genotype (R=0.61, P=0.00001) and the total amount of enniatins (Fig. 1). In the case of F.

0% and 169%, respectively)

There were also some discrep

0% and 16.9%, respectively).

There were also some discrepancies concerning the region of origin: in the cohort, German origin was more common (76.3% and 68.7%, respectively), while patients originating from sub-Saharan Africa and South and South-East Asia were particularly underrepresented. However, a good general correlation with national surveillance data (and hence representativeness at the national level) is the main strength of the ClinSurv HIV cohort compared with another HIV-infected cohort implemented in Germany in 2004, the patient cohort of the German Competence Network Selleck NU7441 for HIV/AIDS (KompNet) [24]. Although KompNet started data collection at 44 sites, because of reduced financing this number had to be reduced and is currently 25 sites. As patient enrolment in KompNet requires informed consent, comparison of the composition of this cohort with the composition of the national German HIV surveillance database reveals significant differences with regard to sex, age and transmission

group category [24]. However, the KompNet cohort collects more variables than ClinSurv HIV. The number of patients enrolled in KompNet HIV decreased from a total of 6817 new annual cases in 2005 to 1147 cases in 2007, while patient enrolment in ClinSurv HIV turned out to be very stable in the long term (Fig. 2). In Germany, Ceritinib clinical trial a growing proportion of HIV-infected patients, especially at early stages of HIV infection, are treated by primary care physicians, who have special training in HIV treatment. They co-operate with the participating clinical

centres if their patients reach advanced disease stages. As the ClinSurv sites are very experienced in HIV treatment, the proportion of patients with advanced clinical stage disease or AIDS may be overrepresented in the cohort, explaining why the cohort is estimated to represent nearly one-third of all patients in HIV stage CDC-C, but only 20% of all PLWHA. In addition to the limited number of variables collected in ClinSurv HIV, another limitation of this cohort study is PTK6 the unequal geographical distribution of sites, which are situated predominantly in the north, north-east and west of the country. However, the study population is surprisingly stable with regard to newly enrolled patients and loss to follow-up, in particular taking into consideration the open observational cohort design. Another advantage is that patients’ informed consent is not needed as the data collection remains under federal law regulations. This makes data collection more representative than in studies requiring informed consent, although the number of variables is more limited. The proportion of ∼11% of patients lost to follow-up seems rather high; however, this number reflects the German situation, where patients, including PLWHA, are free to choose their treating physician when they seek for medical care.

In both cases, the concentration

In both cases, the concentration Selleckchem GSK3 inhibitor of tacrolimus decreased, causing acute rejection, but in case 1 acute rejection was improved by administration of MMF, while in case 2 the lack of administration of MMF resulted in significant reactions that caused ischemia of the

uterus and epithelial detachment, and the effects of acute rejection were not avoided. Therefore, the lack of administration of MMF might have been a cause of the failure to overcome acute rejection, and thus administration of three immunosuppressants, including MMF, may be a favorable protocol for maintenance therapy in future UTx experiments in primate models. In case 1, uterine nutrition was given mainly from the left uterine artery and right ovarian vein, and these vessels and three immunosuppressants facilitated recovery of menstruation. However,

menstruation did not continue despite no subsequent observation of a rejection response. Avasimibe concentration This may be due to insufficient blood flow from the uterine artery to the uterus due to severe adhesion of a region surrounding the uterus. Because heparinized saline was used as perfusate and the ischemic time was 3 h or longer, ischemia–reperfusion injury might have been one of the causes of the failure of recovery of uterine function. However, we also used heparinized saline for cynomolgus monkeys with an ischemic time of 4 h in an examination of autologous transplantation of the uterus, with the result of successful pregnancy and childbirth. Thus, we consider that ischemia–reperfusion injury was not a major cause of the failed recovery of uterine function.[9] However, a protective preservation solution may minimize problems caused by ischemic reperfusion

and further studies of the perfusion solution are required. Studies in humans have shown that uterine myometrial tissue can endure cold ischemia for 6–24 h if stored in protective preservation solution, based on histological findings.[13-15] One advantage of use of cynomolgus monkey as a primate MG-132 research buy transplantation model is that the monkey is physiologically and anatomically similar to humans. Therefore, the results should be meaningful for clinical applications in humans. However, there are also several disadvantages. The body size is the same as human infants and this lengthens the surgery time, the animal cost is significant, and postoperative echo and biopsy require sedation with anesthesia. Also, because the pelvis is highly adhesive after surgery, spontaneous pregnancy is not expected due to adhesive tubal obstruction; therefore, ART is required for pregnancy. Embryo transfer is carried out transvaginally in the uterus in humans, whereas the uterine cervix of the cynomolgus monkey is extremely bent, which makes transvaginal embryo transfer technically difficult.