Time of insemination and its effect on in-vitro fertilization, cleavage and pregnancy rates in GnRH agonist/HMG-stimulated cycles

In this prospective study, we compared the effect of delayed inseminations on fertilization, cleavage and pregnancy rates in two groups of patients. In one group, the ovarian stimulation was performed with a clomiphene citrate/human menopausal gonadotrophin/human chorionic gonadotrophin (CC/HMG/HCG) protocol. The other group was pre-treated with gonadotrophin-releasing hormone agonist (GnRHa) and ovarian stimulation was carried out with an HMG/HCG protocol. Under both protocols, a delay of 2, 4 or 6 h in insemination showed no significant differences in the fertilization, cleavage or pregnancy rates. To find out which type of oocyte has the potential for better fertilization, cleavage and implantation, a simple oocyte classification scheme is proposed. In the GnRHa/HMG group, 9% post-mature, 90% mature and only 1% immature oocytes were retrieved. The post-mature oocytes showed a tendency towards reduced fertilization when insemination was delayed. The mature and slightly immature oocytes fertilized equally well when spermatozoa were added 2, 4 or 6 h after retrieval. Similarly, no significant difference was observed in the cleavage (80%) or fragmentation (20%) rates of these oocytes. The pregnancy rates after inseminations delayed for 2, 4 and 6 h were 14, 27 and 26%, respectively. Though these figures were not statistically significant, the 4- and 6-h groups in both the IVF and zygote intra-Fallopian transfer treatments showed a slightly improved pregnancy rate compared to the 2-h group. An insemination delay of 4 h is advocated on a routine basis.

Splenic enlargement and Traube's space: how useful is percussion?

PURPOSE

The utility of Traube's space percussion in the bedside assessment of splenic enlargement was evaluated. The influence of meals and obesity on this sign were also assessed, because both are believed to interfere with the results of abdominal percussion.

PATIENTS AND METHODS

The inpatient population of a tertiary care hospital was studied where cases and controls were selected according to the results of abdominal ultrasonographic examinations.

RESULTS

Traube's space percussion exhibited a sensitivity of 0.62 (95% confidence interval [CI], 0.51 to 0.71) and a specificity of 0.72 (95% CI, 0.65 to 0.80) when classifying tympanitic examinations as negative. False-positive examinations were reduced by assessing patients more than two hours after mealtime. Obese patients were a source of false-negative examinations.

CONCLUSION

Traube's space percussion compares favorably with other commonly used clinical maneuvers and diagnostic tests. When performed alone in a selected patient population, it adds useful clinical information but is not sufficiently sensitive or specific to obviate the need for further diagnostic testing.

Assisted procreation in the presence of a positive direct mixed antiglobulin reaction test

Twenty-five infertile couples in which the male had antisperm antibodies were treated by in vitro fertilization (IVF), zygote intrafallopian transfer, or gamete intrafallopian transfer in 38 cycles. In 10 females a tubal pathology was present, and in the normal female patients repeated intrauterine insemination with husband sperm had failed. The presence of an andrological factor in 17 male patients did not influence the fertilization and the cleavage of the retrieved oocytes. Although the fertilization rate of 45.8% was significantly lower than in patients with tubal pathology, the pregnancy rate was 34.2% per started cycle and 44.8% per replacement. Furthermore, the embryos were of lesser quality than in couples with tubal and idiopathic infertility. This study suggests that IVF could be considered as a useful therapeutic approach for couples with a positive direct mixed antiglobulin reaction test before advising them the use of heterologous sperm.

Effect of transuterine puncture during transvaginal oocyte retrieval on the results of human in-vitro fertilization

In many in-vitro fertilization (IVF) programmes, the transvaginal approach is now the most widely used method for ultrasound-guided oocyte retrieval. Sometimes, however, the position of the ovaries is such that it might not be possible to aspirate the follicle transvaginally without puncturing the uterine wall. Between May and November 1988, we performed 518 transvaginal, ultrasound-guided oocyte retrievals for IVF or zygote intra-Fallopian transfer (ZIFT). During this period, 22 transuterine punctures (4.2%) were necessary to reach one of the ovaries. To investigate the effect of uterine laceration on the results of IVF/ZIFT treatment, the outcome of treatment was compared between patients who had a transuterine puncture and a control group of patients treated by IVF or ZIFT during the same period without transuterine puncture. Seven of 16 patients who had a transuterine puncture became pregnant after IVF, compared to 84 pregnancies out of 347 cases (24.2%) in the control group. After ZIFT, two pregnancies (2/6) were achieved in patients with uterine laceration, compared to 46 pregnancies out of 149 procedures (30.8%) in the control group. These differences were not statistically significant. Transuterine puncture during transvaginal oocyte retrieval does not seem to have an adverse effect on the results of human IVF and ZIFT treatment.

Zygote intrafallopian transfer as a successful treatment for unexplained infertility

This study describes the zygote intrafallopian transfer treatment in patients with unexplained infertility. After retrieval, the oocytes were inseminated with 80,000 progressive motile sperm cells per milliliter. If fertilization occurred, a maximum of three zygotes were replaced by laparoscopy in the fimbrial end of one healthy fallopian tube. A pregnancy rate of 48.1% per zygote intrafallopian transfer replacement was obtained. Seventeen pregnancies are actually ongoing, two patients delivered, and seven patients miscarried. Even after replacing a maximum of three zygotes, there were 6 twin and 2 triplet pregnancies.

Establishment of 22 pregnancies after oocyte and embryo donation

Donated oocytes inseminated with partner's semen or donated embryos were transferred on 95 occasions in 28 women without ovarian function and in 21 with functional ovaries. Overall, 22 pregnancies were established, 13 after the transfer of fresh embryos and nine after the transfer of frozen-thawed embryos. Eleven of the pregnancies were established in women without ovarian function and 11 in women with functional ovaries. Nine of the pregnancies were established with donated oocytes inseminated with partner's semen and 13 with donated embryos. Fifteen healthy infants were born including one set of twins; three pregnancies are progressing normally and five miscarried.

Performance of different embryo transfer catheters in a human in vitro fertilization program

In a prospective and randomized study on 400 consecutive embryo transfers (ETs), the performance of three different transfer catheters was evaluated. In cases of difficult ET, the TDT catheter (Prodimed, Neuilly-en-Thelle, France) performed the best. However, the pregnancy rate with this catheter was the lowest (9.2%/ET). A better pregnancy rate (19.4%/ET) can be achieved when TDT catheter was used under ultrasound guidance. The Frydman catheter (Prodimed, Neuilly-en-Thelle, France) yielded the highest pregnancy rate (32.3%/ET) but also the highest frequency of difficult transfer procedures. The Wallace catheter (H.G. Wallace Limited, Colchester, England) showed similar performance, but the pregnancy rate was lower (19.2%/ET) compared with the Frydman catheter. Therefore, the Frydman catheter is used as the first choice, and for difficult transfers the TDT catheter under ultrasound guidance can be recommended.

Zygote intra-fallopian transfer as an alternative treatment for male infertility

The results of 42 zygote intra-Fallopian transfer cycles in 37 couples with persistent male infertility are reported. Of 396 retrieved oocytes, 39.1% fertilized normally and 63 zygotes were replaced in 25 cycles. Twelve patients became pregnant, including two twin pregnancies. The pregnancy rate was 28.6% per started cycle and 48.0% per replacement. The implantation rate per replaced zygote was 22.2% (14 of 63 replaced zygotes implanted). Sixty-two supernumerary zygotes or embryos were cryopreserved for later use.

Synchronization of donor's and recipient's cycles with GnRH analogues in an oocyte donation programme

In this oocyte donation programme nine female donors were stimulated using a combination of GnRH analogues and human menopausal gonadotrophins. A total of 149 oocytes were retrieved. Thirty fresh embryos were transferred in 14 uterine replacements, resulting in four pregnancies and 15 fertilized oocytes were placed in the Fallopian tube of six recipients, yielding two pregnancies. A mean number of 2.2 embryos was replaced. The implantation rate per embryo was 13%. Furthermore 36 embryos were cryopreserved for later use. Following 20 replacements, six pregnancies were established (30% per transfer); since two patients aborted, the ongoing pregnancy rate was 20%.

The effect of pneumoperitoneum gases on fertilization, cleavage and pregnancy in human in-vitro fertilization and gamete intra-fallopian transfer

A prospective, randomized study was carried out, creating a pneumoperitoneum with 100% CO2 or with 5% CO2 in air and evaluating the effect(s) of these gas phases on fertilization, cleavage and pregnancy outcome in this in-vitro fertilization and embryo transfer programme. There was no significant difference in the fertilization rate when either 100% CO2 or 5% CO2 in air was used for insufflation during laparoscopy. Further, embryonic development and pregnancy rates also indicated no significant differences between the two groups. Similarly, the oocytes which were retrieved and replaced with spermatozoa in the gamete intra-Fallopian transfer programme using either 100% or 5% CO2, gave similar pregnancy rates. Furthermore, the fertilization and cleavage rates of the supernumerary oocytes were not significantly different in both groups.

Human embryo viability after freezing with dimethylsulfoxide as a cryoprotectant

This study concerns the effects of a slow freezing and thawing protocol using dimethylsulfoxide (DMSO) as a cryoprotectant on the survival and viability of 319 supernumerary human embryos produced after in vitro fertilization. One hundred twenty-one transfers were performed in a natural cycle and 18 pregnancies were achieved (15%), from which 14 were ongoing (12%). Overall, 52% of the thawed embryos retained at least 50% of their initial blastomeres intact after thawing, and were replaced. Survival was strongly correlated to prefreezing embryonic quality, as 78% of type I embryos, 55% of type II, 40% of type III, and none of type IV could be transferred. Implantations were obtained from type I embryos (21% per embryo replaced) and from type II (14.5%), whereas none of the type III embryos resulted in a pregnancy. In the authors' experience, using the DMSO protocol, the best pregnancy rates were achieved when replacing 8-cell embryos of high morphologic prefreezing quality. No statistically significant difference could be demonstrated, however, in implantation rates between 8-cell and 4-cell embryos, or between synchronously and asynchronously dividing concepti.

An 18-month survey of infertility treatment by in vitro fertilization, gamete and zygote intrafallopian transfer, and replacement of frozen-thawed embryos

An 18-month survey of infertility treatment by in vitro fertilization (IVF) and related procedures at the Centre for Reproductive Medicine of the Vrije Universiteit Brussel is described. During this period, 1326 treatment cycles were started in patients with long-standing infertility and 1135 oocyte retrievals were performed in 771 different patients. IVF and embryo transfer (ET) after laparoscopic (N = 793) or ultrasonically guided (N = 342) ovum pickup, gamete intrafallopian transfer (GIFT; N = 284), or zygote intrafallopian transfer (ZIFT; N = 15) combined with IVF as well as the replacement of cryopreserved embryos yielded an overall pregnancy rate of 21.8% per started cycle. Echographic and laparoscopic oocyte retrieval gave similar results except for a higher fertilization rate after echographic-guided retrieval. For in vitro fertilization and embryo transfer an overall pregnancy rate of 26% per transfer was obtained. For GIFT and ZIFT the pregnancy rates were, respectively, 27.8 and 46.7% per replacement. For each procedure one-third of the pregnancies aborted. After the replacement of frozen and thawed embryos, during a natural cycle, a significantly lower fetal loss was observed.

Success rate in gamete intrafallopian transfer using low and high concentrations of washed spermatozoa

The effect of a reduced number of spermatozoa on pregnancies and miscarriages was studied retrospectively in 307 consecutive gamete intrafallopian transfer (GIFT) cycles. The number of spermatozoa introduced per GIFT in each group was as follows: 100,000 (group I), 50,000 (group II), 10,000 (group III), 5,000 (group IV), and 2,500 (group V), which gave a pregnancy rate of 20%, 38%, 37%, 30%, and 24%, respectively (differences were not significant). With respect to the pregnancies, no correlation was found between the number of spermatozoa transferred and the cause of infertility. In the male factor group also no significant difference was observed in the pregnancy rate when the sperms were reduced from 100,000 to 2,500. Lowering the number of sperms in GIFT did not reduce the abortion rate, which remained around 33%. It was the patients with unexplained infertility who benefited most from the GIFT procedure. Their pregnancy rate was significantly higher than the pregnancy rate of those who had endometriosis, or andrologic or immunologic disorders.

Evaluation of different biopsy methods of blastomeres from 2-cell mouse embryos

As an outgrowth of in-vitro fertilization and embryo transfer, detection of genetic and metabolic defects prior to implantation might be possible in the future. The objective for preimplantation diagnosis would be to sample a minimum of cell material of the conceptus for diagnosis prior to transfer. Different protocols for isolating individual blastomeres out of 2-cell mouse embryos were evaluated. 2-cell mouse embryos (from F1 hybrids C57B1 females x CBA males) were collected and the zona pellucida was removed by enzyme treatment (pronase), by exposure to Ca2+-Mg2+-free acid Tyrode (pH = 2.5) or by mechanical force. Individual blastomeres were obtained by exposure to an enzyme (pronase), to a chelating agent (EDTA-glycine mixture), to Ca2+-Mg2+-free PBS or after isolation by mechanical force. The biopsied blastomeres were then cultured in vitro as such or first replaced into a host zona pellucida. Evaluation was performed by culture in vitro up to the blastocyst stage and by transfer of embryos appearing morphologically normal into pseudopregnant foster mothers. A chromosomal study of the second mitotic division of the isolated blastomere was also performed. All isolation procedures had a negative impact on the in-vitro and in-vivo growth patterns of the isolated blastomeres. After culture in vitro to the blastocyst stage, different abnormalities could be observed: embryos lacking compaction, embryos with double blastocoelic cavities and embryos with no inner cell mass (trophoblastic vesicle). After replacement of the isolated blastomeres into a host zona pellucida, similar observations could be made. Chromosomal analysis did not reveal a clear influence of the different biopsy methods on the mitosis of the isolated blastomeres.

Hormonal monitoring for in-vitro fertilization and related procedures

Details of the endocrine monitoring of patients during in-vitro fertilization are analysed. Hormones usually measured are 17 beta-oestradiol, FSH, LH, progesterone and HCG. The assays must be rapid, robust, and have satisfactory precision and reproducibility. Radioimmunoassays have become standardized but immunoradiometric assays are being introduced, where the antibodies can be more easily labelled than antigens, but need care with very high concentrations of antigen. Enzyme immunoassays also have advantages: they are less hazardous than radioimmunoassays and the labelled materials have longer shelf-lives. Chemiluminescence has also been introduced, together with time-resolved fluoroimmunoassays, representing simpler, perhaps cheaper and improved methods. Immunoassays by latex particle counting offer the advantage of being completely automated. Practical examples of these methods are given with details of the treatment of individual patients.

Embryo donation in patients with primary ovarian failure

Thirty-six infertile patients with primary ovarian failure, who were referred for oocyte (embryo) donation are reported. After substitution therapy with oestradiol valerate (per os) and progesterone (i.m. or per os), endometrial tissue was made receptive for embryonic implantation, although the endometrial biopsies on day 21 demonstrated a certain delay in development (of 1.6-2.4 days). Six patients became pregnant, three of them delivered four healthy babies, one pregnancy is progressing normally and two ended in an early clinical abortion.

Hyperstimulation: the need for cryopreservation of embryos

Successful application of in-vitro fertilization (IVF), zygote intra-Fallopian transfer (ZIFT) and gamete intra-Fallopian transfer (GIFT) requires ovarian hyperstimulation for the maturation of multiple follicles. To control the risk of multiple pregnancies, the number of gametes (GIFT) or embryos (IVF, ZIFT) replaced is limited to three. For the supernumerary embryos resulting from IVF, ZIFT or GIFT, the strategy is cryopreservation for a later transfer. Cryopreservation was performed using either dimethylsulphoxide or 1,2-propanediol as a cryoprotective agent. Embryos were frozen either in the pronucleate stage with 1,2-propanediol or in the multicellular stage with dimethylsulphoxide or 1,2-propanediol. Survival after thawing was scored for both cryoprotective agents as a function of the developmental stage of the embryo and the embryonic quality. Evaluation of survival after thawing was performed on the basis of morphological intactness of the 1-cell pronucleate embryo or of the blastomeres of multicellular embryos. For pronucleate stage embryos, the use of 1,2-propanediol resulted in a 60% survival after thawing. For 2-cell stage embryos the survival was similar for dimethylsulphoxide and 1,2-propanediol. Later stage embryos survived better when dimethylsulphoxide was the cryoprotectant. For all stages, embryo quality before freezing was a crucial factor in survival after thawing. The pregnancy rate (12.2%) was similar for the two cryopreservation protocols. In conclusion, the choice of an appropriate cryoprotective agent can increase the survival after thawing when embryos are of good quality before freezing.

Addition of Buserelin to human menopausal gonadotrophins in patients with failed stimulations for IVF or GIFT

The combined therapy of a gonadotrophin-releasing hormone agonist (GnRHa) D-Ser(TBU)6-EA10-LHRH (Buserelin) and human menopausal gonadotrophins (HMG) for ovarian stimulation for in-vitro fertilization and gamete intra-Fallopian transfer was evaluated during 84 cycles. All women selected for this therapy had previously failed stimulations with clomiphene citrate/HMG. The GnRHa prevented spontaneous luteinizing hormone surges and premature luteinization in all patients. After addition of the agonist to HMG, the cancellation rate dropped from 17 to 7% and improved the results in 72.6% of the cycles. Twenty-six per cent of the started cycles resulted in a pregnancy. Eighteen healthy children were born at term.

Inhibition of gonadotropic and ovarian function by intranasal administration of D-Ser (TBU)6-EA10-LHRH in normo-ovulatory women and patients with polycystic ovary disease

We investigated the effectiveness of D-Ser (TBU)6-EA10-LHRH (Buserelin) intranasally 600 micrograms/day given 6 times daily in desensitizing normal ovulatory women and patients with polycystic ovarian disease (PCOD) before initiation of ovarian stimulation for in vitro fertilization. We found that this regimen was sufficient to suppress the gonadotrophs in the normal women and in 8 out of 10 PCOD patients. In PCOD ovarian hormones became normal after Buserelin administration. Adrenal steroidogenesis was not affected by the GnRH agonist. We suggested that the frequency of administration of Buserelin was important to achieve a constant receptor binding and consequently a rapid desensitization. The choice of a monoclonal immunoradiometric assay for luteinizing hormone (LH) and follicle stimulating hormone (FSH) in association with the estradiol-benzoate provocation test were essential in evaluating desensitization.

Oocyte donation in patients without ovarian function

The clinical, hormonal and cytogenetic findings in 36 women with primary ovarian failure, referred for oocyte or embryo donations are reported. Fifteen women were suffering from ovarian dysgenesis and 11 from premature menopause. Six of these 26 patients showed X-chromosome abnormalities. One patient had a Noonan syndrome. The remaining 10 had surgical menopause. The mean duration of their infertility was 6.5 +/- 3.2 years (+/- SD). All patients had elevated serum gonadotrophins within the menopausal range. Hypothalamic, pituitary and thyroid function were found to be intact. In one of the 15 ovarian biopsies on the patients with chromosomal competent ovarian failure, primordial follicles were found. Hysterosalpingograms revealed a normal uterine cavity in all patients. In view of oocyte donation, careful evaluation of the obstetric risk was mandatory in the six patients with X-chromosome aberrations and in the patient with the Noonan syndrome, because of their short stature and possible concomitant cardiovascular and renal disease. After substitution therapy with oestradiol valerate and natural progesterone, 13 pregnancies were established, seven patients delivered (one set of twins), eight healthy children were born, three pregnancies aborted and three pregnancies are progressing normally.

Occupational and residential 60-Hz electromagnetic fields and high-frequency electric transients: exposure assessment using a new dosimeter

One problem that has limited past epidemiologic studies of cancer and exposure to extremely low-frequency (0-100 Hz) electric and magnetic fields has been the lack of adequate methods for assessing personal exposure to these fields. A new 60-Hz electromagnetic field dosimeter was tested to assess occupational and residential exposures of a group of electrical utility workers and a comparison background group over a 7-day period. Comparing work periods only, utility workers' exposures were significantly higher than background levels by a factor of about 10 for electric (E) and magnetic (B) fields and by a factor of 171 for high-frequency transient electric (HFTE) fields. When overall weekly time-weighted averages combining work and nonwork exposures were compared, ratios of the exposed to background groups were lower. B and HFTE exposure ratios remained statistically significant, with values of 3.5 and 58, respectively, whereas the electric field exposure ratio was no longer significant, with a value of 1.7. E-field exposures of the background group were the highest during the nonwork period, probably reflecting the use of electrical appliances at home. Residential E- and B-field exposures were in the same range as published results from other surveys, whereas occupational E-field exposures tended to be lower than exposures reported in other studies. The high variability associated with occupational exposures probably accounts for the latter discrepancy. Worker acceptance of wearing the dosimeter was good: 95% of participants found it to be of little or no inconvenience while at work. At home, 37% found the device to be inconvenient in its present form but would not object to wearing a slightly smaller and lighter dosimeter.