Life table analysis of pregnancy rates in a general infertility population relative to ovarian reserve and patient age

This study evaluated the impact of age and ovarian reserve status on cumulative pregnancy rates. Approximately 1200 women from a general infertile population underwent ovarian reserve screening with the clomiphene citrate challenge test in the first few months of their initial evaluation. All patients then underwent a thorough infertility evaluation with therapy appropriate for their specific diagnoses. Patients with evidence of tubal disease, peritoneal adhesive disease, or male factor were eliminated. The 588 remaining patients were evaluated based on their age and ovarian reserve status, and their long-term pregnancy rates were compared using life table analyses. There was a dramatic decrease in pregnancy rates associated with an abnormal clomiphene citrate challenge test which was uniformly poor independent of age. Patients with normal ovarian reserve had much higher pregnancy rates, but a significant age-related decline in pregnancy rates was clearly identified. We conclude that women with evidence of diminished ovarian reserve have uniformly poor pregnancy rates independent of their age, but that age remains an important prognostic factor among those with a normal ovarian reserve. The combined use of maternal age and ovarian reserve screening should be used when counselling individual patients regarding their long-term prognoses for conception.

Mock embryo transfer with a full bladder immediately before the real transfer for in-vitro fertilization treatment: the Birmingham experience of 113 cases

The technique of embryo transfer can have a great impact on the outcome of in-vitro fertilization (IVF) treatment. Transcervical embryo transfer is a blind procedure and difficulty can unexpectedly arise. Many IVF programmes therefore perform a 'mock' embryo transfer prior to the treatment cycle to determine the most suitable catheter and technique for transfer. This, however, adds an extra separate procedure with time and cost implications. Moreover, as the uterus is mobile, its direction may vary on the day of the embryo transfer from what it was during the mock embryo transfer. Performing mock embryo transfer immediately before the real transfer would circumvent these problems. We report here on 113 embryo transfer procedures where a 'step-wise' mock embryo transfer protocol was performed with a full bladder immediately before the embryo transfer. The number of embryos transferred (mean +/- SD) was 2.6 +/- 0.67, the pregnancy rate per embryo transfer was 45.1%, and the intrauterine implantation rate per embryo transferred was 20.6%.

Clinical performance of the TCu 380A and Lippes Loop IUDs in three developing countries

The clinical performance of the Copper T 380A (TCu 380A) and the Lippes Loop intrauterine devices (IUDs) were evaluated for 12 months in a group of 710 women who had one of the two IUDs inserted. Results are from a randomized clinical trial conducted at three collaborating research sites located in three developing countries. The gross cumulative life-table pregnancy rate of the TCu 380A IUD was found to be lower than that of the Lippes Loop IUD at 12 months (0.7 and 2.1 per women, respectively). Although this difference was not statistically significant (p = 0.25), it is similar to findings from other studies. The 12-month cumulative removal rate due to personal reasons was significantly different (1.4 and 0.0, respectively, p = 0.05). Statistically significant differences between the two study IUDs were not found with regard to IUD expulsion or IUD removal due to bleeding/pain, medical reasons, planned pregnancy or investigator's choice. A statistically significant difference (p = 0.03) was observed in the number of TCu 380A IUD users experiencing dysmenorrhea (26.1%) during the 12-month study period, compared to Lippes Loop IUD users (18.8%).

Human embryo implantation following in-vitro fertilization: is there a seasonal variation?

The purpose of this study was to determine whether there is a seasonal variation in implantation and pregnancy rates following natural cycle replacement of cryopreserved embryos. A total of 321 consecutive cycles were analysed. There were 59 pregnancies (18.4%) and 48 live births or ongoing pregnancies (15.0%). Indicator variables for each month and variables representing temporal cycles of 12, 6, 4, 3 and 2 months were related to outcome. In addition, an analysis of periodicity was performed. No temporal, clinical or demographic variable was significantly related to pregnancy. This study indicated that there was no clear seasonal variation in the pregnancy rate following natural cycle replacement. However, the power of this study was low, and it was estimated that 963 subjects would be required to detect a 10% seasonal difference in pregnancy rates.

When is the post-coital test normal? A critical appraisal

A systematic review was conducted of published studies, which related post-coital test (PCT) results to pregnancy, to evaluate the predictive power of the test and determine a definition of abnormality that yielded the best test properties. Well defined test results and valid outcome data for women attending fertility clinics were present in 11 out of 53 published reports relating to a total of 3093 women. The predictive values of normal and abnormal PCT were 0.37-0.92 and 0.58-0.85 respectively. Sensitivity was 0.10-0.90 and specificity 0.30-0.97. Likelihood ratios for normal and abnormal PCT were 0.77 and 1.85 respectively. When criteria for normality were set at a lower number of motile spermatozoa per field, sensitivity decreased with an increase in specificity and likelihood ratio for an abnormal test result. The discriminating ability of the PCT is poor, and altering definitions of normality hardly enhances its predictive power. As long as the value of the PCT for the assessment and treatment of so-called 'cervical factor infertility' remains unclear, a cut-off point with high specificity and a high likelihood ratio for an abnormal test result is recommended. Hence, an abnormal PCT is best defined as less than one motile spermatozoon per high power field.

Natural cycles for in-vitro fertilization: cost-effectiveness analysis and factors influencing outcome

Improvements in oocyte culture technique, sperm preparation, oocyte retrieval method and ovarian stimulation regimens have produced higher pregnancy rates with in-vitro fertilization (IVF) treatment. However, because ovarian stimulation is expensive and not without risk, there is increasing interest in the option of using natural cycles for IVF. This study was performed to document the experience and outcome in 240 natural cycles. Cancellation occurred in 28 cycles (12%), and LH surge was observed in 56 (23%), leaving 156 (65%) cycles which progressed to oocyte retrieval. No oocytes were retrieved in 26 cycles. Among the successful oocyte retrievals, the majority yielded one oocyte. There was no evidence of fertilization in 26 cases, and triploid fertilization was observed in 12 cases. Embryos suitable for transfer were available in 92 cycles in which 11 (12%) clinical pregnancies were confirmed. Despite the high failure rate at each step in the process, natural cycles are more cost-effective than stimulated cycles which incur an incremental cost per live birth of $48,000. Natural cycles offer a low-cost alternative that may be more accessible to patients.

Sperm morphology using strict criteria after Percoll density separation: influence on cleavage and pregnancy rates after in-vitro fertilization

The main purpose of the study was to evaluate the use of sperm morphology assessment by strict criteria on the post-Percoll separated spermatozoa used for oocyte insemination in an in-vitro fertilization programme. This study included a consecutive unselected series of 213 oocyte aspirations in 159 women. In 177 aspirations the patient had tubal infertility and in 36 unexplained infertility. Data have been analysed from 197 aspirations where the semen sample used for insemination had a normal sperm concentration (> or = 20 x 10(6)/ml). A total of 1413 oocytes were aspirated, resulting in 863 oocytes which were fertilized and cleaved (cleavage rate 61%). In all, 492 pre-embryos were transferred in 193 cycles, resulting in a pregnancy rate of 42% per transfer. Sperm morphology evaluation using strict criteria showed that Percoll separation significantly increased the percentage of sperm cells with normal morphology from 7.7 to 11.3%. Sperm morphology analysis showed that Percoll separation decreased the number of sperm samples in the 'poor prognosis pattern' group from 31 to 13% and increased the number of sperm samples classified as 'normal' from 16 to 33%. After Percoll separation the poor prognosis pattern group had a cleavage rate of 46%, which was significantly lower than in the good prognosis pattern and the normal groups. However, the poor prognosis pattern group had a significantly higher pregnancy rate than the normal group (P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Strategies in frozen donor semen procreation

Data were analysed from 710 couples who had been assessed to determine the effectiveness and the drawbacks of three different methods of insemination using frozen donor semen. Intracervical insemination (ICI) was the first method used when the women had no tubal disorder: 255 pregnancies were achieved in a total of 2558 cycles (10%). Intrauterine insemination (IUI) associated with ovarian stimulation resulted in 152 pregnancies over 966 cycles (16%). In-vitro fertilization (IVF) was proposed after approximately 12 insemination failures using either of the other methods or when the initial gynaecological examination had revealed abnormalities such as tubal occlusions; 48 pregnancies were obtained in 262 cycles (18.3%). The pregnancy rate using ICI was significantly higher when two inseminations were performed per cycle, compared with one insemination per cycle (12.3 versus 7%, P < 0.001). The number of motile spermatozoa per straw was correlated with the pregnancy rate when using ICI, rising from 9% with < 4 x 10(6) motile spermatozoa to 13.8% with 4-8 x 10(6) and 17.2% with > 8 x 10(6). No relationship was found between the number of motile spermatozoa and the pregnancy rate using IUI and IVF. The incidence of primary ovulatory disorder was higher among women whose husbands were oligozoospermic than among those whose husbands were azoospermic (19 versus 9%, P < 0.01), but ovarian stimulation improved the fecundity of subfertile women. The outcome of pregnancies was also analysed for the three methods. From these data, strategic plans have been proposed to maximize the pregnancy rate for women undergoing therapeutic donor insemination with frozen semen.

Production of twin calves with in vitro fertilised embryos: effects on the reproductive performance of dairy cows

Attempts were made to produce twin calves by implanting in vitro fertilised and matured (IVF) embryos into dairy cows. Twinning rates were consistently at the lower end of the range reported to have been obtained with in vivo derived embryos. The low pregnancy rates, higher than expected early embryonic losses, and increased fetal deaths and abortions recorded may indicate that IVF embryos are less viable. Fetal oversize in single calves was a significant problem in the first two years of the trial. The subsequent conception rates of cows that calved twins and those that calved singles were similar in spite of a much higher incidence of retained placenta and an increased interval to first oestrus in the cows bearing twins.

Follow-up of women seeking sterilization reversal: a Brazilian experience

OBJECTIVE

To analyze the follow-up of a cohort of women who requested reversal of surgical sterilization.

METHODS

This retrospective study was carried out at the State University of Campinas, Brazil. A cohort of 394 women who requested sterilization reversal was followed up for one year after reversal surgery. The analysis includes the percentage of women who completed the steps between the initial consultation up to one year after reversal surgery.

RESULTS

After an initial consultation, 55.1% of the patients decided not to continue with the procedures. Of the patients who did undergo laparoscopy (n = 177), 48.6% had no possibility of a successful surgical reversal because the Fallopian tubes were in very poor condition. Only 17.5% of the initial patients requesting reversal ultimately underwent surgery and 3.3% became pregnant.

CONCLUSIONS

The analysis of regret about surgical sterilization should include not only women who undergo surgery but also women requesting surgery. Better patient selection and counseling prior to sterilization are necessary in order to prevent increasing rates of sterilization regret in Brazil.

The frameless GyneFix intrauterine implant: a major improvement in efficacy, expulsion and tolerance

The CuFix (GyneFix), conceived in 1985, was developed to minimize three major problems frequently associated with discontinuation of IUD use: expulsion, bleeding and pain. Since the initial clinical investigations, over 10,000 woman years of experience and up to 8 years of follow-up in international multicenter, non-comparative and comparative clinical trials, including a large proportion of nulligravid/nulliparous women, have been collected. Based on new clinical information about the GyneFix from a long-term multicenter clinical trial, conducted in young nulligravid/nulliparous and parous women, the importance of this new contraceptive is discussed. The following conclusions were reached: The unique design characteristics of the GyneFix (frameless, flexible and fixed to the fundus of the uterus) have resulted in optimal tolerance and almost complete absence of expulsion. The result is enhanced effectiveness (comparable to OCs and male/female sterilization) and a high rate of continued use. The GyneFix reduces the IUD failure rate to a minimum and is, therefore, a welcome reversible alternative to OCs and female surgical contraception. Framelessness and flexibility explain the absence of side-effects and adverse events caused by dimensional incompatibility between the frame of conventional IUDs and the uterine cavity and may also explain the absence of PID and ectopic pregnancies in any of the clinical studies. The GyneFix is a promising new, highly effective and safe, contraceptive option for parous women and an equally effective and well-accepted method for nulliparous women.

Evaluation of different ovarian stimulation protocols for in vitro fertilization

In this study we evaluated retrospectively the efficacy of five different ovarian stimulation protocols in an in vitro fertilization program, in which 512 women were involved. Ovulation was induced by the following protocols: group I (271 cycles): buserelin short protocol (1 mg/day, intranasally) with human menopausal gonadotropin/human chorionic gonadotropin (hMG/hCG); group II (45 cycles): buserelin (short protocol) with pure follicle stimulating hormone (p-FSH)/hMG/hCG; group III (24 cycles): clomiphene citrate (100 mg/day) with hMG/hCG; group IV (122 cycles): hMG (3 ampules/day) and hCG; group V (113 cycles): hMG/hCG and prednisolone (7.5 mg/day) after cycle programming with oral contraceptives. The lowest cancellation rate (3.3%) was noted in group I, followed by group V (9.7%). The highest number of follicles was observed in groups I (8.3 +/- 0.3; mean +/- SEM) and V (7.8 +/- 0.5). Also, more oocytes were retrieved in group I (7.2 +/- 0.3, p < 0.001), which were of good quality based on oocyte maturity as well as on the fertilization rate, and more embryos (4.5 +/- 0.3, p < 0.05) were developed. The correlation between estradiol and the total follicular volume on the day of hCG administration was also examined in the five groups. The best correlation (r = 0.6502) was found in group I, followed by group V (r = 0.5810). Significant differences were observed in the five groups with regard to the number of hMG ampules administered (p < 0.0001, F = 15.393) and the stimulation days (p < 0.0001, F = 35.32). Sixty-six clinical pregnancies were achieved: 37 (17.5%) in group I, seven (25.9%) in group II, one (10%) in group III, ten (15.6%) in group IV and 11 (15.5%) in group V (differences were not statistically significant). In conclusion, all five protocols were satisfactory in ovarian stimulation for in vitro fertilization, and gonadotropin releasing hormone (GnRH) analogs seemed to be more advantageous by reducing the cancellation rate, enhancing the number of oocytes retrieved and embryos developed and by improving the pregnancy rates.

Long oestradiol replacement in an oocyte donation programme

The objective of this study was to optimize, in terms of endometrial receptivity (embryo implantation), the limits of unopposed administration of oestrogens beyond 35 days in an in-vitro fertilization (IVF) and ovum donation programme. Oocytes donated by 182 women undergoing IVF were distributed among 186 women treated by ovum donation. Five groups of recipients were established according to the duration of oestradiol valerate administration, in a 'prolonged follicular phase' protocol, before embryo replacement, employing oestradiol valerate at increasing doses up to 6 mg/day. Gonadotrophin-releasing hormone analogues (GnRHa) were simultaneously administered in ovulatory patients. The dosage of oestradiol valerate was maintained until oocytes were available for insemination and subsequent transfer. Donors and recipients were equally distributed among groups in terms of age and cause of infertility. There was no difference among groups in serum oestradiol concentration the day in which progesterone was added to obtain a secretory transformation of the endometrium. An analysis of the ovum donation cycles showed no difference among groups in pregnancy and implantation rates after the replacement of a similar number of embryos. Successful implantation was observed even after 100 days of unopposed oestradiol valerate administration. Break-through bleeding increasingly appeared according to the duration of oestrogen replacement. These clinical observations provide evidence that the concept of 'prolonged follicular phase' oestrogen replacement for ovum donation can be maintained, at least as long as 15 weeks. However, because of the high (> 44%) incidence of break-through bleeding after 9 weeks, it is advisable to stop oestrogen treatment at this point.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential impact on pregnancy rate of selective salpingography, tubal catheterization and wire-guide recanalization in the treatment of proximal fallopian tube obstruction

A total of 66 patients with proximal Fallopian tube (113 tubes) obstruction, as diagnosed by both laparoscopy and hysterosalpingogram, were each subjected to a transcervical recanalization procedure sequentially using selective salpingography followed, if necessary, by tubal catheterization with a soft Teflon 2-French catheter and finally, if needed, wire-guide cannulation. Each procedure were terminated once patency had been achieved without recourse to the next technique. Bilateral obstruction was present in 47 patients and unilateral in 19 patients. Patency was achieved in 39 (34.5%) Fallopian tubes by selective salpingography alone, in 52 (46.0%) by tubal catheterization and in 10 (8.9%) by wire guide, with 12 (10.6%) tubes remaining obstructed. Pregnancy occurred in 24 (36.4%) patients without recourse to other treatment (mean follow-up, 17 months). Where patency was achieved (59 patients), 19 out of 43 (44.1%) of those treated for bilateral obstruction and five out of 16 (31.3%) of those treated for unilateral obstruction achieved a pregnancy. Pregnancy occurred in six out of 22 patients (27.3%) where selective salpingography was used to produce tubal patency, in 17 out of 30 patients (56.7%) where tubal catheterization was used and in one out of seven (14.3%) where a wire guide was used, which was an ectopic pregnancy. The difference between the ongoing pregnancy rates following tubal catheterization (50.0%) and wire-guide cannulation (0.0%) was significant (P = 0.033). While wire-guide cannulation is the most effective method used to achieve tubal patency, these results indicate that when it is truly necessary, as opposed to electively used by clinicians, the prognosis with regard to pregnancy is poor and alternative therapy such as microsurgery or in-vitro fertilization should be considered early.

Use of GnRH analog for induction of the ovulatory surge of gonadotropins in patients at risk of the ovarian hyperstimulation syndrome

A total of 32 patients undergoing in vitro fertilization (IVF) and 16 treated for ovulatory disturbances were stimulated with clomiphene citrate and human menopausal gonadotropin. Gonadotropin releasing hormone (GnRH) analog was used for induction of the ovulatory surge of gonadotropins, because of the risk of ovarian hyperstimulation syndrome. In four patients after IVF-embryo transfer and four patients after ovulation induction, single pregnancies were obtained. None suffered from ovarian hyperstimulation syndrome. The authors suggest that the use of GnRH analog for induction of the gonadotropin ovulatory surge prevents the development of ovarian hyperstimulation syndrome.

Randomized controlled trial of follicle stimulating hormone versus human menopausal gonadotrophin in in-vitro fertilization

The adverse effect of raised luteinizing hormone (LH) concentrations on reproductive outcome suggests that exogenous LH administration for ovarian stimulation may not be desirable. The aim of this study was to compare the clinical pregnancy rates between follicle stimulating hormone (FSH) and human menopausal gonadotrophin (HMG) used in in-vitro fertilization (IVF) cycles. A total of 232 infertile patients, with a mean duration of infertility of 67.1 +/- 32.9 months, were selected for IVF (female age < 38 years, FSH < 15 IU/l, and total motile sperm count > 5 x 10(6)). A short (flare-up) protocol with daily leuprolide acetate was followed randomly from day 3 with FSH (n = 115) or human menopausal gonadotrophin (HMG; n = 117), at an initial dose of two ampoules per day. A maximum of three embryos was transferred, and the luteal phase was supported with four doses of HCG (2500 IU). No differences were observed between the two groups in any of the cycle response variables except fertilization rates per oocyte and per patient, both of which were significantly higher with FSH. Clinical pregnancy rates per cycle initiated, per oocyte retrieval and per embryo transfer were 19.1, 21.0 and 22.7% respectively for FSH, and 12.0, 12.8 and 15.4% respectively for HMG. Whilst these differences were not statistically significant, the results of this interim analysis suggest that HMG may be associated with a lower clinical pregnancy rate than FSH.

Decreased incidence of severe ovarian hyperstimulation syndrome in high risk in-vitro fertilization patients receiving intravenous albumin: a prospective study

The administration of human serum albumin has been reported to prevent severe ovarian hyperstimulation syndrome (OHSS) while undergoing ovarian stimulation protocols for in-vitro fertilization (IVF). This prospective, randomized study investigated the effectiveness of a single dose of human serum albumin (20 g) administered i.v. immediately after oocyte retrieval. Women enrolled in the IVF programme were treated with long gonadotrophin-releasing hormone agonist, triptorelin, and an individually-adjusted human menopausal gonadotrophin protocol. The criteria for inclusion in the study were young age, non-obesity, oestradiol concentration > 9200 pmol/l on the day of human chorionic gonadotrophin administration and > 20 follicles > 14 mm diameter as observed by transvaginal sonography. The treatment group (n = 22) received albumin while the control group (n = 18) did not. Patients were followed-up using ultrasound every 3 days. There was a significantly higher number of severe OHSS cases in the control group (n = 4) than in the treatment group (n = 0) (P = 0.035). Where the data base was restricted to patients with an oestradiol concentration > 15,000 pmol/l, the difference between control and treatment groups was highly significant (P = 0.008). These findings support the use of i.v. albumin in preventing severe OHSS during IVF treatment.

Uterine vascularity during stimulation and its correlation with implantation in in-vitro fertilization

The changes in uterine artery blood flow in women undergoing in-vitro fertilization cycles were studied throughout stimulation after gonadotrophin-releasing hormone (GnRH) desensitization. The data obtained showed that the uterine vascularity was related to hormonal changes. The GnRH agonist effect was seen only after the third week of administration, and the uterine perfusion was significantly (P = 0.002) improved by the oestradiol secretion. Human chorionic gonadotrophins increased the resistance index (RI) significantly (P = 0.0001) for a period of 48 h. Then the progesterone secretion modified the curve with a significant improvement in the uterine blood flow (P = 0.03). Comparison of the RI value 2 days before human menopausal gonadotrophin (HMG) commencement, in patients with and without pregnancy, showed a higher RI in patients who did not conceive but no difference was observed on the day of embryo transfer. The pregnancy rates were similar whatever the range of the RI observed. The data available so far suggest that haemodynamic parameters alone, detected by Doppler sonography, do not provide full information on endometrial receptivity on the day of embryo transfer. A resistance index > 0.79 before HMG commencement seems to indicate poor uterine vascularity and may necessitate an increase in the HMG doses to prevent endometrial immaturity.

Medical management should be routinely used as primary therapy for ectopic pregnancy

It does not appear that methotrexate can or should be used to totally replace laparoscopic salpingostomy. However, given its success rate in selected patients, its cost-effectiveness, and its low incidence of side effects, methotrexate therapy certainly can be used as an alternative therapy. The next step in developing this treatment option will be to conduct a randomized clinical trial comparing laparoscopic salpingostomy with intramuscular methotrexate. This type of study will answer questions regarding the patient's health related quality of life and economic impact of the two treatment modalities. For now, it seems prudent to offer methotrexate to those patients with an unruptured ectopic gestational mass 3.5 cm or less in greatest dimension.

A cohort study of Norplant implant: side-effects and acceptance

OBJECTIVES

Menstrual irregularity is the main cause of termination of Norplant use; a study of its safety and level of acceptance is needed.

STUDY METHODS

A cohort study using medical records of Dr Kariadi Hospital, Semarang, Indonesia and interviews between Norplant and IUD users who had in 1993 been followed-up for 5 years. Expulsion rate, removal rate, level of acceptance and satisfaction were examined.

RESULTS

From 170 Norplant and 168 IUD acceptors, the net cumulative pregnancy rates by month 36 of the Norplant and the IUD groups were 0.0% and 1.19%, respectively (p > 0.05). The net cumulative expulsion rates were 0.61% and 1.32% (p > 0.05). The net cumulative rates of removal for medical reasons were 2.37% and 1.97% (p > 0.05). The net cumulative removal rates for non-medical reasons were 1.80% and 10.38% (p < 0.001); the net cumulative continuation rates were 95.29% and 85.60% (p < 0.002). The net cumulative acceptance rates were 97.04% and 93.83% (p > 0.05). The Norplant users experienced less menstrual and inter-menstrual bleeding and more amenorrhea than the IUD group. The psychological satisfaction scores among the Norplant and IUD users were high (p > 0.05). The Norplant contraceptive is well accepted.

CONCLUSIONS

The findings could be very useful for further steps in promoting Norplant as a contraceptive that is long-acting, with good efficacy, acceptance, and safety.

Sexual behavior of natural family planning users in Germany and its changes over time

For 10 years, a prospective study has been taking place in Germany to examine the use of natural family planning (NFP). As natural methods are behavioral methods, use-effectiveness, acceptability and continuation rates are very much influenced by patterns of sexual behavior. Therefore we performed an analysis of the sexual behavior of NFP users. Out of the data base of 1211 clients and 12,591 cycles we could identify a group of 300 women, all NFP beginners, with 5900 contraceptive cycles, who contributed at least 12 cycles with reliable recording of their sexual activity. Different groups were analyzed with methods of analysis of variance and regression models to find out significant differences in their sexual behavior with respect to sociodemographic structure and time of use. Nearly half of all the women systematically combine the fertility awareness part of NFP with other family planning methods. They use barriers in more than 60% of their cycles. The other half never or only in about 7% of their cycles use additional barrier methods. The latter show a clear decrease in barrier use in the course of time, whereas the frequent barrier users constantly combine the advantages of two family planning methods. Regarding the frequency of intercourse they are the sexually more active ones and show distinct sociodemographic characteristics. We could confirm the existence of three groups of NFP users, which differ significantly in their use of NFP as a family planning method. Despite these differences the low pregnancy rates indicate the conscious and risk-related sexual behavior of the group members.

Do the suppression criteria in GnRH-a cycles predict in vitro fertilization outcome?

The addition of gonadotropin releasing hormone analog (GnRH-a) to controlled ovarian hyperstimulation regimes has been reported to have several advantages, such as reduced cancellation rate, fewer premature luteinizations and increased clinical pregnancy rate. The aim of this study was to determine the effect of pituitary/ovarian suppression, in terms of the levels of luteinizing hormone (LH), estradiol and follicle stimulating hormone (FSH), and the duration of GnRH-a administration, on in vitro fertilization (IVF) outcome. Retrospectively, 153 IVF cycles with GnRH-a and human menopausal gonadotropin (hMG) were examined. After a minimum of 10 days of GnRH-a administration, the patients were started on hMG. The correlations were investigated between the fertilization rates, the numbers of retrieved oocytes and transferred embryos, the cancellation rates, the suppressed LH, FSH and estradiol levels, the total ampules of hMG used and the duration of GnRH-a usage. The duration of GnRH-a usage and the total ampules of hMG used were not correlated. The number of oocytes retrieved and total number of hMG ampules used showed weak correlations with suppressed levels of FSH (-0.297 and 0.285, respectively). However, the fertilization, cleavage and pregnancy rates did not correlate with the LH, FSH and estradiol levels on hMG start days. In conclusion, for selected cases, 10 days of GnRH-a administration is sufficient to suppress endogenous gonadotropin levels. Since FSH and LH are protein hormones and their bioactivity may change in a manner that is unrelated to their immunological levels, it is not necessary to measure FSH, LH and estradiol levels to detect whether suppression is adequate.

Influence of nocodazole on the development of donor blastomeres from 16-cell stage bovine embryos in nuclear transfer

The aim of the present study was to establish a reliable procedure with nocodazole treatment for the synchronous cleavage of blastomeres of bovine embryos used as nuclear donors for nuclear transfer. Sixteen-cell stage embryos derived from in vitro-maturation, fertilization and culture were used. In three initial experiments, embryos were incubated in mTCM-199+FCS with various concentrations (0-20 microM) of nocodazole under 5% CO2 in air. The concentrations required to arrest the blastomeres in the mitotic phase were examined. The effects of 10 microM nocodazole were also examined by observation of the division rate of blastomeres after the removal of nocodazole. Ninety percent (90%) of the blastomeres were arrested in the mitotic phase when embryos were exposed to 10 and 20 microM nocodazole. Exposure to 10 microM nocodazole had the highest blastomere-cleavage rate (47%). When the exposure period to 10 microM nocodazole was prolonged to 36 hr, the division rate of the blastomeres decreased. Furthermore, the effects of 2 culture conditions (mTCM-199 under 5% CO2 in air vs modified synthetic oviduct fluid medium under 5% CO2, 5% CO2 and 90% N2) were compared on the division rate of blastomeres of embryos exposed to 10 microM nocodazole for 12 hr. When the embryos were exposed to nocodazole in mSOF, the division rate of blastomeres was improved to about 60%. The blastomeres produced by this treatment condition were used as nuclear donors and the developmental potential of the reconstituted embryos was investigated. The developmental rate to the blastocyst stage was 30.1% (58/193). Five embryos were transferred to 5 recipient cows and 2 of the 5 recipients (40%) became pregnant. Subsequently, one normal calf was born.

Influence of endometrial cysts on conception rate of mares

A total of 259 normally fertile mares were examined gynecologically by means of rectal palpation and ultrasonography in order to record the presence of uterine cysts and pregnancy. The incidence of endometrial cysts was 22.4%. Of the 95 cysts observed during the trial, 87.4% were located in the middle and posterior segments of both uterine horns. The size of all endometrial cysts ranged between 3 and 48 mm. When all mares were assigned to three age groups, A < 7 years (n = 116), B 7-14 years (n = 117) and C > 14 years (n = 26), a significant (P < 0.01) increase in the number of endometrial cysts was observed with advancing age (4.3%, 29.1% and 73.1%, respectively). The pregnancy rates at Days 14 and 40 were significantly (P < 0.01) lower in mares with cysts (77.6% and 71.4%) compared to mares without cysts (91.5% and 88.0%). This suggests that the presence of uterine cysts plays an important role in the reduction of fertility of Thoroughbred mares.

Preimplantation adoption: establishing pregnancy using donated oocytes and spermatozoa

The experience of transferring embryos produced through in-vitro fertilization (IVF) utilizing donated oocytes and spermatozoa is described. Recipients (n = 28; aged 38-59 years) received oral micronized oestradiol and i.m. progesterone and were synchronized to donors undergoing ovarian stimulation. Reasons for selecting therapy included advanced reproductive age (> 42 years; n = 21) or hypergonadotrophic hypogonadism (n = 7), combined with severe male factor infertility in 23 couples. Five women were single and without partners. Oocytes were fertilized by cryopreserved spermatozoa designated for use by the recipient. Up to five embryos were transferred transcervically. Supernumerary embryos were cryopreserved. A total of 36 aspirations produced 15.6 +/- 7.3 oocytes per retrieval. In 10/36 cycles (27.8%), embryos were available for cryopreservation. Using fresh embryos, the overall pregnancy rate was 38.9% (14/36), clinical pregnancy rate 33.3% (12/36), and ongoing/delivered pregnancy rate 30.6% (11/36). Three ongoing pregnancies were later established by transferring cryopreserved embryos. Adjusting for these events, the per aspiration overall pregnancy rate per retrieval was 47.2%, clinical pregnancy rate 41.7%, and ongoing/delivered pregnancy rate 38.9%. Implantation rates per individual embryo transferred were 16.6% following fresh embryo transfer. A viable pregnancy was achieved by 14 of 28 women (50% cumulative pregnancy rate). We conclude that using donor oocytes and donor spermatozoa is efficacious and allows couples of whom both members suffer from severe gamete abnormalities and single functionally agonadal women an effective means of achieving pregnancy.

A randomized comparative study of the TCu380A and Cu-Safe 300 IUDs

The Cu-Safe 300 is one of the latest additions to the array of available IUDs. It was specifically designed to decrease unwanted side-effects (e.g. bleeding, pain and expulsion) while providing simplicity of insertion, ease of removal and fair contraceptive protection. For comparison, the TCu380A was chosen. Both types were inserted at random in 600 recipients by a group of independent physicians with a long standing experience in intrauterine contraception. Life table analysis was used for comparison over a period of three years. The Cu-Safe 300 produced a slightly but not statistically significant higher pregnancy rate and more expulsions. Removals for bleeding and pain, however, were significantly less frequent. All inserting physicians agreed that insertion and removal of this new device was remarkably easy.

Pregnancies after testicular sperm extraction and intracytoplasmic sperm injection in non-obstructive azoospermia

In this study (May 1 until August 31, 1994) a total of 15 azoospermic patients suffering from testicular failure were treated with a combination of testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI). Spermatozoa were available for ICSI in 13 of the patients. Out of 182 metaphase II injected oocytes, two-pronuclear fertilization was observed in 87 (47.80%); 57 embryos (65.51%) were obtained for either transfer or cryopreservation. Three ongoing pregnancies out of 12 replacements (25%) were established, including one singleton, one twin and one triplet gestation. The ongoing implantation rate was 18% (six fetal hearts out of 32 embryos replaced).

Evaluation of the Tru-Trax cervical mucus penetration test in predicting fertilization and pregnancy rates in in-vitro fertilization

To evaluate the role of the Tru-Trax cervical mucus penetration testing of prognosis of patient performance in in-vitro fertilization (IVF) and to examine its use as a possible screening test prior to IVF, 133 couples presenting with infertility prospectively underwent in-vitro cervical mucus penetration testing. Of these, 66 couples subsequently underwent IVF. The penetration distance of the vanguard spermatozoa in both human and bovine mucus was compared to the fertilization and pregnancy rates during IVF. The fertilization rates in couples with normal human mucus penetration (n = 42, 80.6%) were higher than those with abnormal scores (n = 24, 49.6%; P < 0.001). Similarly, the fertilization rates in those couples with normal bovine mucus penetration (n = 50, 77.5%) were higher than those with abnormal results (n = 16, 40.0%; P < 0.001). Fertilization rates and penetration scores were highly correlated for both human (r = 0.66; P < 0.0001) and bovine (r = 0.66; P < 0.0001) mucus. However, the predictive value of an abnormal result for failed fertilization was poor for both human and bovine penetration, since 83.33 and 81.25% fertilized respectively. Pregnancy rates did not differ among couples with normal and abnormal penetrations. In conclusion, in-vitro cervical mucus penetration testing was highly correlated with fertilization rates in IVF. However, the poor predictive value of an abnormal result may limit the value of this test for generalized pretreatment screening.

The echoguide embryo transfer maximizes the IVF results

The performance of two different methods of embryo transfer for IVF has been evaluated in 132 consecutive embryo transfers. Thirty Eight pregnancies were achieved, corresponding to a pregnancy rate of 28.7% of all embryos transfers. The embryo transfer under ultrasound control was used in 61 cases of our study whereas 71 cases were performed with the "clinical feel" method without ultrasound control. The echoguide embryo transfer procedure yielded a significantly higher pregnancy rate than the blind method (36.06% versus 22.6%). The mean number of embryos transferred per attempt was similar in the two groups (3.1 +/- 0.1 and 3.0 +/- 0.1) as was the quality. The randomized comparative study will continue in order to get more data.

High success with gestational carriers and oocyte donors using synchronized cycles

PURPOSE

Our purpose was to determine if exogenous hormone stimulation of the endometrium improves the implantation and pregnancy rate with a host uterus or gestational carrier.

RESULTS

Nine couples underwent 14 embryo transfer cycles with a gestational carrier. The median age was 31.3 years for the infertile women donating the oocytes and 36.6 years for the gestational carriers. Eight pregnancies were achieved documented by ultrasound confirmation of cardiac activity. The pregnancy rate was 64.3%, with 1.6 cycles per patient.

CONCLUSION

We show that synchronized exogenous hormone stimulation of the gestational carrier improves the success rate of embryo transfer. When the success rate is compared to a timed embryo transfer with the gestational carrier's natural cycle, from previous reported studies, exogenous hormonal stimulation appears to enhance endometrial receptivity and improve the implantation rate.

A randomized study of intracytoplasmic sperm injection (ICSI) versus subzonal insemination (SUZI) for the management of severe male-factor infertility

OBJECTIVE

Our objective was to compare the fertilization rates achieved by ICSI versus SUZI in couples with severe male infertility.

DESIGN

This was a randomized, prospective study.

SETTING

The study took place at the In-Vitro Fertilization-Embryo Transfer Unit, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center.

MATERIALS AND METHODS

Oocytes of 12 patients were randomly allocated to either ICSI or SUZI procedures. Each woman thus served as her own control. All 12 patients had undergone at least two previous in vitro fertilization cycles with no fertilization or had a very low sperm count, i.e., a total motile sperm count of less than 0.5 x 10(6).

RESULTS

A total of 117 oocytes was obtained for fertilization. Of these oocytes, 16% (10/63) were successfully fertilized by SUZI, compared to 33% (18/54) treated by ICSI. This difference was statistically significant (P < 0.05). Of the 12 cycles, ICSI provided embryos in 10 cycles (83%), while SUZI was successful in only 6 cycles (50%). Four pregnancies were achieved: 33% per attempt, or 40% per transfer.

Sperm stimulants can improve fertilization rates in male-factor cases undergoing IVF to the same extent as micromanipulation by partial zona dissection (PZD) or subzonal sperm insemination (SUZI): a randomized controlled study

PURPOSE

Our purpose was to evaluate the efficacy of direct insemination (IVF), micromanipulation by partial zona dissection (PZD), and subzonal sperm insemination (SUZI) using sperm-treated with pentoxifylline (PF) +/- 2-deoxyadenosine (2DA).

RESULTS

The overall fertilization rate achieved was similar for all three fertilization techniques (33.1, 30.2, and 26.9% for IVF, SUZI, and PZD, respectively). Patients who had reduced fertilization in previous IVF attempts showed improved fertilization with sperm stimulants, either PF alone or PF in combination with 2DA in standard IVF. In certain cases, SUZI or PZD gave significantly improved fertilization rates in comparison to IVF.

CONCLUSION

Selective use of sperm stimulants in IVF can achieve fertilization for the majority of male-factor cases. However, PZD and SUZI techniques are useful, especially when sperm stimulants fail to achieve fertilization or achieve poor fertilization in direct insemination.

Human oocyte cytometry and fertilisation rate after subzonal insemination

The cytometry of 545 oocytes was evaluated during subzonal insemination (SUZI; 85 attempts), on day 0 (egg retrieval and SUZI), day 1 and day 2 (embryo transfer). On day 0, the egg and oolemma diameters (mean +/- SD) were 164.0 +/- 19.6 microns and 114.2 +/- 16.8 mu 5m respectively. The zona thickness was 17.8 +/- 13.4 microns and correlated with the oolemma diameter (r = 0.24, p < 0.001). The fertilisation rate was significantly lower for the smaller oocytes (less than 108 microns diameter) compared with the larger oocytes (over 108 microns) (9.8% vs 21.2% respectively; p < 0.05). There was little variation in oocyte diameter according to nuclear status. However, oocyte diameter increased significantly between day 0 and day 1 (p < 0.001) for both fertilised and unfertilised oocytes. Six different indications for SUZI were investigated in detail: three with non-specific (normal and subnormal sperm with in vitro fertilization failure, oligoasthenospermia) and three with specific sperm defects (flagellar dyskinesia, absence of outer dynein arms, antisperm antibodies). Oocytes from the non-specific defect groups had significantly smaller diameters than the others (p < 0.05). The mean fertilisation rate was related to the mean oolemma diameter for the groups with non-specific sperm defects and the group lacking dynein arms (LODA) (r = 0.91, p < 0.05). Eggs from the groups of patients with LODA and those with antisperm antibodies had thicker zona pellucida than others (p < 0.05). These findings suggest that in addition to nuclear criteria of maturity, the growth of oocytes is an important factor for fertilising ability.(ABSTRACT TRUNCATED AT 250 WORDS)

Ovarian activity during follicular-phase down regulation in in vitro fertilization is associated with advanced maternal age and a high recurrence rate in subsequent cycles

PURPOSE

Previous reports have suggested that the ovarian response to leuprolide acetate is predictive of in vitro fertilization pregnancy rates. This study evaluated the outcome of in vitro fertilization cycles complicated by elevated estradiol levels during leuprolide acetate down regulation and the outcome of subsequent cycles in the same patients.

METHODS

Two hundred fifty-two in vitro fertilization cycles were initiated utilizing leuprolide acetate down regulation beginning on cycle day 1.

RESULTS

Seventy-four of these cycles had an elevated estradiol level at the time of the baseline scan (28%). This group of patients had a higher maternal age, a higher cycle cancellation rate (27.5 vs 16.3%), and a high rate of recurrence on subsequent cycles (63%).

CONCLUSIONS

The pregnancy rate per retrieval was equivalent in the two groups. This suggests that patients with advanced maternal age or a history of failure to suppress in a previous cycle may benefit from alternate regimens of superovulation.

The predictive value of serum progesterone and 17-OH progesterone levels on in vitro fertilization outcome

PURPOSE

In order to identify parameters which predict prognosis for success with in vitro fertilization, 17-hydroxyprogesterone and progesterone levels were evaluated in 254 patients undergoing 296 in vitro fertilization cycles. Selected response and outcome data were recorded.

RESULTS

Patients with intermediate values of serum progesterone (0.7-0.8 ng/ml) at the time of human chorionic gonadotropin administration achieved significantly higher pregnancy rates than patients with lower (< 0.7 ng/ml) or higher (> 0.8 ng/ml) levels. The clinical pregnancy rates were 46%, 31%, and 27% respectively (P = 0.02). There was no change in 17-hydroxyprogesterone concentration which predicted a higher pregnancy rate.

CONCLUSION

Excellent clinical pregnancy rates were noted in cycles with a progesterone level of 0.7-0.8 ng/ml, as well as good results in cycles above 0.8 ng/ml. There is therefore no reason to administer human chorionic gonadotropin at a smaller follicle size to prevent a rise in serum progesterone.

Cumulative birth rates following cryopreservation of all embryos in stimulated in vitro fertilization (IVF) cycles

OBJECTIVE

To cryopreserve all good-quality embryos available after IVF is one way to avoid an impending hyperstimulation and a more attractive alternative to a couple than cancellation of the cycle. At Sahlgrenska University Hospital this method has been practiced since 1991. The aim of this study was to assess the success rate (defined as childbirth per couple) after IVF treatment including one stimulated cycle, resulting in cryopreservation of all good-quality embryos available, followed by replacement of frozen/thawed embryos in one or more natural cycles.

DESIGN

A cohort of 32 women undergoing one stimulation for IVF between January 1991 and December 1993 where all good-quality embryos were cryopreserved and transferred in a later spontaneous cycle were studied retrospectively. The cumulative childbirth rate per couple was calculated.

RESULTS

A total of 28 women underwent a total of 45 transfers with frozen-thawed embryos. In 4 women no transfer has taken place so far. The clinical pregnancy rate per embryo transfer was 33% (15/45) and per patient 54% (15/28). Three spontaneous abortions occurred giving a cumulative childbirth rate per patient of 39% (11/28). In addition, 6 out of the 28 women still have embryos left in the freezer.

CONCLUSION

Cryopreservation of all good-quality embryos available after IVF is a highly effective alternative to cancellation of a cycle when there is impending hyperstimulation. The use of this approach results in a cumulative childbirth rate per couple of at least 39%. Since only one stimulation was performed, it also seems to be cost effective.

Treatment by assisted conception of severe male factor infertility due to spinal cord injury or other neurologic impairment

PURPOSE

This retrospective study evaluated the pregnancy rates of 23 couples with male factor infertility due to traumatic spinal cord injury (N = 21), multiple sclerosis (N = 1) or transverse myelitis (N = 1).

METHODS

Ovulation induction by clomiphene citrate or gonadotropins was used in combination with intrauterine insemination as an initial approach for assisted conception in all but one couple.

RESULTS

Six pregnancies occurred in 60 cycles of intrauterine insemination (mean of 2.6 cycles). In this group, the cumulative pregnancy rate was 26%. Six couples who failed after a total of 33 intrauterine insemination cycles (mean of 5.5 cycles), and 1 couple with no previous intrauterine insemination cycles, initiated 10 cycles of in vitro fertilization (mean of 1.4 cycles). In this group, five pregnancies occurred. The pregnancy rate was 71%.

CONCLUSION

We conclude that ovulation induction in combination with intrauterine insemination offers an effective initial therapy of severe male factor infertility due to spinal cord injury.

Intrauterine insemination with husband's semen as alternative to other assisted reproduction techniques

The objectives of this study was to assess the efficacy and clarify how many intrauterine insemination cycles can justifiably be proposed, in terms of cost and benefits for the patient, as alternative to other assisted reproduction procedures. Two hundred and twenty infertile couples were referred to our centre and six intra-uterine insemination cycles in combination with controlled ovarian hyperstimulation were proposed for them. A total of 650 treatment cycles were completed. The indications of intra-uterine insemination were male factor (147 couples), cervical factor (31 couples), male and cervical factor (30 couples) and unexplained infertility (12 couples). Superovulation was induced in 92 patients with human menopausal gonadotrophins, in 90 with clomiphene citrate, in 22 with FSH HP, while in 16 patients the intra-uterine inseminations were carried out during spontaneous cycles. Considering the entire population, a mean monthly pregnancy rate equal to 8.9% was obtained and a cumulative pregnancy rate equal to 39% at the end of six intra-uterine insemination cycles. In particular, in the patients treated with HMG+hCG, a mean monthly pregnancy rate equal to 10.9% and a cumulative pregnancy rate to 46% at the end of the six cycles were obtained. In conclusion, when the indications allow, we believe it is justified to propose six cycles of intra-uterine insemination in combination with controlled ovarian hyperstimulation with HMG and hCG. The theoretical probability of success at the end of six cycles has proved comparable and advantageous in terms of cost and risks for the patient, if compared with other assisted reproduction techniques.

Progesterone concentration as a predictor of pregnancy normalcy is the most useful when hCG levels are less than 2000 mIU/mL

OBJECTIVE

Measurements of serum progesterone to predict early gestational normalcy have been found to be as predictive as serial hCG titers. Since ultrasound would be the diagnostic tool of choice if hCG was > 2000 mIU/ml, the purpose of the present study was to determine the best predictive value of a single progesterone measurement when hCG levels were < 2000 mIU/ml.

DESIGN

Relative operating characteristic analysis of progesterone level as a predictor of early gestational normalcy when hCG is < 2000 mIU/ml.

MATERIALS AND METHODS

Ninety-three pregnant patients that conceived spontaneously were evaluated with progesterone measurements when the patient's hCG was < 2000 mIU/ml. Two-by-two contingency tables were constructed that compared pregnancy outcome with multiple discriminatory serum progesterone concentrations between 0 and 38 ng/mL. From these tables, a relative operating characteristic (ROC) curve was generated to compare the sensitivity and false-positive rates.

RESULTS

Of a total of 93 pregnancies, 27 had a normal outcome and 66 had an abnormal outcome. The ROC curve indicated that a serum progesterone concentration of 12 ng/ml had the highest sensitivity associated with the lowest false-positive rate. The area under the curve was equal to 0.941 +/- 0.024. This observation was compared to our previously reported data of progesterone levels that included hCG levels > 2000 mIU/ml, yielding an area under the curve of 0.772 +/- 0.053. Calculation of the critical ratio z revealed that there is a significant improvement in the predictive value of progesterone when hCG is < 2000 mIU/ml (P < 0.005).

CONCLUSION

A single serum progesterone level has a better predictive value of pregnancy normalcy when hCG measurements are < 2000 mIU/ml.

Basal serum follicle stimulating hormone (FSH) and estradiol levels as predictors of pregnancy in unstimulated donor insemination cycles

PURPOSE

The purpose of this study was to evaluate the utility of basal serum follicle stimulating hormone and estradiol levels in predicting pregnancy in women undergoing artificial insemination with donor sperm for severe male factor infertility.

METHOD

A retrospective chart review of 48 women who had at least 2 cycles of artificial insemination with donor sperm and who had undergone testing for basal serum follicle stimulating hormone and estradiol levels prior to or during therapy.

RESULTS

There was no difference in age or mean basal serum follicle stimulating hormone between women who conceived (clinical pregnancy) and those who did not. Women who conceived had significantly lower mean serum basal estradiol levels (P = 0.02) and significantly fewer numbers of treatment cycles (P = 0.041). The highest pregnancy rate was among those women with normal basal serum follicle stimulating hormone and estradiol levels. Receiver operating characteristic curve analysis revealed basal serum estradiol to be a more reliable predictor of pregnancy than follicle stimulating hormone.

CONCLUSIONS

Basal serum follicle stimulating hormone and estradiol levels may be useful in predicting success with artificial insemination with donor sperm. It may be useful to obtain basal serum follicle stimulating hormone and estradiol prior to initiating artificial insemination with donor sperm.

[State and prospects of demographic processes in the Udmurt Republic]

Analyzes the time course of demographic indices in Udmurtia in recent years. Socioeconomic measures are offered, aimed at deceleration and arrest of the depopulation process.

Controlled ovarian hyperstimulation in women > or = 40 years old undergoing IVF-ET: mid-luteal versus early follicular (flare-up) GnRH analog regimens

The aim of this study was to compare results obtained using two different GnRH analogue regimens in women > or = 40 undergoing IVF cycles. Patients using GnRH-a from mid-luteal phase of the previous cycle (group A) needed more days of ovarian stimulation than patients GnRH-a in the follicular phase of the same cycle "flare-up" (group B) (11.7 +/- 1.3 vs 10.8 +/- 2 respectively). Group A patients developed more follicles and obtained more oocytes than group B (9.2 +/- 4.9 vs 6.1 +/- 4.4; And 7.6 +/- 4.7 vs 4.2 +/- 3.2, respectively). The cancellation rate was significantly higher in B than A (20 vs 8.6%, respectively). Pregnancy rates however were significantly lower in "flare-up" than in mid-luteal group (3 vs 14% per cycle, 4.7 vs 17% per patient, 3.8 vs 15.2% per oocyte retrieval and 5.4 vs 18.8% per transfer, respectively). Different results obtained in the two groups suggest that Gn-RH-a long protocol allows better ovarian stimulation and consequently improved pregnancy rate than "flare-up" in women > or = 40 years old.

Ovulation triggering in clomiphene citrate-stimulated cycles: human chorionic gonadotropin versus a gonadotropin releasing hormone agonist

PURPOSE

To compare the use of human chorionic gonadotropin (hCG) to a gonadotropin releasing hormone (GnRH) agonist, nafarelin, in initiating ovulation and supporting the luteal phase after priming with clomiphene.

METHODS

In 26 infertile women 50 mg clomiphene citrate produced a preovulatory-size follicle. Then, 11 women were randomized to receive two 400-micrograms doses of nafarelin intranasally 16 h apart, and 15 women were injected intramuscularly with 5000 IU of hCG (luteal day 0 = LD0). Starting on LD6, 7 more 400-micrograms doses of nafarelin were repeated on an every 16-h schedule or a single 2500 IU dose of hCG was given, respectively. Serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), progesterone (P), and hCG were measured. On LD13, endometrium was evaluated with ultrasonography and biopsy in 19 nonpregnant women.

RESULTS

As judged by a threefold rise in serum LH, an LH surge was detected on LD1 in all 11 nafarelin patients, but in only 8 hCG patients (P = 0.01). LH and FSH levels were significantly higher on LD1, 7, and 8 and were significantly suppressed on LD13 in the nafarelin group. All patients had mid-luteal P levels greater than 10 ng/ml and luteal phases longer than 13 days. Significantly different luteal E2 or P levels were noted only on LD13, with lower values in the nafarelin group. Pregnancies were achieved in 3 of 11 nafarelin cycles and 2 of 15 hCG cycles. Luteal phase defects were also similar: 4 of 8 nafarelin patients and 7 of 11 hCG patients.

CONCLUSION

Nafarelin or hCG in conjunction with clomiphene can result in viable pregnancies, but is associated with low pregnancy rates and a high incidence of luteal phase defects.

Epidural anesthesia in an in vitro fertilization and embryo transfer program

OBJECTIVES

To investigate the potential advantages of epidural anesthesia in an in vitro fertilization and embryo transfer program.

STUDY DESIGN

Between January 1991 and December 1992, 148 infertile patients underwent transvaginal ultrasound guided oocyte retrieval. A total of 44 patients (group A) had 50 retrievals under epidural anesthesia, and 104 patients (group B, control group) 112 retrievals under intravenous sedation (propofol) with mask-assisted ventilation (nitrous oxide).

RESULTS

In group A satisfactory anesthesia was achieved in 49 of the 50 cases (98%); one patient required additional intravenous administration of propofol owing to extreme anxiety. No complications were observed. Adversely, in group B nausea was observed in 16 cases (14%) and nausea and vomiting in 7 cases (6%). In group A the fertilization, cleavage and pregnancy rates were 67.2%, 92% and 20% respectively, while in group B the rates were 69.3%, 93% and 19.6% respectively; the differences are not statistically significant.

CONCLUSIONS

Epidural anesthesia is an effective method for transvaginal oocyte retrieval but does not improve the treatment outcome as compared to an intravenous sedation with mask-assisted ventilation using propofol and nitrous oxide.

Comparison between depot leuprorelin and daily buserelin in IVF

OBJECTIVES

To compare the effects of depot and daily forms of GnRH analogs in IVF programs.

METHODS

One hundred seventeen patients undergoing IVF, with no severe male factor, were randomized between two treatment groups. Pituitary desensitization was obtained in group 1 (60 patients) with a single IM injection of leuprorelin (3.75 mg), and in group 2 (57 patients) with buserelin (0.3 mg SC twice daily). In a subgroup of 10 patients (5 for the depot form and 5 for the daily form) several GnRH tests were performed to investigate pituitary desensitization.

RESULTS

No differences were found in the time to reach desensitization. Resumption of pituitary activity occurred in 7 days with the daily form and in about 2 months with the depot form. No significant differences were found in the stimulation pattern, oocyte quality, percentage of fertilization. The pregnancy rate per transfer was slightly, but not significantly, better in the depot group (29.4% vs 25.9%). Implantation rate (11.9% vs 12.3%) and the percentage of miscarriages (26.6% vs 28.5%) were similar.

CONCLUSION

Depot and daily forms of GnRH analogs are equally effective in superovulation induction for IVF. Considering improved patient compliance and preference, depot forms are advantageous.

Clomiphene citrate and hMG: an alternative stimulation protocol for selected failed in vitro fertilization patients

PURPOSE

This study was carried out to evaluate the potential role of the combination clomiphene citrate/human menopausal gonadotropin (CC/hMG) for patients who failed previous in vitro fertilization (IVF) attempts with gonadotropin-releasing hormone analogs (GnRH-a) and/or exogenous gonadotropins.

METHODS

Patients were stimulated with CC/hMG (n = 93) after unsuccessfully undergoing 182 gonadotropin cycles with (n = 106) or without (n = 76) luteal-phase GnRH-a. Cancellation rate, length of stimulation, and peak estradiol levels did not differ significantly between the two regimens.

RESULTS

Although fewer oocytes were retrieved when the CC/hMG combination was used, 16 patients were able to successfully achieve a pregnancy (26.2% delivery rate/transfer). When daily follicle stimulating hormone (FSH) levels were measured in two successive cycles in those women who conceived with the CC/hMG stimulation, baseline levels did not differ when compared with a previous GnRH-a/hMG cycle. Nevertheless, serum FSH levels rose rapidly and remained higher in the GnRH-a/hMG cycle, reaching significantly higher levels on day of human chorionic gonadotropin (hCG) administration.

CONCLUSION

Selected patients who failed previous IVF attempts with gonadotropins with or without GnRH analogs may benefit from the addition of CC to their ovarian stimulation protocol.

Techniques of sperm selection and in vitro fertilization results

This study was performed to evaluate the effectiveness of four techniques for sperm selection in vitro fertilization (IVF) programme. Swim Up, Percoll, Sedimentation and Mini-Percoll were evaluated in 440 IVF cycles. The various methods were performed according to the motility and the number of spermatozoa, and the degree of cellularity of the sample; Swim Up and Percoll were used when sperm count was superior 20 million/ml, Sedimentation and Mini-Percoll when the sperm count was less than 20 million/ml. There was no difference in fertilization rate and in the number of replaced embryos per transfer with Swim Up compared to Percoll procedure; the Sedimentation technique improved fertilization (p < 0.05) and embryos rate (p < 0.001) compared to Mini-Percoll sperm preparation. There was no difference in pregnancy rate with Swim Up compared to Percoll and Sedimentation compared to Mini-Percoll procedure. We conclude that with advanced reproductive procedures where serious sperm disorders exist, the choose of the tecnique of sperm selection, most appropriate, according with the motility and the number of spermatozoa, the debrits and nonspermatic cells of the semen, might produce a suspension of spermatozoa with high fertilization potential.

Comparison of efficacy of high-dose pure follicle-stimulating hormone versus human menopausal gonadotropins for in vitro fertilization

The advent of recombinant DNA technology will soon produce for the market a product that has pure follicle-stimulating hormone (pFSH) but no luteinizing hormone. A prospective randomized study was performed to see if pFSH (Metrodin) was able to stimulate the same in vitro fertilization parameters as human menopausal gonadotropin when preceded by gonadotropin suppression by leuprolide acetate. The results showed similar parameters between the two drugs, i.e., number of oocytes, number of embryos, endometrial thickness at time of human chorionic gonadotropin, fertilization rates and pregnancy rates in a protocol purposely designed to stimulate as many follicles as safely as possible because of a shared oocyte and successful cryopreservation program.

Cytogenetic and cryobiology of human cocultured embryos: a 3-year experience

PURPOSE

Coculture, which allows good-quality human blastocysts with good yields to be obtained, has been designed mainly to select the best embryos for transfers.

METHODS

In a first attempt during coculture, we have studied by fluorescent in situ hybridization the chromosomic content of the in vitro blocked embryos, using centrometric probes for chromosomes 1, 12, and 18. Close to 37% of the arrested embryos show aneuploidymosaicism.

RESULTS

Freezing cocultured blastocysts gives good recovery rates after transfer (83%). The ongoing pregnancy rates per transfer (19%) are high, and the implantation rate per embryo is 13%. This compares favorably with freezing at an early stage.

CONCLUSIONS

We observed that the quality of the endometrium is always the limiting step, as first of all we observed wide variations according to the hormonal preparation of the patients. Moreover the implantation per embryo in the pregnant patients is very high (57%), indicating that most of the losses are directly related to the receptivity of the endometrium.