[Prenatal screening and diagnostics after infertility treatment]

Women who get pregnant after infertility treatment differ from women with naturally conceived pregnancies concerning prenatal screening: on average they are older and therefore they have a greater risk of carrying a child with Down's syndrome, their children have an increased risk of congenital malformations, and they have a great wish to avoid invasive prenatal diagnostic tests. The conclusion of this review is that first trimester screening is an acceptable choice for these women, although larger studies are needed to clarify whether a correction factor is necessary for the biochemical markers.

Fulminant Sepsis after Second-Trimester Amniocentesis in Pregnant Women by in vitro Fertilization and Embryo Transfer

Second-trimester amniocentesis is a common procedure for prenatal diagnosis. Sepsis is a rare complication after amniocentesis and may rapidly deteriorate if prompt treatment, including broad-spectrum antibiotics and removal of the infected abortus, is delayed. In vitro fertilization and embryo transfer (IVF-ET) is a standard final treatment for infertile women. Transvaginal oocyte retrieval is necessary for such women; this procedure potentially causes Escherichia coli attaching and effacing in the abdominal cavity. Here we report that two pregnant women by IVF-ET developed sepsis after second-trimester amniocentesis. The cause of sepsis after amniocentesis is still unknown. We provided the possibility of the causation of the E. coli infection associated with the previous intra-abdominal procedure, but it needs more evidence to prove it.

[Main principles and IVF-ET results of the centre for assisted reproduction "Varna", Bulgaria]

The authors formulate the main principles of IVF-ET, based on personal experience i.e. hormonal ovarian stimulation, ovarian puncture, fertilization and ET, prophylaxis and therapy of early complications. Clinical pregnancy was achieved in 287 of 612 patients (43.9% per cycle and 46.9% per transfer). The cancellation rate is 9.6% (42 patients), the miscarriage rate is 14.2% (41 patients). In three cases the pregnancy was ectopic. The multiple pregnancy rate is 32.7% (94 cases): 84 bigemini, 9 trigemini and 1 quadrigemini. In 2006 the multiple pregnancy rate was reduced to 28%. The mean number of transferred embryos was 3.2 and in 2006--2.8; 80.5% of the pregnant women were under 35 years of age. Severe complications occurred in 16 cases--2.6%: OHSS in 15 cases and one with massive intraabdominal hemorrhage from ruptured ovaries. In conclusion the authors stressed the necessity of undelayed resort to ART treatment. Hydrosalpinxes have to be removed preliminarily and partial resection of the ovaries should be done only in rare cases. In Bulgaria at least 6000 fully reimbursed IVF-ICSI procedures yearly ought to be done because of the considerable rate of the inflammatory female and male infertility.

Episcleritis as a possible complication of lymphocyte immunotherapy--case report

INTRODUCTION

Recurrent episceleritis is uncommon. Lymphocyte immunotherapy (LIT) is frequently useful in establishing successful pregnancies in women with previously failed in vitro fertilization (IVF) cycles.

METHODS

A woman with recurrent episcleritis and previous splenectomy was carefully questioned to see if there was any association with having had the LIT procedure. Methylprednisone 10 mg/day x 5 days was always given before embryo transfer because of assisted embryo hatching.

RESULTS

There was a tendency for the episodes to occur immediately after the LIT, especially four days after embryo transfer. However, they also occurred several times between IVF cycles before she ovulated.

CONCLUSIONS

Since she had never had an episode of episcleritis before LIT and because she always developed the problem shortly after the procedure it seems that the procedure could have this potential side-effect. The possibility exists that LIT may not cause this problem in people with intact spleens. Possibly, the use of an immunosuppressive, e.g., methyprednisone exacerbates the problem.

Mitochondrial Dysfunction of In Vitro Grown Rabbit Oocytes Results in Preimplantation Embryo Arrest After Activation

To clarify the mechanism that impairs development of in vitro grown (IVG) oocytes, we assessed whether the developmental disability of IVG oocytes is caused by cytoplasmic dysfunction. First, we assessed the cleavage of nuclear-substituted oocytes cultured in vitro. The nuclei, but not the cytoplasm, of the IVG oocytes were able to support subsequent cleavage after artificial activation. The mitochondrial activity of the oocytes increased as the follicles grew. However, the mitochondrial activity of the IVG oocytes was significantly lower than that of ovulated oocytes and oocytes recovered from follicles with diameters of more than 300 microm. Furthermore, the expression levels of mitochondrial transcriptional factor A (TFAM) in the oocytes increased in a similar manner. However, the expression levels of TFAM in the IVG oocytes was significantly lower than that of ovulated oocytes and oocytes recovered from follicles with diameters of more than 300 microm. Taken together, these results indicate that the low developmental competence of IVG oocytes is caused by a cytoplasm deficiency due to low mitochondrial activity.

Case of progressive intrauterine twin pregnancy after surgical treatment of cornual pregnancy

OBJECTIVE

To report on a case of heterotopic triplet pregnancy after in utero transfer of three embryos obtained by in vitro fertilization (IVF), with progression of the intrauterine twin pregnancy after resection of the cornual pregnancy.

DESIGN

Technique and instrumentation.

SETTING

Département de Médecine de la Reproduction, Hôpital Edouard Herriot, Lyon, France.

PATIENTS

A 32-year-old woman, nulliparous with primary infertility for the previous 12 years due to mixed causes (tubal and male infertility).

INTERVENTIONS

Diagnosis by ultrasound scan and per-laparoscopic confirmation, followed by resection of the cornual pregnancy by laparotomy.

MAIN OUTCOME MEASURES

Ultrasound diagnosis and follow-up of the pregnancy. Delivery.

RESULTS

Complete ablation of the cornual pregnancy. Progression of the intrauterine twin pregnancy without difficulties until 31 weeks of gestation. Cesarean upon onset of labor. Birth of two living infants. The scar of the uterine horn, examined during the caesarean, was thick and solid.

CONCLUSIONS

The early diagnosis and surgical treatment of an ectopic pregnancy permitted the development of the intrauterine pregnancy. The risk of heterotopic pregnancy is increased by medical techniques that facilitate procreation. This risk is directly related to the number of embryos transferred. In the case of heterotopic pregnancy, the rate of progressive intrauterine pregnancy after treatment of the ectopic pregnancy is encouraging.

[Gynaecological epidemiology]

Epidemiological research has good possibilities in Denmark due to the fact that all people have a personal PIN code and due to our many National health registers. In gynaecology the National Register of Patients, the Birth Registry, IVF-registry, Cancer Registry and latest the National Prescription Database offer unique possibilities of linking exposure data with many clinical outcomes. Danish epidemiology has contributed with morbidity analyses on children concieved by in vitro fertilisation, pharmacoepidemiological studies on short and long term effects of oral contraceptives and hormone therapy and, now, with routine assessment of clinical quality.

Policy efforts to prevent ART-related preterm birth

At 12.5%, the preterm birth rate is the highest it has ever been in the US. In tandem with the rise in preterm birth is a dramatic increase in multiple birth rates. The recent trend of delayed maternal age at first birth and the associated use of assisted reproductive technologies (ARTs) have led to the increase in multiple gestation and its attendant increased risk for preterm birth. While ARTs are not responsible for the majority of preterm births, the attributable fraction has increased, is iatrogenic- and preventable. Despite widespread recognition of this problem, the rate of associated twin gestation has not decreased. We offer options for policymakers on several levels--from medical to health systems to societal policy--to decrease ART-related preterm births.

Course of ovarian hyperstimulation syndrome in 19 intact twin pregnancies after assisted reproduction techniques, with a case report of severe thromboembolism

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of assisted reproduction techniques using in vitro fertilization and intracytoplasmic sperm injection (IVF/ICSI). Its etiology has still not yet been fully resolved. Human chorionic gonadotrophin, administered exogenously as well as produced endogenously during pregnancy, is responsible for the onset of OHSS, and high levels of estradiol appear to worsen the condition. In this case series, the course of mild to severe OHSS was evaluated in 19 intact twin pregnancies after IVF/ICSI. Another serious complication associated with OHSS is thromboembolic events. In these cases, the pregnancy can be protected through anticoagulation treatment, but there may be exceptions to this. This series includes a case of bilateral thrombosis of the internal and external jugular veins in the 7th gestational week in a twin pregnancy after OHSS and ICSI, with termination of the pregnancy in the 9th gestational week due to progressive thrombosis during anticoagulation therapy.

The empty follicle syndrome

The empty follicle syndrome (EFS) is a rare complication of in vitro fertilization (IVF) treatment, leading to cycle cancellation. Low human chorionic gonadotropin (hCG) bioavailability and ovarian dysfunction have been implicated with this condition. This case report illustrates a typical case of EFS and several strategies suggested to overcome this problem.

Incidence of Pericardial Effusion in Females Stimulated in "in Vitro Fertilization" Program

AIMS

To evaluate the incidence of pericardial irritation in females after hormonal stimulation in in vitro fertilization program, and to set its clinical significance as a symptom of ovarian hyperstimulation syndrome (OHSS).

PATIENTS

Thirty-nine females, aged 30 +/- 5 years (20-46), with a normal echo finding prior to hormonal stimulation.

METHODS

Serial echocardiography: baseline A, in hCG application B, embryo-transfer C.

RESULTS

Thirty-nine, 39, and 35 echocardiography examinations were done on A, B, and C respectively. On B, in 7 (17.9%) of 39 patients either new pericardial effusion "1," increased pericardial echogenicity "2," or both "3" were detected (4 patients, 2 patients, and 1 patient, i.e., 10.3%, 5.1%, and 2.6% respectively.). On C, in 8 of 35 patients (22.8 %) abnormalities were detected: "1" in 2 patients (5.7 %), "2" in 1 patient (2.9 %), and "3" in 5 patients (14.2 %). No clinical symptoms related to these findings were present. No OHSS occurred in these patients. On the contrary, clinical OHSS developed later in 2 patients, classified as medium degree (1 patient) and severe degree (1 patient)-both patients had negative echo during follow-up.

CONCLUSION

Echocardiographic signs of mild pericardial irritation may appear also in patients with no clinical signs of OHSS. The incidence of these changes increases during stimulation procedure. Development of OHSS may not be preceded by the incidence of these warning signs. Consequently, routine echocardiographic examination during stimulation is not indicated, since significant pericardial effusion is rather a late sign of OHSS.

Right ectopic gestation following in vitro fertilisation: case report

The management of ectopic gestation has in recent years transformed from the normally accepted laparotomy to the laparoscopic approach. The objective of this case report is to describe a rare occurrence of an ectopic gestation following in vitro fertilisation procedure. A 35-year-old para 0 + 0, presented with lower abdominal pain and per vaginal bleeding six weeks after an in vitro fertilisation was done in South Africa. The patient was admitted with severe lower abdominal pain and per vaginal bleeding at six weeks gestation following an in vitro fertilisation procedure. She had undergone an "evacuation" one-week prior to this episode due to an initial diagnosis of an incomplete abortion. No chorionic villi were reported on histology. The repeat serum BhCG was 777 mimicro/l and at laparoscopy a right unruptured ampullary ectopic gestation (4 cms in size) was evident. A right linear salpingostomy was subsequently performed laparoscopically. Histology confirmed the presence of tubal chorionic villi. The laparoscopic management of ectopic pregnancies is now regarded as the gold standard in many centres in the world. In this patient the ectopic pregnancy resulted following an intra-uterine zygote transfer, and was managed successfully.

[Analysis of 92 ectopic pregnancy patients after in vitro fertilization and embryo transfer]

OBJECTIVE

To investigate the occurrence of ectopic pregnancy among women who received in vitro fertilization and assess the influential factors.

METHODS

The indications, methods of assisted conception and ectopic types were analyzed retrospectively after the patients received in vitro fertilization and embryo transfer (IVF-ET), intracytoplasmic sperm injection (ICSI), or freezing-thawing embryo transfer (FET).

RESULTS

A total of 6007 embryo transfers were performed, and 2322 (38.7%) clinical pregnancies were obtained. Ninety-four (4.05%) of them were ectopic pregnancies; and 92 were tubal pregnancies. The occurrence rate was 3.96%, which constituted 97.87% (92/94) of all ectopic pregnancies. There were 2 cases of other parts: one in abdominal cavity and the other in cornual pregnancy with the occurrence rate of 0.86%, constituting 2.32% (2/94). Twenty heterotopic pregnancies occurred (0.86%), constituting 21.28% (20/94). Among all ectopic pregnancies, the assisted conception of 86 cases was tubal pathology and/or pelvic adherence (91.49%), and 24 patients had a history of ectopic pregnancy (25.53%). The differences of clinical pregnancy rates between IVF-ET, ICSI and FET were not significant (P>0.05). The ectopic rate of IVF-ET group was significantly higher than that of ICSI or FET group (P<0.05), respectively. The ectopic rate in FET group was also higher than that in ICSI group (P<0.05).

CONCLUSION

The occurrence rate of ectopic pregnancy after IVF is higher than that of spontaneous pregnancy, and the main cause for ectopic pregnancy is the tubal pathological changes.

Recurrent heterotopic pregnancy after bilateral salpingectomy in an IVF patient: case report

PURPOSE

To report a rare clinical case of recurrent heterotopic pregnancy in the same patient following bilateral salpingectomy and in-vitro fertilization (IVF) treatments.

METHODS

A 35 year-old woman, suffering from mechanical infertility, was treated by IVF, resulting in two episodes of heterotopic pregnancies within 2 years. The first episode ended in bilateral salpingectomy due to unilateral tubal pregnancy and contralateral severely damaged tube. The intrauterine pregnancy ended in early missed abortion. The second heterotopic pregnancy presented as bleeding cornual pregnancy, managed by laparoscopic resection of the tubal stump, and ended in a term singleton delivery.

CONCLUSION

The possibility of cornual heterotopic pregnancy following bilateral salpingectomy, though very rare, should be considered by every gynecologist treating IVF patient.

Transvaginal oocyte retrieval for in vitro fertilization complicated by ovarian abscess during pregnancy

OBJECTIVE

To describe an ovarian abscess presenting very late after oocyte retrieval for IVF with several unusual clinical features.

DESIGN

Case report.

SETTING

Academic medical center.

PATIENT(S)

A 35-year-old nulliparous woman underwent IVF with uncomplicated transvaginal oocyte retrieval (TVOR), resulting in a dizygotic twin pregnancy. At 13 weeks of pregnancy she presented with vaginal discharge, but was otherwise constitutionally well. At 30 weeks she developed a low-grade fever, and the diagnosis of ovarian abscess was made. She received broad-spectrum antibiotics, and the abscess was drained percutaneously after cesarean delivery of twins.

INTERVENTION(S)

Antimicrobial therapy; cesarean section; postpartum percutaneous drainage.

MAIN OUTCOME MEASURE(S)

Clinical and radiologic resolution of infection.

RESULT(S)

Complete resolution of the abscess; delivery of healthy twins.

CONCLUSION(S)

Infectious complications of TVOR and other surgical procedures usually occur within days of the intervention. Our case illustrates the possibility of infectious complications of TVOR presenting months after the procedure. Our patient did not become acutely ill due to the formation of a spontaneous vaginal fistula, which allowed the abscess to drain. The optimal management of this complication is unclear, but final resolution of any pelvic abscess generally requires drainage.

Subchorionic hematoma associated with heterotopic pregnancy following in vitro fertilization: a case report

BACKGROUND

After treatment for infertility using in vitro fertilization (IVF)-embryo transfer, a high index of suspicion must be maintained for early diagnosis and treatment of concurrent ectopic pregnancy; however, the likelihood of a positive outcome for the intrauterine pregnancy remains uncertain.

CASE

A subchorionic hematoma threatening an intrauterine gestation noted concurrently with ultrasound diagnosis of a heterotopic IVF pregnancy resolved following laparoscopic salpingectomy.

CONCLUSION

Although symptomatic subchorionic hematoma may be associated with an increase in the rate of spontaneous miscarriage for a singleton pregnancy, it may not present a similar risk in the presence of a concurrent heterotopic gestation.

Increased risk of placenta previa in pregnancies following IVF/ICSI; a comparison of ART and non-ART pregnancies in the same mother

BACKGROUND

The risk of placenta previa may be increased in pregnancies conceived by assisted reproduction technology (ART). Whether the increased risk is due to factors related to the reproductive technology, or associated with maternal factors, is not known.

METHODS

In a nationwide population-based study, we included 845,384 pregnancies reported to the Medical Birth Registry of Norway between 1988 and 2002 and compared the risk of placenta previa in 7568 pregnancies conceived after assisted fertilization, with the risk in naturally conceived pregnancies. To study the influence of ART more directly, we compared the risk of placenta previa between consecutive pregnancies among 1349 women who had conceived both naturally and after assisted fertilization. Odds ratios (OR), adjusted for maternal age, parity, previous Caesarean section and time interval between pregnancies were estimated using logistic regression.

RESULTS

There was a six-fold higher risk of placenta previa in singleton pregnancies conceived by assisted fertilization compared with naturally conceived pregnancies [adjusted OR 5.6, 95% confidence interval (CI) 4.4-7.0]. Among mothers who had conceived both naturally and after assisted fertilization, the risk of placenta previa was nearly three-fold higher in the pregnancy following assisted fertilization (adjusted OR 2.9, 95% CI 1.4-6.1), compared with that in the naturally conceived pregnancy.

CONCLUSIONS

The use of ART is associated with an increased risk of placenta previa. Our findings suggest that the increased risk may be caused by factors related to the reproductive technology.

Ovarian hyperstimulation causing ureteral obstruction in a pregnant woman

Obstruction of the urinary collecting system in pregnant women can present a unique challenge to the urologist. Although ureteral obstruction due to stone disease is well-documented and ureteral obstruction is a well-known and defined cause of acute renal failure, obstruction from extrinsic compression is a less-understood phenomenon. We report a case of ureteral obstruction from hyperplastic ovaries in a pregnant woman receiving hormonal therapy that was managed initially with ureteral stenting.

Are congenital anorectal malformations more frequent in newborns conceived with assisted reproductive techniques?

One of the major concerns about ART is the risk of birth defects in children born after in vitro fertilization. We report on a cohort of consecutive children affected with anorectal malformation (ARM) requiring surgical correction in which we found a significantly high proportion (Odds ratio 13.31, 95% confidence limits 4.0-39.6) of children born after ART. Our data is in agreement with the result of a recent epidemiological study in Sweden. Further studies are necessary to define the risk and identify the causes, if any. At present, couples undergoing ART should be informed of the general risk of congenital anomalies, of which, ARM can be suggested as an example.

Confocal microscopic analysis of the spindle and chromosome configurations of human oocytes matured in vitro

OBJECTIVE

To assess the potential effects of in vitro maturation (IVM) of human oocytes on the meiotic spindle and associated chromosome configuration.

DESIGN

Prospective study.

SETTING

Hospital-based IVF center.

PATIENT(S)

Patients with polycystic ovary syndrome (PCOS) undergoing unstimulated and stimulated cycles of oocyte retrieval.

INTERVENTION(S)

Immature (germinal vesicle and metaphase I) and mature (metaphase II) oocytes were collected from PCOS patients. The meiotic spindle and chromosome configurations in oocytes matured in vitro and in vivo were studied by confocal microscopy, with fluorescent labeling techniques for visualization of both microtubules and chromatin.

MAIN OUTCOME MEASURE(S)

Meiotic spindle and associated chromosome configurations.

RESULT(S)

Oocytes can develop to the metaphase II stage after IVM. Confocal microscopic observations revealed that the oocytes matured in vitro had a higher frequency of abnormal meiotic spindle and chromosomal alignment morphology than in vivo-matured oocytes. These abnormalities included a partial or total disorganization of the meiotic spindle microtubules. Abnormal chromosome organization included dispersal of chromosomes or chromosomes with an aberrant, less-condensed appearance. The proportions of abnormality in spindle and chromosome configurations in oocytes matured in vitro were 43.7% and 33.3%, respectively, which was significantly higher than in those oocytes matured in vivo (13.6% and 9.1%).

CONCLUSION(S)

In vitro maturation can have deleterious effects on the organization of the meiotic spindle and chromosome alignment of human oocytes. This result suggests one possible explanation for the reduced developmental potential of oocytes matured in vitro compared with those matured in vivo. This is likely a contributing factor to the overall lower clinical outcomes observed after IVM and ET.