Developmental potential of in vitro- and in vivo-matured human oocytes collected from stimulated and unstimulated ovaries

The study by Li and coworkers demonstrated that human oocytes collected from the unstimulated ovary have high rates of meiotic spindle and chromosome abnormalities. Until improvements can be made to culture conditions, in vitro maturation protocols for patient treatment should be considered experimental.

Need for an Urgent Ultrasound Examination for Neck Lump

Thromboembolic phenomenon is rare but serious consequence of ovarian hyperstimulation syndrome (OHSS) and in vitro fertilization (IVF) treatment. We present a case of thrombosis of the right internal jugular vein presenting as a neck lump to the ENT department. Ultrasonography of the neck and upper extremity revealed thrombosis of right internal jugular vein. The patient was started on low molecular weight heparin, which resulted in resolution of her clinical condition. Interestingly, the majority of cases after OHSS involve thrombosis of the upper extremities. ENT surgeons, general physicians, and infertility experts should consider this in the differential diagnosis of neck swellings, particularly after OHSS and IVF treatment, and in this case report, we emphasis the need for an urgent ultrasound of the neck in such patients.

The risk of neuro-orthopaedic malformations following in-vitro fertilization

The purpose of this study was to assess the risk of neuro-orthopaedic malformations after in-vitro fertilization. We compared the prevalence of neuro-orthopaedic malformations in two groups of pregnancies conceived either naturally or by in-vitro fertilization, and used multivariate analysis to study the impact of each variable. The results showed a prevalence of 0.89% neuro-orthopaedic malformations in the in-vitro fertilization cohort and 0.32% in the natural conception cohort. The three times greater risk of malformations in the in-vitro fertilization cohort was reduced after adjustment to other variables. We concluded that the increased risk of neuro-orthopaedic malformations after in-vitro fertilization is not due to the technique itself but rather to factors associated with it.

Elevated serum müllerian-inhibiting substance may be a marker for ovarian hyperstimulation syndrome in normal women undergoing in vitro fertilization

We identified patients who experienced ovarian hyperstimulation syndrome (OHSS) (n = 16) and compared their baseline pretreatment levels of müllerian-inhibiting substance (MIS) to age- and weight-matched patients with normal responses to gonadotropins (n = 14). Baseline serum MIS in patients with OHSS were sixfold higher than those seen in normal controls (3.62 +/- 0.87 vs. 0.63 +/- 0.09 ng/mL; P=.0036), indicating that MIS could potentially serve as a useful marker for identifying patients at risk for OHSS.

Pneumonitis and Eosinophilia After In Vitro Fertilization Treatment

A 33-year-old woman presented to the emergency department (ED) with tachypnea, tachycardia, and hypoxia, complaining of dyspnea and paroxysms of dry cough for 2 days. The patient had undergone an unsuccessful in vitro fertilization procedure 1 month earlier and had had another embryo implantation 6 days earlier. She had been receiving intramuscular injections of estradiol and progesterone in sesame oil to support implantation. A chest radiograph demonstrated extensive bilateral pulmonary consolidation; a leukocytosis count of 19.7 x 10(9) with 20% eosinophils was noted on a CBC count. A MEDLINE search yielded a case report in infertility literature describing an eosinophilic pneumonitis with similar clinical features after injections of progesterone in sesame oil. Treatment with intravenous corticosteroids was initiated in the ED, resulting in symptom and chest radiograph result improvement within 2 days and sparing the patient further imaging and antibiotic therapy.

Spontaneous preterm delivery in primiparous women at low risk in Denmark: population based study

OBJECTIVES

To analyse trends in preterm delivery and the factors contributing to preterm delivery in Denmark. To construct a standard population at low risk (white European, 20-40 years of age, with a singleton spontaneous pregnancy) and describe the changes in this population so that time trends can be compared internationally.

DESIGN

Population based study.

PARTICIPANTS

99.8% of all deliveries in Denmark, 1995-2004.

MAIN OUTCOME MEASURES

Proportion of babies born at less than 37 weeks' completed gestation for each year in the overall population and in a standard population at low risk.

RESULTS

Overall, the proportion of preterm deliveries increased by 22% from 1995 to 2004. During the same period, known risk factors for preterm delivery such as in vitro fertilisation, multiple pregnancies, and elective deliveries also increased, and logistic regression analyses showed that these factors were associated with an increased risk of preterm delivery. Spontaneous preterm deliveries in primiparous women at low risk rose 51% (from 3.8% to 5.7%) during this time compared with 20% (2.7% to 3.2%) in multiparous women at low risk.

CONCLUSIONS

The overall proportion of preterm deliveries increased significantly from 1995 to 2004 and primiparity and multiple birth were the most important contributing factors. The rise in spontaneous preterm deliveries in the standard population of primiparous women at low risk was greater than in the total population.

Single versus double embryo transfer: cost-effectiveness analysis alongside a randomized clinical trial

BACKGROUND

Twin pregnancies after IVF are still frequent and are considered high-risk pregnancies leading to high costs. Transferring one embryo can reduce the twin pregnancy rate. We compared cost-effectiveness of one fresh cycle elective single embryo transfer (eSET) versus one fresh cycle double embryo transfer (DET) in an unselected patient population.

METHODS

Patients starting their first IVF cycle were randomized between eSET and DET. Societal costs per couple were determined empirically, from hormonal stimulation up to 42 weeks after embryo transfer. An incremental cost-effectiveness ratio (ICER) was calculated, representing additional costs per successful pregnancy.

RESULTS

Successful pregnancy rates were 20.8% for eSET and 39.6% for DET. Societal costs per couple were significantly lower after eSET (7334 euro) compared with DET (10,924 euro). The ICER of DET compared with eSET was 19,096 euro, meaning that each additional successful pregnancy in the DET group will cost 19,096 euro extra.

CONCLUSIONS

One cycle eSET was less expensive, but also less effective compared to one cycle DET. It depends on the society's willingness to pay for one extra successful pregnancy, whether one cycle DET is preferred from a cost-effectiveness point of view.

The in vitro maturation (IVM) of human oocytes for in vitro fertilization (IVF): is it time yet to switch to IVM-IVF?

The recent study by Li et al. observed that human oocytes from patients with polycystic ovary syndrome (PCOS) matured in vitro exhibited a higher proportion of abnormal spindle structures and disturbed chromosomal configurations compared with in vivo-matured oocytes from a control group of PCOS patients. This article discusses the obstacles that must be overcome and factors that must be monitored when attempting to optimize conditions for the in vitro maturation of human oocytes, with particular attention to the strengths and weaknesses of the study by Li et al.

IVF and ICSI in male infertility: update on outcomes, risks, and costs

Assisted reproductive technology with intracytoplasmic sperm injection (ICSI) is becoming an international panacea for couples struggling with infertility. The increasing popularity of these techniques and the data generated has given us a better understanding of the efficacy, consequences and costs of these procedures. There still remain many unanswered questions and controversies surrounding the use of IVF and ICSI. Increased experience, better refinement of these techniques and clearer indications for IVF and ICSI will inevitably minimize the risks associated with this procedure.

Very low-birth-weight-infants conceived by in vitro fertilization are not at higher risk for mortality and morbidity: a population-based study

OBJECTIVE

To determine whether excess mortality, neonatal morbidity, and congenital malformations occurred in in vitro fertilization (IVF) conceived compared with naturally conceived singleton, twin and triplet very low birth weight (VLBW) infants.

DESIGN

Population-based observational study from 1995 through 2002.

SETTING

Israel National VLBW infant database.

PATIENT(S)

A total of 8,181 VLBW infants conceived naturally or by IVF were stratified into groups of singletons and complete sets of twins and triplets.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Neonatal mortality and morbidity.

RESULT(S)

In the unadjusted analyses, mortality and neonatal morbidity rates were generally similar between the IVF-conceived and the naturally conceived infants stratified by plurality groups. When adjusted for multiple confounding variables, no excess neonatal mortality or morbidity occurred among IVF-conceived infants. The risk for congenital malformations adjusted for ethnicity, maternal age, and parity was also not increased in the IVF-conceived groups.

CONCLUSION(S)

In our population, VLBW infants conceived by IVF were not at increased risk for congenital malformations, postnatal morbidity, or mortality when compared with naturally conceived infants.

Preimplantation genetic diagnosis significantly reduces pregnancy loss in infertile couples: a multicenter study

OBJECTIVE

The inicidence of miscarriage is correlated with maternal age. The majority of miscarriages are chromosomally abnormal. The purpose of this study was to determine in a large population of infertility patients (>2000 cycles) if preimplantation genetic diagnosis (PGD) reduced the rate of spontaneous abortions.

DESIGN

Multicenter retrospective controlled study.

SETTING

One hundred IVF centers referring samples to a reference PGD laboratory.

PATIENT(S)

Infertile women.

INTERVENTION(S)

The spontaneous abortion rate after PGD was retrospectively compared to non-PGD cycles from the 2002 American Society for Reproductive Medicine-Society for Assisted Reproduction Technology report on IVF cycles.

MAIN OUTCOME MEASURE(S)

Spontaneous abortions and trisomic offspring rates.

RESULT(S)

The study included 2,279 cycles of PGD. The pregnancy rate per retrieval was 26.7% (average age 39.6). The mean pregnancy loss for the PGD group (0.167) was significantly lower than for the general IVF group (0.215) (P<.001). After PGD, the spontaneous abortion rate was 14.1% for ages 35-40, and 22.2% for women over 40, compared to 19.4% (P=.03) and 40.6% (P<.001), respectively, in controls. The clinical error rate of PGD (1.2%) was significantly lower than expected (4.7%) (P<.001).

CONCLUSION(S)

The data suggests that PGD significantly reduces the risk of spontaneous abortions in women undergoing IVF and PGD, particularly in women over 40. In addition, PGD may also reduce the risk of trisomic offspring.

Obstetric and perinatal outcome and preliminary results of development of children born after in vitro maturation of oocytes

BACKGROUND

Careful follow-up of children born after in vitro maturation (IVM) of human oocytes is essential because the technique is still very new.

METHODS

Obstetric and perinatal data were collected from all deliveries after IVM treatment during 1999-2004. The growth and development of IVM children was assessed at 6, 12 and 24 months using Muenchener Funktionelle Entwicklungs Diagnostik and Bayley Scales of Infants.

RESULTS

In total, 43 women [age 31.2 +/- 3.9 (mean +/- SD) years] gave birth to 40 singleton infants and three sets of twins (multiple rate 7.0%). Obstetric complications occurred in 15 pregnancies (35%). The mean birthweight of singleton infants was 3550 +/- 441 g and that of twins 2622 +/- 194 g. The rate of preterm birth infants was 5% in singletons. No perinatal deaths occurred. At the age of 12 months, eight children (19%) expressed minor developmental problems and one girl was found to have optical glioma. At 2 years of age, neuropsychological development was within the normal range.

CONCLUSIONS

The obstetric and perinatal outcome was good, and the mean birthweight of the infants was normal. Minor developmental delay was overexpressed at 12 months, but the development of the children was normal at 2 years.

Is there increased monozygotic twinning after assisted reproductive technology?

Over the past two decades there has been an association between assisted reproductive technologies and increased monozygotic twinning. The association is not clear nor are the causes of assisted reproductive technology-related monozygotic twinning understood, although there are several theories as to the possible mechanisms involved. This review looks at some of the assisted reproductive technologies which may be associated with an increased risk of monozygotic twinning such as intracytoplasmic sperm injection, assisted hatching and blastocyst transfers. Determining the true incidence of monozygotic twinning after assisted reproductive technologies is important as there is a well-documented increase in perinatal morbidity and mortality of monozygotic twins compared to singleton and dizygotic pregnancies.

Children born after assisted fertilization have an increased rate of major congenital anomalies

OBJECTIVE

To study the occurrence of major congenital anomalies (CAs) among children born after IVF (IVF, microinjections, and frozen embryo transfers) and after ovulation inductions with or without insemination (other assisted reproductive technologies [ART]).

DESIGN

Register-based study.

SETTING

Data regarding CAs were obtained from the Register of Congenital Malformations.

PATIENT(S)

Children from IVF (n = 4,559), children from other ART (n = 4,467), and controls (n = 27,078, a random sample of naturally conceived children) from the Medical Birth Register.

INTERVENTION(S)

In vitro fertilization and other ART treatment in ordinary practice.

MAIN OUTCOME MEASURE(S)

Rate of major CAs. Children from IVF and other ART were compared with control children, both overall and by plurality, controlling for confounding factors by logistic regression.

RESULT(S)

For IVF children, the adjusted odds ratio (OR) was 1.3 (95% confidence interval [CI], 1.1-1.6). Stratifying by gender and plurality showed that the risk was only increased for boys, and the risk was decreased for multiple IVF girls (OR = 0.5, 95% CI 0.2-0.9). The crude OR of major CA for other ART children was 1.3 (95% CI 1.1-1.5), but adjusted differences by gender and plurality were statistically insignificant.

CONCLUSION(S)

In vitro fertilization was associated with an increased risk for major CAs among singleton boys and a decreased risk among multiple girls. The risk after other ART was only slightly increased.

Occurrence and developmental consequences of vacuoles throughout preimplantation development

OBJECTIVE

Since little is known about the actual incidence and fate of vacuoles at different stages of development this preliminary study was set up to accurately measure vacuoles and track them to day 5.

DESIGN

Prospective study.

SETTING

Women's General Hospital in Austria.

PATIENT(S)

A total of 223 consecutive IVF and intracytoplasmic sperm injection (ICSI) cycles (206 patients).

INTERVENTION(S)

Accurate measurement of vacuoles. Affected gametes and embryos were cultured individually and tracked until day 5.

MAIN OUTCOME MEASURE(S)

Size and number of vacuoles, fertilization rate, blastocyst formation rate, blastocyst quality.

RESULT(S)

There was a significant relationship between size of the vacuole (cut-off value 14 microm) and fertilization (P<.05). At zygote stage the incidence of vacuoles was higher (P<.01) in ICSI (11.6%) than in IVF (5.3%). Only 32.2% of affected ICSI-embryos reached blastocyst stage on day 5 compared with 53.0% of the normal ones (P<.001). In terms of blastocyst formation vacuolization on day 4 (P<.001) turned out to be the most severe one. At blastocyst stage inner cell mass was affected less frequently than the trophectoderm (P<.05).

CONCLUSION(S)

Three types of vacuoles could be identified: (1) those already present at oocyte collection, which develop during maturation (day 0); (2) those artificially created by ICSI (day 1); and (3) those accompanied with developmental arrest (day 4). The later that vacuoles arose, the more detrimental their effect on blastocyst formation.

Assisted procreation: too little consideration for the babies?

Recent studies have revealed much higher risks of cerebral palsy and malformations in babies conceived by in vitro fertilization (IVF) than in babies conceived naturally. Here we question whether parents can legitimately accept this risk on behalf of offspring. We argue that parents can expose their baby to a risk only to preserve it from a worse possibility, and this is not the case of IVF, which is not a therapeutic tool for children because when the IVF decision is taken, the child has not yet been conceived. It is concluded that procreative techniques require considerably more research before being made available to couples.

Evaluation of risks of viral transmission to recipients of bovine embryos arising from fertilisation with virus-infected semen

This scientific review was prompted by recent legislation to curtail the use of semen from potentially virus-infected bulls to produce embryos for import into the European Union. From studies in laboratory animals, humans and horses, it is apparent that viruses may sometimes attach to, or be integrated into, spermatozoa, although in domestic livestock, including cattle, this seems to be a rare phenomenon, and carriage of virus through the zona pellucida into the oocyte by fertilising sperm has never been described in these species. Four specific viruses; enzootic bovine leukosis (EBLV), bovine herpesvirus-1 (BoHV-1), bovine viral diarrhoea virus (BVDV) and bluetongue virus (BTV), all of which tend to cause subclinical infections in cattle, but which can occur in bovine semen, are examined with regard to the risks that use of infected semen might lead to production of infected embryos. With regard to in vivo-derived embryos, when internationally approved embryo processing protocols are used, the risks from EBLV- and BTV-infected semen are negligible, and the same is almost certainly true for semen infected with BoHV-1 if the embryos are also treated with trypsin. For BVDV, there is insufficient data on how the virus is carried in semen and how different BVDV strains can interact with sperm, oocytes and embryos. There is a potential, at least, that in vivo-derived embryos resulting from infected semen might carry BVDV, although field studies so far suggest that this is very unlikely. With regard to in vitro-produced embryos, use of semen infected with any of the four viruses, with the probable exception of EBLV, will often lead to contaminated embryos, and virus removal from these embryos is difficult even when the internationally approved embryo processing protocols are used. However, it has never been demonstrated that such embryos have resulted in transmission of infection to recipients or offspring.

Prevention of multiple pregnancy following IVF in Spain

Since the development of assisted reproduction techniques most countries have witnessed increased rates of multiple pregnancy. Despite the guidelines proposed by various scientific societies these rates continue to be abnormally high. In Spain, as in other Mediterranean countries, a greater number of embryos are transferred than in northern and central European countries and the incidence of multiple pregnancies is greater in comparison. Effective strategies must be established to prevent multiple pregnancy without reducing overall pregnancy rates. In the authors' institute, taking into account the authors' experience, the relevant literature, and despite the limitation of retrospective studies, it is recommended that a maximum of two embryos are transferred in young women with good quality embryos at the time of transfer. The transfer of three embryos is only recommended in women >or=38 years who have one or no good quality embryos available at the time of transfer. The responsibility for preventing multiple pregnancy lies with health professionals, who must be aware of the risks involved in twin and triplet pregnancy. Couples must be provided with objective information before starting an IVF cycle. Professional societies should highlight the problem and make suitable recommendations.

Mild ovarian hyperstimulation syndrome coexisting with ectopic pregnancy after in vitro fertilization

Ovarian hyperstimulation syndrome (OHSS) is an entity arising in women undergoing assisted reproductive techniques (ART). The simultaneous presence of two different clinical complications such as OHSS and ectopic pregnancy (EP) is not frequent. The diagnosis of an extrauterine pregnancy can be obscured by the stimulated ovaries and ascites, and actually be missed, especially in women with increased body mass index. We report a case of a woman who presented with mild OHSS after in vitro fertilization (IVF), (intracytoplasmatic sperm injection (ICSI) and embryo transfer). The ectopic pregnancy was ascertained soon after by transvaginal ultrasound (TVS) and right salpingectomy was performed.

[Heterotopic pregnancy after in vitro fertilization]

In our paper we described a rare case of heterotopic pregnancy after in vitro fertilization (IVF-ET). Heterotopic pregnancy (coexistence of intrauterine and ectopic pregnancy) appears in 1 per 30 thousand cases of natural pregnancies and in 1% of pregnancies after IVF. The pregnancy was obtained after ICSI and transfer of 2 embryos. The pregnancy was confirmed by HCG serum presence--13 days after ET. On day 39 after IVF procedure, the patient was admitted to the hospital because of abdominal pain. At admission, ultrasound examination confirmed an 8 week intrauterine pregnancy and enlarged polycystic ovaries. After 3-day-long observation, patient status worsened and laparoscopy procedure was performed. The ectopic pregnancy was confirmed during operation and the ovum was removed a long with fallopian tube. Ultrasound examination on the 6th day after operation confirmed single intrauterine viable fetus. in order to diagnose the possible complications, women undergoing IVF procedure should be carefully observed by IVF performing physicians.

Serum PAPP-A levels at 10–14 weeks of gestation are altered in women after assisted conception

OBJECTIVES

Increased screen-positive rate was observed in the first-trimester screening for trisomy 21 (T21) among women after assisted conception. The aim of this study was to identify the trends of changes in serum marker levels after different modes of assisted conception.

METHODS

Retrospectively, we analyzed the levels of free beta human chorionic gonadotrophin (f beta HCG), pregnancy-associated plasma protein-A (PAPP-A) and inhibin A in maternal serum, and fetal nuchal translucency (NT) thickness at 10-14 gestational weeks in 1098 women with singleton pregnancies: 130 after IVF-ET, 54 after ICSI and 914 after spontaneous conception.

RESULTS

In women after IVF-ET and ICSI, PAPP-A was decreased (0.94 MoM and 0.82 MoM, respectively) and inhibin A increased (1.11 MoM and 1.48 MoM, respectively) in comparison to the women after spontaneous conception. With increasing number of oocytes retrieved PAPP-A decreased and inhibin A increased. In women pregnant after assisted conception without ovarian stimulation (transfer of frozen-thawed embryo or in spontaneous cycle) the marker levels were not significantly different from those in women after spontaneous conception.

CONCLUSIONS

The presence of multiple corpora lutea may be responsible for the changes in marker levels. In spite of the differences in marker levels, the screen-positive rate for T21 is not significantly increased in women after assisted conception.