Assisted hatching reduces the age-related decline in IVF outcome in women younger than age 43 without increasing miscarriage or monozygotic twinning

PURPOSE

Our purpose was to examine the benefits of assisted hatching in our program and to determine whether the procedure increases the implantation of nonviable embryos or monozygotic twinning.

METHODS

Consecutive in vitro fertilization cycles using assisted hatching were compared with historical controls. The impact of assisted hatching was analyzed according to the woman's age. Outcome measures were clinical pregnancy, implantation rate, delivery rate, multiple pregnancy, spontaneous abortion, and incidence of monozygotic twins.

RESULTS

The implantation rate was increased in women aged 35-39 and markedly increased in women aged 40-42. There was no change in spontaneous abortions and no increase in monozygotic twins.

CONCLUSIONS

Assisted hatching is a safe and highly effective adjunct to in vitro fertilization for women aged 35-42 and did not increase spontaneous abortion or monozygotic twinning.

A simplified method of timing frozen embryo transfers

OBJECTIVE

Our purpose was to compare a simple artificial hormone replacement regimen with two other protocols incorporating pituitary down-regulation with gonadotropin-releasing hormone agonist for frozen embryo transfers.

STUDY DESIGN

We performed a retrospective analysis of pregnancy outcomes after 366 frozen embryo transfers timed by one of three hormone replacement regimens. The three regimens used were regimen A, leuprolide acetate and transdermal estradiol patches; regimen B, leuprolide acetate and oral micronized estradiol; regimen C, only oral micronized estradiol.

RESULTS

The outcomes of 366 consecutive frozen embryo transfers according to one of the three regimens were compared and analyzed. The clinical pregnancy rates were 13.7%, 11.4% and 13.5% in regimens A, B and C, respectively. No statistical differences were found among the three regimens. The mean age of the patients in the three groups was comparable. The mean number of frozen embryos transferred with regimen B was slightly higher, but it did not have a positive impact on the pregnancy rate in this group.

CONCLUSION

Controlled sequential hormone replacement results in an endometrium suitable for frozen embryo transfers. Pituitary down-regulation is not necessary. Therefore this regimen is not only more simple to use but also more economical.

Successful implantation of frozen sibling embryos is influenced by the outcome of the cycle from which they were derived

OBJECTIVES

To determine if the success of frozen embryos obtained from assisted reproductive technology (ART) cycles is dependent upon the outcome of the ART cycle from which they were derived and to determine if the length of time in cryostorage affects pregnancy rates (PRs).

DESIGN

Retrospective analysis of pregnancy outcome of consecutive frozen ETs compared with their corresponding "'fresh" cycles.

SETTING

University-affiliated private ART program.

PATIENTS

Between July 1986 and December 1992, 375 oocyte retrieval cycles had at least one subsequent frozen ET for comparison. Of the 375 patients, 94 achieved a clinical pregnancy during their fresh cycle (group A) and 281 patients did not (group B).

INTERVENTIONS

Frozen ETs were performed using either natural (unstimulated) cycles (n = 79) or artificial cycles (n = 296). Transfers during natural cycles were timed with a combination of serum LH levels and ultrasound (US). These transfers were performed 2 days after ovulation. Ovarian suppression with leuprolide acetate followed by sequential estrogen and P replacement were used in the artificial cycles. These transfers were performed on the 3rd day of P administration. Clinical pregnancies were defined as the presence of a gestational sac on transvaginal US.

MAIN OUTCOME MEASURES

Patients were compared based on the pregnancy outcome of their frozen ET cycle and fresh ART cycle. chi 2 analysis and Student's-tests were used to test for statistical significance.

RESULTS

Twenty-three patients (24.1%) from group A achieved a pregnancy from their frozen transfers compared with only 24 patients (8.5%) in group B who achieved a pregnancy from their frozen cycle. PRs did not differ based on the method of follicle aspiration, laparoscopy versus transvaginal US retrieval. Significantly lower PRs were noted in frozen ETs done within the first 10 months after cryopreservation compared with fresh cycle PRs.

CONCLUSIONS

Sibling embryos from a prior successful ART cycle are more likely to initiate a frozen pregnancy and prolonged cryostorage did not affect PRs. This higher PR probably reflects better quality in both fresh and frozen embryos. Therefore, the outcome of the initial cycle can be used to predict the success or failure of subsequent frozen transfers and oocyte-embryo quality appears to be key.

A 3,3'-diiodothyronine sulfate cross-reactive compound in serum from pregnant women

Recently, we found high serum/urine concentrations of 3,3'-diiodothyronine sulfate (T2S) in both fetal and maternal sheep. In the present study, a RIA was employed to detect and measure serum T2S in women of different gestational ages and after delivery. Results were compared with values in nonpregnant women. In maternal serum, we identified a material that cross-reacts with T2S antibody, but is not T2S. Its concentration increased with the progression of pregnancy. The exact chemical structure of the T2S-like material (which we designated compound W) is unclear. It is immunologically (or chemically) similar to T2S, but does not cochromatograph with synthetic T2S in high pressure liquid chromatography. The serum concentrations of compound W were expressed as T2S equivalents (nanomoles per L +/- SE). Serum compound W concentrations were slightly elevated in women during the first trimester compared to those in nonpregnant women (0.73 +/- 0.04 vs. 0.17 +/- 0.02 nmol/L; P < 0.01). There was a moderate and progressive rise in the compound W concentration between 14-35 weeks gestation. The maternal serum compound W concentration then rapidly peaked before parturition (36-40 weeks gestation, 3.49 +/- 0.49 nmol/L; 27-35 weeks, 1.67 +/- 0.11 nmol/L; P < 0.01). After parturition, maternal serum levels of compound W decreased from 2.61 +/- 0.18 nmol/L (n = 25) to 1.47 +/- 0.12 nmol/L (n = 18) at 1 day, 0.89 +/- 0.07 nmol/L (n = 15) at 3 days, and 0.33 +/- 0.03 nmol/L (n = 8) at 7 days. hCG increased serum concentrations of T2S-cross-reactive material 6.2-fold (P < 0.01) in nonpregnant women. In summary, whereas hCG stimulation may account for some increase in maternal serum concentrations of this T2S-like material in the first trimester, the more rapid increase in maternal serum compound W concentrations during the late third trimester are probably related to changes that occur in fetal thyroid hormone economy. It is speculated that placental transfer and transformation of fetal T3 may be related to the rise in the level of T2S-like compound W in the serum of pregnant women.

The androgen control of sebum production. Studies of subjects with dihydrotestosterone deficiency and complete androgen insensitivity

To evaluate the androgen control of sebum, subjects with complete androgen insensitivity and male pseudohermaphrodites with inherited 5 alpha-reductase deficiency and decreased dihydrotestosterone (DHT) production had sebum production studied. A hydrophobic polymeric film applied to the forehead was used to measure sebum production through the use of air filled micropores. Sebum scores of normal preadrenarchal children (ages 2-6), and normal age-matched adult males and females, were studied as well as males treated with the 5 alpha-reductase inhibitor, finasteride, for benign prostatic hyperplasia who were studied at baseline and after drug therapy. Androgen insensitive subjects had no sebum production by this methodology, and the results were identical to preadrenarchal children. In contrast, adult male pseudohermaphrodites with 5 alpha-reductase deficiency and a selective decrease in DHT production had sebum production scores identical to normal age-matched males. Males with benign prostatic hyperplasia treated with the 5 alpha-reductase inhibitor, finasteride, to lower DHT levels did not decrease the sebum score from baseline values. The lack of demonstrable sebum in androgen-insensitive subjects clearly demonstrates the absolute androgen control of sebum production. The DHT dependency of the sebaceous gland, however, could not be demonstrated in this study. Two 5 alpha-reductase isoenzymes 1 and 2, have been described. 5 alpha-reductase-2 is the gene responsible for inherited 5 alpha-reductase deficiency. Although the degree of inhibition of DHT in utero and in adulthood in male pseudohermaphrodites with a defect in 5 alpha-reductase-2 enzyme activity caused severe impairment of external genital and prostate differentiation and decreased facial and body hair, it had no demonstrable effect on sebaceous gland development or function. Furthermore, lowering DHT levels in adulthood had no effect on sebum production. If the gland is rich in the enzyme 5 alpha-reductase-2, it is proposed that the sebaceous gland is either exquisitely sensitive to DHT, requiring only small amounts for normal development and function, or that male levels of testosterone compensate for DHT and maintain normal sebaceous gland activity throughout life. It is also possible that 5 alpha-reductase-1 is the enzyme of the sebaceous gland and is unaffected in the inherited condition and by finasteride.

Comparison of the effects of the 5 alpha-reductase inhibitor finasteride and the antiandrogen flutamide on prostate and genital differentiation: dose-response studies

Studies were performed to compare the effects of 5 alpha-reductase inhibition and antiandrogen receptor blockade on differentiation of male internal and external genital structures and prostate in the rat. Dose-response studies were performed on male rats treated in utero during the period of sexual differentiation with either the potent 5 alpha-reductase inhibitor finasteride or the antiandrogen flutamide. The treated animals were raised to adulthood and killed, and genital structures were evaluated. Treatment with the 5 alpha-reductase inhibitor finasteride at a dose of 25 mg/kg.day resulted in significant feminization of the external genitalia. There was no further feminization of the genitalia at doses up to 300 mg/kg.day. Wolffian ductal differentiation occurred at all doses evaluated. Seminal vesicle weight, however, significantly decreased at 25 mg/kg.day, but without a further decrease at higher doses of the 5 alpha-reductase inhibitor. Vas deferens and epididymal weights were unchanged at all doses evaluated. There was a significant decrease in prostate size at 25 and 50 mg/kg.day, with no further decrease at higher doses. In flutamide-treated animals, complete feminization of the genitalia occurred at 24 mg/kg.day in all animals. At 18 mg/kg.day, Wolffian ductal differentiation occurred, but seminal vesicle weight was decreased. At dosages of 100, 200, and 300 mg/kg.day flutamide, the vas deferens was absent unilaterally or bilaterally, with small remnants of epididymal head and tail present. At dosages of 24 mg/kg.day and above, the prostate was absent. Studies with the 5 alpha-reductase inhibitor finasteride demonstrate the dependency of prostate and male external genital differentiation on dihydrotestosterone (DHT). However, unlike androgen receptor blockade with flutamide, finasteride did not totally abolish prostate differentiation or completely feminize the external genitalia, despite increasingly higher doses. Since there is no evidence of multiple 5 alpha-reductase isoenzymes to date in the rat, these results suggest that testosterone (T) can compensate for DHT to some degree at the level of the androgen receptor. Wolffian differentiation, however, was not affected by inhibition of DHT, demonstrating its T dependency, but seminal vesicle growth was impaired. Thus, inhibition of 5 alpha-reductase activity limits seminal growth potential in adulthood. Studies with the antiandrogen flutamide show that at doses significantly above that required to completely block prostate differentiation and cause genital feminization, Wolffian ductal differentiation is significantly impaired. Thus, higher doses of flutamide are needed to block the paracrine effect of T on the Wolffian ducts.

Pulmonary paragonimiasis in Southeast Asians living in the central San Joaquin Valley

We describe four cases of pulmonary paragonimiasis in Southeast Asians who emigrated to the central San Joaquin Valley of California. Physicians should be alerted to the possibility of this disease in Asian patients with hemoptysis and pulmonary infiltrates. Paragonimiasis can masquerade as pulmonary tuberculosis, especially in patients from areas that are endemic for both the parasite and the tubercle bacillus. The ease and safety with which this infection can be treated, in contrast to tuberculosis, reiterates the importance of diagnosing this lung fluke when it is present.

Ovulation induction in women with premature ovarian failure: a prospective, crossover study

A prospective crossover study comparing ovulation induction techniques in eight women with premature ovarian failure is presented. These patients were treated with FSH rebound techniques using the GnRH-a, LA, alone in one treatment cycle and the same plus menopausal gonadotropins in the other treatment cycle. Two women ovulated in each group. We conclude that ovulation does occur in women with premature ovarian failure, but that luteal P may be inadequately secreted.

Predicting pregnancy outcome by the observation of a gestational sac or of early fetal cardiac motion with transvaginal ultrasonography

Transvaginal ultrasound (US) allows for observation of the gestational sac and cardiac motion as early as 3 and 4 weeks after ovulation, respectively. The purpose of this study was to determine how well the first observation of cardiac motion, using weekly transvaginal US examinations, predicted pregnancy outcome. Three hundred sixteen pregnancies wherein the date of ovulation was known and a single gestational sac was visualized at 3 weeks after ovulation were studied. Cardiac motion was first detected at 4 weeks after ovulation in 226 (71.5%), and at 5 weeks in 67 (21.2%). In 23 patients, cardiac motion was never observed. In those patients with cardiac motion visible at 4 weeks after ovulation, 94.2% have subsequently delivered viable infants. This contrasts with only 70.1% for those patients who first had observable cardiac motion 1 week later (P = 6.7 X 10(-6]. This study demonstrates that the solo finding of a gestational sac is a poor predictor of pregnancy outcome (82.3% accurate) and that the earlier that cardiac motion is initially observed, the better the pregnancy prognosis.

Bilateral congenital absence of the fibula

The syndrome caused by congenital absence of the fibula has a number of pathologic abnormalities frequently associated with it, which are illustrated by the case reported. Postsurgical therapy on the involved extremity should take into account the patient's lack of joint motion within the tarsal region. With this in mind, special shoes or accommodative insoles, alone or in combination, should be prescribed in order to facilitate an increase in weightbearing activity with minimal discomfort.

Correlation of acrosomal status and sperm performance in the sperm penetration assay

The sperm of some infertile men are unable to penetrate zona pellucida-free hamster oocytes but gain that ability after treatment with human follicular fluid (hFF). We asked whether altered incidences of acrosome reacted sperm explained these observations. Patient sperm failing to penetrate oocytes had fewer acrosome reactions than did healthy males, but the percentage reacted was not correlated with oocyte penetration. Sperm incubated 3 hours, then exposed to hFF, exhibited increased penetrations for 7 of 10 males, without an increase in percentage reacted sperm. Sperm incubated 22 hours before hFF treatment had penetrating ability enhanced 250- to 1000-fold, but the percentage reacted increased only sixfold. We conclude that factors other than the percentage reacted sperm are the major determinants of penetration capacity.

Gamete intrafallopian transfer: the effect of the number of eggs used and the depth of gamete placement on pregnancy initiation

The role of the fallopian tube in initiating pregnancy was examined in 246 consecutive gamete intrafallopian transfer (GIFT) cycles. Before actual transfer, the ampulla of each tube was measured to determine the depth at which gametes could be placed. Fifty-seven transfers were made with four oocytes into a single tube; of these, when gametes were deposited deeper than 4 cm, the pregnancy rate was higher than when they were placed at between 3 to 4 cm (69.6% compared with 41.2%). Presumably, a deeper placement is more secure and decreases the likelihood of gamete displacement. The pregnancy rate also rose with the number of oocytes used: from 0% with a single oocyte to 42.9% with four oocytes.

Elevated plasma atrial natriuretic factor and vasopressin in high-altitude pulmonary edema

A diagnosis of acute high-altitude pulmonary edema was made in five male skiers (age, 35.0 +/- 1.8 years) by history and physical examination and was confirmed by a characteristic chest radiogram showing alveolar infiltrates associated with a normal cardiac silhouette. Five healthy age- and sex-matched subjects with similar physical activity at the same altitude served as controls. Plasma sodium was 135.0 +/- 1.5 mmol/L in the acutely ill patients compared with 144.0 +/- 3.3 mmol/L in the controls (P less than 0.025). Mean plasma atrial natriuretic factor immunoreactivity averaged 17.6 +/- 5.6 pmol/L in patients with high-altitude pulmonary edema compared with 6.8 +/- 0.7 pmol/L in the controls at the same altitude (P less than 0.05). Elevated atrial natriuretic factor levels normalized to 7.5 +/- 1.9 pmol/L (P less than 0.05) during recovery in Denver (altitude, 1600 meters) 24 hours later. Plasma arginine vasopressin levels were 1.8 +/- 0.37 pmol/L in patients with high-altitude pulmonary edema at diagnosis compared with 0.92 +/- 0.28 pmol/L in controls (P = 0.07). The inappropriately elevated arginine vasopressin levels decreased to 1.29 +/- 0.37 pmol/L during recovery (P less than 0.025), but the lowered plasma sodium concentration had not normalized by discharge within 24-hours of transfer to Denver and averaged 135.8 +/- 1.2 mmol/L. The pathophysiologic implications of these findings are discussed.

Modification of the sperm penetration assay using human follicular fluid to minimize false negative results

Controversy surrounds the hamster test because of its frequent lack of correlation with human in vitro fertilization (IVF). This may be due to the low percentage of acrosome-reacted sperm that results from the assay's methodology. With the use of human follicular fluid (hFF) to increase the proportion of acrosome reactions, the penetration rate was raised by an average of 38% in 74% of samples from the subfertile men tested. Consistent enhancement prevailed in three subfertile patients, who were tested over a 6-month period. Brief exposure of the spermatozoa to follicular fluid may more accurately simulate the human IVF condition leading to capacitation and perhaps minimizing false-negative sperm penetration assays (SPAs).

Successful pregnancies from cryopreserved human embryos produced by in vitro fertilization

Sixty-three embryos produced after in vitro fertilization in 30 infertile couples were frozen and stored. Dimethylsulfoxide was used as a cryoprotectant and embryos were frozen from the two-cell stage to early blastocyst development. Replacement occurred during spontaneous ovulatory cycles 2 to 15 months after embryo freezing. Embryo replacement was performed 3 to 6 days following identification of the luteinizing hormone surge in the spontaneous cycle. Thirty-five embryos were replaced into 25 women and two viable pregnancies resulted.

Correlation of transabdominal and transvaginal ultrasound measurements of follicle size and number with laparoscopic findings for in vitro fertilization

This paper compared the use of a transvaginal scanning approach with the conventional transabdominal scanning method. In study I, 15 patients with previous suboptimal abdominal ultrasounds were evaluated in subsequent cycles with both the transabdominal and the transvaginal techniques. With the transvaginal method, improvement was observed in 13 patients (87%). Study II compared both the transabdominal and transvaginal ultrasound measurements of follicle number and size with surgical findings. A high correlation (r = 0.914, P less than 0.001) was demonstrated between the number of follicles visualized by transvaginal sonogram and the number of follicles aspirated. A significant correlation (r = 0.639, P less than 0.001) was also observed between follicular fluid volume and the mean ultrasound follicle diameter determined transvaginally.

Reliability of urinary pregnancy tests in the diagnosis of ectopic pregnancy

Recently a new generation of urinary pregnancy tests with increased sensitivity and specificity for beta-human chorionic gonadotropin (beta-HCG) was introduced. The clinical sensitivity of seven of these tests was evaluated in patients with surgically proven ectopic pregnancy. Two enzyme-linked immunosorbent assays (Tandem Visual, Hybritech; Mod C1, Monoclonal Antibodies), with a sensitivity of 50 mIU of beta-HCG, were positive in 90% of ectopic pregnancies. The three-tube tests (Sensitex, Roche; UCG Beta Stat, Wampole; beta-Neocept, Organon), with a sensitivity of 150-250 mIU of beta-HCG, were positive in 81-85% of ectopic pregnancies. Two slide tests (UCG Beta Slide, Wampole, and Sensislide, Roche), with a sensitivity of 500-800 mIU of beta-HCG, were positive in 51-61% of ectopic pregnancies. Both the immunosorbent assays and the tube tests were statistically more sensitive than the slide tests (P less than .001). There was no statistically significant increase in sensitivity between the tube tests and the immunosorbent assays. The sensitivities of these tube tests in ectopic pregnancy are similar to those of tube tests from other manufacturers previously reported on.