Outcome in the second year of life after in-vitro fertilisation by intracytoplasmic sperm injection: a UK case-control study

BACKGROUND

There have been reports suggesting that children born after in-vitro fertilisation by intracytoplasmic sperm injection (ICSI) are at increased risk of neurodevelopmental delay. We have undertaken a case-control study of this issue.

METHODS

We studied 208 singleton children conceived by ICSI and a control group of 221 normally conceived singleton children. Children were recruited from 22 fertility centres and local nurseries throughout the UK. Controls were selected to match cases as closely as possible for social class, maternal educational attainment, region, sex, and race. The primary outcome measure was neurodevelopmental scoring; secondary measures were perinatal outcomes, postnatal health, and congenital abnormalities. A single examiner assessed all the children.

FINDINGS

A follow-up rate of 90% for the ICSI group was achieved at a mean age of 17 months. No difference between the study children and controls was found in mean neurodevelopmental scores (98.08 [SD 10.93] vs 98.69 [9.99]) or any subscales on the Griffiths' scales of mental development. Perinatal outcome was similar apart from a higher rate of caesarean section (73 [35.1%] vs 53 [24.0%], p=0.015) and a lower mean birthweight (3163 [SD 642] vs 3341 [606] g, p=0.013) in the study group. Rates of major congenital abnormality were also similar overall (ten [4.8%] study vs ten [4.5%] control), although there were significantly more congenital anomalies among children born to fathers with oligozoospermia than in other children.

INTERPRETATION

This population study did not show any significant difference between children conceived after ICSI and their naturally conceived peers in terms of physical health and development.

Early pregnancy is elusive and robust

We describe a live birth occurring following bilateral ovarian diathermy, hysteroscopy and dye test in women with clomiphene citrate resistant polycystic ovarian syndrome performed inadvertently during early pregnancy. A woman with polycystic ovarian syndrome resistant to Clomiphene citrate had bilateral laparoscopic ovarian diathermy performed inadvertently during early pregnancy. The patient was treated by Clomiphene citrate for 12 cycles then she had bilateral laparoscopic ovarian diathermy and hysteroscopy and dye test. Pelvic ultrasound examination, serum beta hCG, serum LH, FSH, Prolactin, T, SHBG, DHAS and serum E2 level. Successful outcome of pregnancy following bilateral laparoscopic ovarian diathermy and hysteroscopy and dye test inadvertently performed during early pregnancy. That all women scheduled for elective pelvic surgery should be advised to use effective contraception or avoid unprotected sexual intercourse in the preceding month as well as having an hCG test prior to surgery to exclude pregnancy.

Prevention of severe ovarian hyperstimulation syndrome in IVF with or without ICSI and embryo transfer: a modified 'coasting' strategy based on ultrasound for identification of high-risk patients

Ovarian hyperstimulation syndrome (OHSS) can be a severe and potentially life-threatening complication of ovarian stimulation for IVF. Coasting or withholding gonadotrophin stimulation relies on frequent estimation of serum oestradiol to identify patients at risk. A modified coasting protocol was developed in which identification of patients at risk of severe OHSS was based on ultrasound monitoring. Serum oestradiol concentrations were measured only in patients with >20 follicles on ultrasound (high risk). If serum oestradiol concentrations were <3000 pmol/l, the gonadotrophin dose was maintained; if concentrations were >/=3000 pmol/l but <13200 pmol/l and >/=25% of the follicles had a diameter of >/=13 mm, the gonadotrophin dose was halved; and if serum oestradiol concentrations were >/=13 200 pmol/l and >/=25% of the follicles had a diameter of >/=15 mm, patients were coasted. In the latter group, human chorionic gonadotrophin (HCG) 10000 IU was administered when at least three follicles had a diameter of >/=18 mm and serum oestradiol concentrations were <10000 pmol/l. Over a 10 month period, serum oestradiol concentrations were measured in 123 out of 580 cycles (24%) and in 50 cycles, gonadotrophins were withheld. Overall, moderate OHSS occurred in three patients (0.7%) and severe OHSS in one patient (0.2%). The pregnancy rates in the cycles where the gonadotrophin dose was reduced or withheld were 39.6 and 40% per cycle respectively; corresponding implantation rates were 30.7 and 25.6%. It is concluded that the modified coasting strategy is associated with a low risk of moderate and severe OHSS to a minimum without compromising pregnancy rates. Identification of patients at risk by ultrasound reduces the number of serum oestradiol measurements and thus inconvenience to patients as well as costs and workload.

Does laparoscopic ovarian diathermy affect the outcome of IVF-embryo transfer in women with polycystic ovarian syndrome? A retrospective comparative study

Controlled ovarian stimulation for IVF and embryo transfer and outcome parameters were compared retrospectively in 31 women with clomiphene-resistant polycystic ovarian syndrome (PCOS). Of these women, 15 had previously undergone laparoscopic ovarian diathermy before IVF (group A, total 22 cycles) and 16 had not had surgical treatment (group B, total 24 cycles). No statistically significant differences were observed in the number of oocytes retrieved, although the number of embryos available for transfer was significantly higher in group B (7.1 +/- 3.8 versus 4.6 +/- 2.7, P < 0.01). The clinical pregnancy rate per embryo transfer appeared to be higher in group B (63.2 versus 41.2%), as did the miscarriage rate (66.7 versus 28.6%), giving an apparent improved ongoing pregnancy rate per embryo transfer in group A (29.4 versus 10.5%), but this was not statistically significantly different. The incidence of severe ovarian hyperstimulation syndrome (OHSS) was apparently higher in group B (4.2 versus 0%), but this difference was not statistically significant. No cases of severe OHSS were seen in group A. Ovarian diathermy does not appear to have a deleterious effect on controlled ovarian stimulation, and the outcome of IVF-embryo transfer may be beneficial in decreasing the risk of severe OHSS and improving the ongoing clinical pregnancy rate.

Serum oestradiol and progesterone concentrations during prolonged coasting in 15 women at risk of ovarian hyperstimulation syndrome following ovarian stimulation for assisted reproduction treatment

Serum oestradiol and progesterone concentrations were examined for up to 7 days after withholding gonadotrophins whilst continuing pituitary down-regulation in 15 women at serious risk of severe ovarian hyperstimulation syndrome (OHSS) (serum oestradiol >6000 pg/ml and >15 follicles per ovary). Serum oestradiol concentrations rose on day 1 of coasting in all but two of the 15 women before falling, the decrement being in the order of 40% on each day. This observation permits a rational basis for the estimation of frequency of serum oestradiol measurements and duration of coasting. The trends and rates of fall of serum oestradiol do not seem to predict the occurrence of moderate and severe OHSS, being similar in the six women who developed OHSS compared with nine women without OHSS. The trends in progesterone concentrations were unrelated to any aspects of the clinical outcome.

Influence of position and length of uterus on implantation and clinical pregnancy rates in IVF and embryo transfer treatment cycles

In a prospective study of 807 consecutive women shown to have an apparently normal uterus after hysterosalpingography, hysteroscopy or pelvic ultrasonography prior to IVF or intracytoplasmic sperm injection (ICSI) and embryo transfer, the position and length of the uterine cavity was measured routinely at a pre-treatment mock transfer procedure. The apparent length of the uterine cavity was <7 cm in 128 women (group 1), 7-9 cm in 594 women (group 2) and >9 cm in 85 women (group 3). The uterus was noted to be retroverted in 38. 2% (308) women. The embryo transfer catheter was advanced to 5 mm from the uterine fundus based on the previously determined cavity length in all the embryo transfer procedures at 48 h after oocyte collection. Implantation and clinical pregnancy rates were not significantly different with respect to position of the uterus, difficulties encountered in passage of the catheter, mean age of the women, aetiology or duration of infertility or embryology events. An apparently greater cavity length was seen in older and/or parous women, but the difference was not statistically significant. Although the highest implantation and clinical pregnancy rates were seen in women with a cavity length of 7-9 cm (group 2) the differences were not statistically significant: group 1, 18.9 and 36. 7%; group 2, 21.0 and 46.5%; and group 3, 17.3 and 32.9% respectively. The incidence of ectopic pregnancy per reported clinical pregnancy was highest in group 1 women, being 14.9% (7/47) in comparison with group 2 (1.8%, 5/276) and group 3 (0%, 0/27) (P: < 0.0005), suggesting that the size of the uterus is a critical factor in the aetiology of ectopic pregnancy in IVF/ICSI-embryo transfer.

Does pretreatment with progestogen or oral contraceptive pills in low responders followed by the GnRHa flare protocol improve the outcome of IVF-ET?

PURPOSE

Women undergoing in vitro fertilization with low ovarian reserve and poor response to controlled ovarian hyperstimulation (COH) present a management dilemma. In a retrospective observational study, we compared the pretreatment use of the gestogen medroxyprogesterone acetate (10 mg twice daily from day 15 of the cycle for a minimum of 2 weeks) with an oral contraceptive pill (one tablet daily from day 4 of the cycle for a minimum of 3 weeks).

METHODS

The criteria for inclusion in the study included one or more of the following: abandoned cycles due to poor response, fewer than four oocytes retrieved following a standard COH protocol, age > 39 years, and elevated basal serum follicle-stimulating hormone (FSH). Thirty-eight women received pretreatment with gestogen, and a similar number of women received pretreatment with the pill. The flare protocol was used in all treatment cycles combined with an individualized dose of human menopausal gonadotropin (hMG) (4-8 ampoules/day of 75 units FSH/ampoule) depending on previous response, age, and early follicular serum FSH level. Both groups were similar in mean age, duration of infertility, early follicular FSH levels, and the distribution of various aetiologies.

RESULTS

Twenty-nine cycles were abandoned before oocyte retrieval, 15 (39.5%) in the pill group and 14 (36.8%) in the gestogen group, because of an inadequate ovarian response. The mean (+/- SD) number of ampoules (75 IU FSH/ampoule) of hMG used per cycle was similar in the pill and gestogen groups (59.7 +/- 19.3 vs. 70.2 +/- 29.4, respectively). There also was no difference seen in the numbers of oocytes retrieved (4.4 +/- 2.3 vs. 4.2 +/- 2.5), total number of embryos (2.5 +/- 2.4 vs. 2.2 +/- 1.1), or the number of embryos transferred (1.8 +/- 1.2 vs. 2.1 +/- 1.0) in the pill and gestogen groups, respectively. One pregnancy in each group resulted following embryo transfer in 22 women in the pill group and in 24 women in the gestogen group.

CONCLUSIONS

We conclude that pre-IVF treatment with oral contraceptive pill or gestogen combined with the flare protocol in women at high risk of or with a history of poor ovarian response, as defined in this study, did not appear to result in an improvement in outcome of IVF-embryo transfer.

Intrauterine donor insemination in single women and lesbian couples: a comparative study of pregnancy rates

The outcome of intrauterine donor insemination (IUI-DI) with frozen spermatozoa was analysed retrospectively in 675 cycles in single women (n = 122; 536 cycles) and lesbian (n = 35; 139 cycles) couples. The lesbian patients were younger at the initiation of treatment (mean 34.5 years; range 26-44) than the single women (mean 38.5; range 29-47) (P = 0.005). Clinical pregnancy rate was 36% in single women and 57% in lesbians (P < 0.05), the cumulative pregnancy rate after six cycles being 47% and 70% respectively, although the outcome was similar when related to age. The miscarriage rate was higher (35%) in single women than in lesbians (15%; P < 0.05), the rate being independent of maternal age. There were no apparent differences seen between the two groups with respect to the possible effect of parity, duration of infertility, causes of infertility and type of treatment at initiation of treatment; the sole exception was that the age of lesbian women was statistically significantly younger than that of single women (P < 0.005). When corrected for age, the pregnancy rates and complications were lower and higher respectively in single women but these differences did not reach statistical significance. However, the disparity between the treatment outcomes of single women and lesbian patients of similar ages may also reflect the fact that single women are likely to have failed to conceive for a period of time prior to referral to a specialist centre for treatment.

Superoxide dismutase activity in human follicular fluid after controlled ovarian hyperstimulation in women undergoing in vitro fertilization

OBJECTIVE

To determine the activity of superoxide dismutase (SOD) and the total protein concentration in human preovulatory ovarian follicular fluid (FF) in relation to corresponding serum levels and the fertilization capacity of oocytes.

DESIGN

Prospective, observational study.

SETTING

Academic-based center for reproductive medicine.

PATIENT(S)

Twenty-eight female partners of infertile couples, 13 of whom were smokers, undergoing controlled ovarian hyperstimulation for IVF.

INTERVENTION(S)

Blood and follicular fluid samples were collected 34-36 hours after hCG administration.

MAIN OUTCOME MEASURE(S)

Levels of SOD activity and total protein concentrations.

RESULT(S)

Superoxide dismutase activity was present in all the FF studied and mean levels were statistically significantly higher than in serum. Total protein concentrations in serum were statistically significantly correlated with corresponding concentrations in FF. There was no difference in SOD activity between smokers and nonsmokers. Total protein concentrations in FF were marginally and statistically significantly lower in nonsmokers. Follicular fluid from patients whose oocytes did not become fertilized had a statistically significantly higher level of SOD activity than that from patients whose oocytes did become fertilized.

CONCLUSION(S)

Superoxide dismutase activity is present in FF and is higher than in serum. The degree of SOD activity is variable and seems to be inversely related to the fertilization of oocytes.

Prophylactic antibiotics and endocervical microbial inoculation of the endometrium at embryo transfer

Prophylactic antibiotics administered routinely to women at the time of oocyte retrieval were associated with a reduction in positive microbiology cultures of embryo catheter tips 48 h later in 78.4% of patients. The implantation and clinical pregnancy rates were significantly lower (9.3% vs 21.6%, p<0.001; 18.7% vs 41.3%, p<0.01) in the women with positive microbial catheter-tip cultures.

Antiphospholipid antibodies in infertile couples with two consecutive miscarriages after in-vitro fertilization and embryo transfer

Of 682 women who had undergone in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) with embryo transfer, 84 were successful on two occasions, with 16 of these resulting in miscarriage before 20 completed weeks. Antiphospholipid antibodies (APA) were estimated by enzyme-linked immunosorbent assay in these women (group 1) and compared to two control groups: 42 fertile women with three or more miscarriages (group 2) and 60 women with primary infertility undergoing IVF or ICSI (group 3). An apparently higher prevalence of seropositivity was seen in group 1 women (25%) compared to the group 3 women (6.6%) and it was similar to that seen in group 2 women (21.4%). Therefore the recommendation that women with two consecutive miscarriages after IVF or ICSI should have APA estimations performed routinely may be justified.

Early unilateral follicular aspiration compared with coasting for the prevention of severe ovarian hyperstimulation syndrome: a prospective randomized study

Thirty women undergoing in-vitro fertilization or intracytoplasmic sperm injection considered to be at high risk of ovarian hyperstimulation syndrome (OHSS) were randomly allocated to have early unilateral follicular aspiration (EUFA) (group 1) or coasting (group 2) when the serum oestradiol concentration was >6000 pg/ml and there were more than 15 follicles each of >/=18 mm diameter in each ovary. EUFA was performed in group 1 at 10-12 h after the human chorionic gonadotrophin (HCG) trigger injection and human menopausal gonadotrophin (HMG) were withheld for 4.9 +/- 1.6 days until serum oestradiol concentrations fell below 3000 pg/ml when HCG was administered. The mean total dose and duration of administration of HMG were similar in groups 1 and 2 (48.3 +/- 17.4 and 50.2 +/- 16.5 ampoules; 13.7 +/- 2.2 and 14.1 +/- 3.2 days respectively). The mean serum oestradiol concentrations (9911 pg/ml versus 10 055 pg/ml) and number of follicles (43.3 versus 41.4) seen in both ovaries on the day of HCG administration in group 1 and on the day coasting was commenced in group 2 were also similar. After coasting, the mean serum oestradiol concentration on the day of HCG administration in group 2 was lower than in group 1 (1410 pg/ml versus 9911 pg/ml; P < 0.001). The mean serum progesterone concentrations on the day of HCG administration in both groups were similar, and fell in all women in group 2. The mean number of oocytes retrieved and percentage of oocytes retrieved per follicle punctured was significantly higher in group 1 (15.4 +/- 2.1 versus 9.6 +/- 3.2, P < 0.001; 91.4 +/- 4.4% versus 28.3 +/- 3.7%, P < 0.001 respectively). The fertilization and embryo cleavage rates were similar in both groups. Clinical pregnancy was diagnosed in 6/15 (40%) patients in group 1 and in 5/15 (33%) patients in group 2, while four women in group 1 and three in group 2 developed severe OHSS.

Concentrations of placental protein 14 in uterine flushings from infertile women: validation of the collection technique and method of expression of results

Concentrations of various proteins in uterine flushings have been described as a direct method for assessment of the secretory activity of the endometrium. We investigated levels of the endometrial protein known as placental protein 14 (PP14) in flushings obtained from 271 infertile women. Under transvaginal ultrasonographic control, 2 ml of 0.154 M sodium chloride solution were injected into the uterine cavity and re-aspirated, five times. In contrast to previous studies the recovered volume of each flushing was not consistent (range: 0.05-2.1 ml); the volume varied significantly between serial samples obtained from an individual (P = 0.02, one-way ANOVA), different cycle days (P < 0.0001, one-way ANOVA) and women with bilaterally blocked versus patent Fallopian tubes (P < 0.05, Student's t-test). Concentrations of PP14 showed a better correlation with protein content (r = 0.506, P < 0.0001) than with the recovered volume (r = 0.087, P = 0.095). We therefore corrected PP14 concentrations for total protein content as an indicator of the efficiency of the flushing process. Corrected PP14 concentrations varied significantly relative to time since the onset of menstruation (P = 0.001, Kruskal Wallis ANOVA) with higher levels on days 1-8, as previously observed in plasma samples. No significant difference in PP14 levels was found with different causes of infertility. This study shows that uterine flushing is not a consistent process in women with differing physical characteristics and at varying times throughout the menstrual cycle.

Routine use of saline hysterosonography in 500 consecutive, unselected, infertile women

Saline hysterosonography was attempted as a routine, first-line screening test of uterine structure in 500 consecutive, unselected, infertile women. The procedure was completed in 96.8% (484/500) women and the observations were interpretable in 483 of these women. Intrauterine pathology was suspected in 67/499 (13.4%) women on plain ultrasound scan and 58/484 (12%) women with saline hysterosonography. Ultrasound alone had a superior specificity (96.3%) to sensitivity (81.8%) and better negative (97.6%) than positive (73.8%) predictive value for the detection of any intrauterine abnormality, using saline hysterosonography as the reference procedure. Suspected pathology at saline hysterosonography led to hysteroscopy in 20 women, after a median of 5.7 months (range, 1-14). The overall concordance rate between the two procedures was 65% with lesions suspicious of intrauterine polyps not present at subsequent hysteroscopy on six occasions. Criteria were established to help identify women with potentially self-limiting lesions, in whom a re-scan should be considered before resorting to hysteroscopy. The procedure was well tolerated with no significant complications. Saline hysterosonography appeared to be an acceptable first-line screening procedure for uterine structure which enhanced the predictive power of ultrasound alone for uterine anomalies and provided additional information which was potentially of value when planning operative hysteroscopy.

Effect of smoking on ovarian reserve and ovarian stimulation in in-vitro fertilization and embryo transfer

The effect of cigarette smoking on ovarian reserve as measured by basal serum follicle stimulating hormone (FSH) concentrations, and by the response to a standard ovarian stimulation protocol, was examined retrospectively in 173 consecutive women (108 non-smokers and 65 smokers) undergoing in-vitro fertilization (IVF) and embryo transfer treatment. Women who smoked had a higher mean basal serum FSH concentration (P < or = 0.0001), in particular younger (<36 years) women, and required a statistically significantly higher mean dosage of gonadotrophins for ovarian stimulation than the non-smokers (48.1 +/- 15.6 versus 38.9 +/- 13.6 ampoules, 75 IU/ampoule; P < 0.0001). A lower mean number of oocytes was obtained in smokers than non-smokers (6.2 +/- 3.4 versus 11.1 +/- 6.3, oocytes P < or = 0.0001) and the rate of abandoned cycles (18.5 versus 8.5%) and total fertilization failure (18.5 versus 8.5%) was higher. The clinical pregnancy rate per cycle in smokers was 16.9% versus 21.3% in non-smokers but this was not statistically significant. In conclusion, cigarette smoking in women appears to significantly reduce their ovarian reserve and lead to poor response to ovarian stimulation at an earlier age.

Evaluation of the performance of hysterosalpingo contrast sonography in 500 consecutive, unselected, infertile women

The performance of hysterosalpingo contrast sonography (Hy Co Sy) as a first-line, outpatient investigation of tubal patency was examined in 500 consecutive, infertile women, at one centre. Hy Co Sy was completed in 463 (92.6%) cases, using a galactose microbubble contrast agent (Echovist-200) and transvaginal sonography. Initial plain scanning identified adnexal pathology in 198 women (39.6%). Examination with Echovist was attempted for 905 tubes and only 67 (7.4%) were not assessable; after the first 100 women this decreased to 35 tubes (4.8%). A sonographic appearance compatible with blocked tubes was found on 118 (14.1%) occasions but it was also possible to identify variations in the appearance/filling/spilling patterns of individual tubes which increased the number assessed as abnormal to 193 (23.0%). Comparison with laparoscopy and dye chromopertubation findings from the past three years was possible for 185 (37%) women, representing 282 tubes, which gave Hy Co Sy an overall concordance rate of 85.8%, sensitivity of 90.4%, specificity of 70.3%, positive predictive value of 91.2% and negative predictive value of 68.2%. Some 51.0% of women described only mild discomfort and there were no significant postprocedure complications. Hy Co Sy appears to be an acceptable first-line screen and may select out women in whom more invasive investigations are likely to reveal pathology.

First trimester maternal serum concentrations of fetal antigen 2 in normal pregnancies and those affected by trisomy 21

Serum concentrations of fetal antigen 2 (FA-2), the amino-propeptide of the alpha1 chain of collagen type I, were measured in peripheral blood from women with normal (n = 234) and trisomy 21 affected (n = 14) pregnancies between 9 and 11 weeks gestation. Serum FA-2 concentrations were seen to be stable throughout this period, and though raised FA-2 concentrations were seen at the 10th week of gestation, a statistically significant difference between normal and trisomy 21 affected pregnancies was not found overall. Therefore it seems unlikely that FA-2 has a role in first trimester screening for trisomy 21, despite the fact that significantly higher FA-2 concentrations in trisomy 21 and significantly lower concentrations in trisomy 18 had been previously demonstrated in amniotic fluid in the second trimester.

Maternal and perinatal outcomes of multiple pregnancy following IVF-ET

OBJECTIVE

To analyze the course of pregnancy and perinatal outcome in 31 twins, 22 sets of triplets and five quadruplet clinical pregnancies following conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) procedures and in relation to 58 singleton pregnancy following the same procedure.

METHODS

Retrospective analysis of maternal and neonatal medical records of 58 singleton, 31 twin, 22 triplet and five quadruplet pregnancies diagnosed at 7-8 weeks gestation following 561 embryo transfer procedures in 628 oocyte collections at the IVF Center in the Maternity Hospital, Kuwait from July 1994 to December 1996.

RESULTS

The clinical pregnancy rate in 628 cycles proceeding to oocyte collection was 32.6%, there being 58 singletons (50.6%), 31 twins (33.5%), 22 triplets (10.8%) and five quadruplets (2.5%). Early complicated outcomes included 47 miscarriages (23.7%), four ectopic pregnancies (1.9%) and one hydatidiform mole. The spontaneous fetal reduction rate was 20.6% in twin, 45.5% in triplet and 40% in quadruplet pregnancies. There was a significantly higher maternal and neonatal complication rate in the triplet group compared to singletons and twins, including threatened miscarriage, pre-eclampsia, antepartum hemorrhage, longer hospital stay and preterm labor. The chance of operative delivery was higher in high-order multiple pregnancy (HOMP). The major neonatal complications were related to prematurity. Neonatal morbidity and mortality were significantly higher in the triplet group. The need for admission to the Special Care Baby Unit (SCBU) and the Neonatal Intensive Care Unit (NICU) was significantly higher in HOMP. However, there were no statistically significant differences in the perinatal mortality in relation to the degree of HOMP.

CONCLUSION

Maternal complications, perinatal and neonatal morbidity after 2 years activities in the IVF Center have been reviewed leading to changes in policies of management, notably a reduction in the number of embryos transferred.

Attitudes towards routine human immunodeficiency virus (HIV) screening and fertility treatment in HIV positive patients--a UK survey

Of 70 fertility units licensed by the Human Fertilisation and Embryology Authority in the UK, 58 responded to a questionnaire regarding attitudes towards human immunodeficiency virus (HIV) screening and fertility treatment in HIV positive patients in November 1995. Of these 58 centres, 23 only performed routine screening for HIV for both partners, 24 for hepatitis B and eight for hepatitis C. In the event of a positive result in the male, fertility treatment would be offered in the form of donor insemination (n = 21), intrauterine insemination (IUI) after sperm washing (n = 21), and in-vitro fertilization (IVF) (n = 1). If the woman was HIV positive, two centres would offer IUI and three centres IVF. Nine centres had already provided treatment for couples in whom the male partner was HIV positive and two centres to HIV positive women.