High-quality embryos retain their implantation capability in overweight women

To assess the effect of obesity on implantation rate, pregnancy rate and course of pregnancy in young women undergoing IVF in whom only high-quality embryos were transferred, a cohort study included women attending the IVF unit in 2006-2007 with favourable parameters to achieve pregnancy (<38years, fewer than three IVF cycles, transfer of two high-quality embryos), grouped by body mass index (BMI). Of 230 women, 160 had a BMI ⩽25kg/m(2) (mean 21.6±2.2) and 73 had BMI >25kg/m(2) (mean 29.5±3.7). The overweight group had a higher consumption of gonadotrophins during stimulation. There were no between-group differences in treatment protocols, duration of gonadotrophin stimulation, maximal oestradiol concentrations, endometrial thickness and number of oocytes retrieved/fertilized, or in rates of pregnancy (51.3%, 52.1%), implantation (34.5%, 37.5%), multiple pregnancy, and abortion. Rate of gestational diabetes or pregnancy-induced hypertension was higher in the overweight group (23.3%, 8.2%; P=0.045). Within the overweight group, those with multiple pregnancies were at highest risk (31.3%, 6.9%; P=0.031). In conclusion, implantation and pregnancy rates are not compromised in overweight women when high-quality embryos are transferred. However, in overweight women, pregnancy complications remain high, mainly in those with multiple pregnancies.

The association between follicular size on human chorionic gonadotropin day and pregnancy rate in clomiphene citrate treated polycystic ovary syndrome patients

OBJECTIVE

To examine leading follicle size on human chorionic gonadotropin (hCG) day and pregnancy rate in anovulatory polycystic ovary syndrome (PCOS) patients treated with clomiphene citrate (CC).

DESIGN

Retrospective cohort study.

SETTING

Fertility clinics in women's health centers.

PATIENTS

Data on 291 infertile women with PCOS and irregular cycles who underwent 685 CC treatment cycles were used. Only cycles with one or two follicles >14 mm were included. hCG was administered once the leading follicle reached the size of 17-24 mm.

MAIN OUTCOME MEASURE(S)

Pregnancy rates in relation to leading follicle size.

RESULTS

Mono/bi-follicular response was observed in 418 cycles. Pregnancy rates were highest (13.6-18.6%) when hCG was administered in the presence of an 18-22 mm follicle, lowest with 17 mm, 23 mm and 24 mm (8.8%, 8.8% and 5.7%, respectively). No differences were observed in pregnancy rates between mono and bi-follicular cycles.

CONCLUSIONS

In CC treatment, hCG should be administered when follicular size is at the range of 18-22 mm.

Cumulative clinical pregnancy rates after COH and IUI in subfertile couples

To evaluate the influence of female age and cause of infertility on the outcome of controlled ovarian hyperstimulation (COH) and intrauterine insemination (IUI), we studied 2717 COH cycles in 1035 subfertile couples. The cumulative clinical pregnancy rates were 39% and 58% after three and six COH cycles, respectively. The cumulative pregnancy rate significantly decreased with maternal age and differed by cause of infertility. The cumulative pregnancy rate continued to increase with an increase in COH cycle number up to the third, or forth cycle, in patients with mechanical and combined infertility, respectively, and in up to the second cycle in patients aged 40 years or more. These findings provide treatment guidelines for clinicians in determining the likelihood of treatment success and the point at which to proceed to the next treatment strategy.

Neurotrophin 4 enhances in vitro follicular assembly in human fetal ovaries

OBJECTIVE

To investigate the in vitro effect of neurotrophin 4 (NT-4) on follicular assembly in human fetal ovaries.

DESIGN

Human ovarian tissue from fetuses at 19-20 gestational weeks was placed in organ culture for two weeks with NT-4. Control groups were cultured with a neutralizing antibody against NT-4.

SETTING

Infertility unit at an university-affiliated tertiary medical center.

PATIENT(S)

Four patients who underwent pregnancy terminations at 19-20 gestational weeks.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Histologic findings of follicular assembly.

RESULT(S)

Follicular assembly was significantly increased in the specimens cultured with NT-4 than in the uncultured specimens, the samples cultured without NT-4, and samples cultured with the neutralizing antibody. In the second week of culture, additional follicular assembly was promoted in the presence of 100 ng/mL NT-4 but not with 10 ng/mL NT-4.

CONCLUSION(S)

This is the first report showing that NT-4 seems to promote human follicular assembly in fetal ovaries, probably in a dose-dependent manner. Follicular assembly is regulated by multiple signals, and additional studies on the effects of other growth factors in combination with NT-4 are warranted.

High serum oestradiol concentrations in IVF cycles increase the risk of pregnancy complications related to abnormal placentation

The study was designed to evaluate the isolated effect of high serum oestradiol concentration on human chorionic gonadotrophin (HCG) day in IVF cycles on endometrial receptivity and placentation. A retrospective cohort included all women attending the IVF unit in 2006 and 2007, with the best prognosis to achieve pregnancy: age (<38 years), less than three IVF cycles, transfer of two highest grade embryos and no evidence of factors known to impair implantation or that are associated with increased risk of pregnancy complications. The total included 280 patients were categorized into three groups according to their serum oestradiol concentration on HCG day: group 1, oestradiol <5000 pmol/l, group 2, oestradiol in the range 5000-10,000 pmol/l and group 3, oestradiol in the range of 10,000-15,000 pmol/l. No significant differences were found between the groups in implantation, pregnancy and abortion rates. The high oestradiol group was characterized by high rate (20.8%) of pregnancy complications related to abnormal placentation--fetal growth restriction, pregnancy-induced hypertension and abnormal implantation of the placenta. Hence, the decision to perform embryo transfer in high-responder patients should take into consideration both possible risks of ovarian hyperstimulation syndrome and pregnancy complications related to abnormal placentation.

Expression of growth-differentiating factor 9 and its type 1 receptor in human ovaries

The expression of growth-differentiating factor 9 (GDF9) has not been studied in ovaries from girls and human fetuses nor has its receptor transforming growth factor-beta1 receptor (TGFbetaR1) been investigated in ovaries of girls/women. The aim of this study was to fill these gaps. Ovarian samples were obtained from 16 human fetuses at 21-35 gestational weeks and from 34 girls/women aged 5-39years. These specimens were prepared for immunohistochemical staining of the GDF9 and TGFbetaR1 proteins. Reverse transcription polymerase chain reaction was used to detect GDF9 mRNA transcripts and in-situ hybridization to localize TGFbetaR1 mRNA transcripts. Positive staining for the GDF9 protein was identified in oocytes and granulosa cells in all samples tested. GDF9 mRNA transcripts were present in all samples. Protein expression of TGFbetaR1 was identified in granulosa cells in all samples. Oocyte staining was identified in samples from girls/women but in only one fetal sample. TGFbetaR1 mRNA transcripts were identified in granulosa cells and oocytes in 50% of the samples from fetuses aged over 22 gestational weeks and in samples from girls/women. The detection of GDF9 and TGFbetaR1 at both at the protein and mRNA levels suggests that GDF9 may have functions in human preantral follicles.

Effect of coasting on IVF cycle characteristics and outcome in short vs. long GnRH agonist protocols

AIMS

To compare the results of IVF cycles following coasting in patients treated with long versus short GnRH agonist protocols.

METHODS

A retrospective comparative study in which all women aged 35 years or less attending the IVF unit from 2000 to 2006 in whom coasting was used in GnRH agonist protocols were included. Data on coasting-related variables and outcome were collected from the files and compared between the short GnRH agonist (n = 78) and long GnRH agonist (n = 181) cycles.

RESULTS

The short GnRH agonist cycles were characterized by higher E2 levels during coasting and longer duration of coasting than the long GnRH agonist cycles. Although the number of retrieved oocytes was lower following coasting in the short protocol, there was no difference between the groups in fertilization rate, number of high-quality embryos available for transfer, and pregnancy rate. Pregnancy rate in both protocols was negatively correlated to E2 level at initiation of coasting. The overall moderate and severe OHSS rate after coasting was 5.1% in the short-protocol group and 6.0% in the long-protocol group (p = 0.76).

CONCLUSIONS

The ovarian response curve to coasting is longer in the short than in the long GnRH-agonist protocol, but there is no significant difference in pregnancy or OHSS rates.

Administration of clomiphene citrate in patients with polycystic ovary syndrome, without inducing withdrawal bleeding, achieves comparable treatment characteristics and outcome

In an attempt to evaluate the effect of random timing of the start of clomiphene citrate (CC) treatment in anovulatory patients with polycystic ovary syndrome on treatment characteristics and outcome, with no regard to time of menstruation, we studied 291 women in their first CC treatment cycle. Duration of treatment was shorter by 2 days and number of leading follicles was higher when treatment was started late (7-29 days from starting a bleed, as compared with day 5), but no effect of starting day was observed on response rate to CC, maximal E(2) level, endometrial thickness, and pregnancy rate.

The effect of oral contraceptive pill for cycle scheduling prior to GnRH-antagonist protocol on IVF cycle parameters and pregnancy outcome

OBJECTIVE

To evaluate the effect of oral contraceptive pills (OCP) pretreatment on IVF cycle outcome in GnRH-antagonist protocol.

DESIGN

Retrospective cohort study.

SETTING

Major tertiary university-affiliated center.

PATIENTS

All patients treated with GnRH antagonist in our IVF unit during the last 3 years were included in the study. Overall 1,799 IVF cycles were performed. Of these, in 604 cycles OCP pretreatment was used prior to GnRH-antagonist for cycle scheduling. Patients were divided into two age groups-young group aged < or = 35 years and older group aged > or = 36 years.

INTERVENTIONS

The young group underwent 927 cycles, 281 cycles with OCP pretreatment and 646 cycles without. The older group underwent 872 cycles, 323 cycles with OCP pretreatment and 549 cycles without. Data was analyzed within each age group.

MAIN OUTCOME MEASURES

Treatment duration and total dose of FSH IU used for stimulation, number of oocytes retrieved, implantation and pregnancy rates.

RESULTS

All OCP-pretreated cycles required significantly longer stimulation than non-pretreated cycles (young: 10.76 vs. 9.21 days; older: 10.48 vs. 8.73 days, respectively) and higher total dose of FSH IU (young: 3,210 IU vs. 2,565 IU; older: 4,973 IU vs. 3,983 IU, respectively). There were no other differences in cycle characteristics between groups. Implantation and pregnancy rates were not affected by OCP pretreatment.

CONCLUSIONS

OCP pretreatment can be offered as a mode for cycle scheduling prior to GnRH-antagonist protocol, though it may be associated with longer stimulation and higher gonadotropin consumption.

Combined intrauterine and twin cervical pregnancy managed by a new conservative modality

OBJECTIVE

To describe a rare case of a heterotopic pregnancy with two gestational sacs in the cervix and one in the uterine cavity.

DESIGN

Case report.

SETTING

Tertiary university hospital.

PATIENT(S)

A 45-year-old woman was diagnosed with a triplet gestation 7 weeks following IVF treatment for primary infertility of 5 years' duration. Transvaginal ultrasound scan revealed three gestational sacs: one sac inside the uterine cavity containing a live fetus, and two sacs in the uterine cervix, one containing a live fetus and a second empty sac.

INTERVENTION(S)

Pregnancy termination was performed by selective intraarterial catheterization of the uterine artery, intraarterial administration of methotrexate, and uterine artery embolization with Gelfoam.

MAIN OUTCOME MEASURE(S)

Intra- or postprocedural complications and fertility preservation.

RESULT(S)

The pregnancy termination was successfully performed without intra- or postprocedural complications, with preservation of the patient's fertility.

CONCLUSION(S)

Intraarterial methotrexate with uterine vessel embolization is an effective conservative approach to heterotopic cervical pregnancy.

Risk of major congenital malformations associated with infertility and its treatment by extent of iatrogenic intervention

BACKGROUND

Cumulative evidence from large cohort studies, multicenter studies, and meta-analyses suggests that assisted reproductive technologies are associated with an elevated risk of congenital malformations. Theoretically, there are several putative factors in infertility treatments which may be related to the development of congenital malformations. These include, in part, the exposure to gonadotrophin stimulation and the exposure to supra-physiological levels of E2; the altered physiological environment of implantation; the in-vitro culture conditions at early stages of embryonic development; the artificial selection of sperm for fertilization and the sperm injection process in ICSI and the process of embryo cryopreservation. However, it is also possible that the culprit is not the infertility treatment that leads to the increased risk of congenital malformations but a factor or factors inherent to infertile patients.

OBJECTIVE

The aim of this review is to present the current data, summarize it and define the association between major congenital malformation and different types of infertility treatments as well as to infertility per se.

MATERIAL AND METHODS

We conducted an extensive search of the medical literature (Pubmed, 1985-2006) to identify all data relating major congenital malformations to infertile couples, infertility treatments or to characteristics of the infertile population. The rates of congenital malformations associated with infertility were analyzed by the degree of iatrogenic intervention to better define the relative risks.

RESULTS

The findings confirmed the increased risk of congenital malformations in relation to in vitro fertilization even in singleton infants. There was no difference in the occurrence of major congenital malformations by either the laboratory maneuvers of sperm or embryos of varying complexity or by the specific medications used for ovarian stimulation or luteal support. Increased risk for congenital malformations was also found in infertile couples in relation to infertility treatment with ovulation induction with or without intrauterine insemination and even in spontaneous conception.

CONCLUSIONS

The data seems to indicate that infertile couples harbor an inherent, a priori risk for congenital malformations in their offspring. The risk increases in direct relation to the severity of infertility treatment in which the pregnancy was obtained. The question still remains if this direct relation reflects the severity of the infertility status of the couple or is related to an added value imposed by the infertility treatment.

Timing intra-Fallopian transfer procedures

With the gradual decline in the use of zygote intra-Fallopian transfer (ZIFT), current practice is to offer ZIFT almost exclusively to patients with repeated implantation failure (RIF). For practical reasons, the procedure is sometimes deferred by 1 day and embryo intra-Fallopian transfer (EIFT) is performed. The aim of the present study was to compare the reproductive outcome of ZIFT versus EIFT. In a retrospective analysis, 176 patients who failed in 7.65 +/- 3.7 previous IVF cycles underwent 200 ZIFT and 73 EIFT procedures. Implantation and live birth rates were compared for both groups. Patients in both groups were found comparable for demographic and clinical parameters. Similar numbers of oocytes were retrieved and fertilized in both groups, and 5.2 +/- 1.2 zygotes/embryos were transferred. Implantation and live birth rates (10.5 and 26.5% versus 10.9 and 24.7% for ZIFT and EIFT respectively) were comparable. It is concluded that tubal transfer of zygotes and day-2 cleavage stage embryos are equally effective.

Diagnosis of ruptured fetal membranes in pregnancy with the use of urograffin

The objective of our study was to assess the value of intraamniotic injection of urograffin in the diagnosis of premature rupture of membranes (PROM). Intra-amniotic injection of urograffin with the concomitant insertion of a vaginal tampon was performed in 30 consecutive patients who were admitted because of suspected PROM and the presence of a heavy bloody vaginal secretion. The vaginal tampons were X-rayed for the presence of radio-opacity. In 23 patients, traces of urograffin were found in the vaginal tampons by X-ray. No fetal or maternal complications were observed during delivery and puerperium. We suggest the use of intraamniotic injection of urograffin for the diagnosis of PROM in cases where heavy bloody vaginal discharge is present.

Prospective evaluation of two stimulation protocols for low responders who were undergoing in vitro fertilization-embryo transfer

OBJECTIVE

To compare two stimulation protocols designed for low responders undergoing IVF.

DESIGN

Randomized, prospective study.

SETTING

University hospital IVF unit.

PATIENT(S)

Sixty low responders who were recruited on the basis of results in previous cycles.

INTERVENTION(S)

Modified flare protocol in which a high dose of GnRH agonist was administered for the first 4 days, followed by a standard agonist dose, or a modified long protocol in which a standard agonist dose was used until pituitary down-regulation, after which the agonist dose was halved during stimulation.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved.

RESULT(S)

Twenty-nine cycles were performed with the modified flare protocol and 31 were performed with the modified long protocol. Significantly more oocytes were obtained with the modified long protocol than the modified flare protocol (4.42 +/- 2.6 vs. 3.07 +/- 2.15). The number and quality of embryos available for transfer was similar in both groups. One clinical pregnancy (3.4%) was achieved with the modified flare protocol, and 7 pregnancies (22.5%) were achieved using the modified long protocol.

CONCLUSION(S)

These preliminary results substantiate the poor prognosis and outcome for low responders undergoing IVF. A modified long "mini-dose" protocol appears to be superior to a modified mega-dose flare protocol in terms of oocyte yield and cycle outcome.