The predictive value of an initial serum beta human chorionic gonadotropin level for pregnancy outcome following in vitro fertilization

Management of early gestations with low beta-human chorionic gonadotropin conceived by assisted reproductive technologies: performance of M4 predictive model

OBJECTIVES

To assess the safety and performance of the M4 model for classifying as high risk or low risk for ectopic pregnancy (EP) pregnancies conceived by assisted reproductive technologies (ART) that present with low beta-human chorionic gonadotropin (β-hCG) concentration in early gestation.

METHODS

This was a prospective cohort study of 243 pregnancies conceived by ART with low β-hCG levels (5-50 IU/L) at 4 + 0 to 4 + 2 weeks' gestation. After subsequent β-hCG testing at 48 h, pregnancies were classified according to the M4 model into the following categories: (i) high risk, probable EP/persistent pregnancy of unknown location (PPUL), when the risk for EP was ≥ 5%; (ii) low risk, probable intrauterine pregnancy (IUP), when the risk of EP was < 5% and the likelihood of IUP was greater than that of a failed pregnancy of unknown location (FPUL); and (iii) low risk, probable FPUL, when the risk of EP was < 5% and the likelihood of a FPUL was greater than that of an IUP. The predictive performance of the M4 model for EP and its ability to discriminate between high- and low-risk pregnancies was assessed using the final pregnancy outcome at 11 to 13 weeks of gestation as reference, which was classified as EP/PPUL, FPUL or IUP.

RESULTS

The sensitivity and specificity of the M4 model in detecting a high-risk pregnancy (EP/PPUL) were 60.0% (95% CI, 43.6-74.4%) and 79.8% (95% CI, 73.8-84.7%), respectively. The area under the receiver-operating-characteristics curve of the M4 model for discriminating between high-risk and low-risk (FPUL/IUI) pregnancies was 0.72 (95% CI, 0.62-0.81). The model had a positive likelihood ratio of 2.97 (95% CI, 2.03-4.36) and a negative likelihood ratio of 0.50 (95% CI, 0.33-0.76). The kappa index was 0.30 (95% CI, 0.16-0.43), indicating a low degree of agreement between the model classification and the final diagnosis. No serious adverse events related directly to the application of the M4 model were observed, although 14 pregnancies classified ultimately as high risk had been categorized initially as low risk by the M4 model. Of these, seven resolved with expectant management, five with methotrexate (MTX) and two required laparoscopic surgery (one after failure of medical treatment with MTX and one after deviation from the follow-up protocol). There were no cases of EP/PPUL with additional complications or need for blood or other blood product transfusion. Of the 243 ART pregnancies with low β-hCG concentration in early gestation, only 47 (19.3%) had an IUP, half (24/47) of which had an early miscarriage, resulting in only 9.5% (23/243) cases having an ongoing pregnancy.

CONCLUSIONS

Application of the M4 model in pregnancies conceived by ART with low β-hCG concentration in early gestation showed limited capacity in classifying them as being at low or high risk for EP, therefore, its use in pregnancies of this type is not recommended. No serious adverse events or complications related to the use of the model were observed. These pregnancies have a low probability of ending in an IUP as well as a high rate of early miscarriage. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Predictive value of serum HCG concentrations for outcomes of vitrified-warmed blastocyst transfers in women of different ages

RESEARCH QUESTION

Can serum human chorionic gonadotrophin (HCG) concentrations on day 10 after single-blastocyst transfer (SBT) in cryopreserved transfer cycles help to predict the cycle outcome in patients of different maternal ages?

DESIGN

The study included 772 vitrified-warmed SBT cycles. The initial maternal serum HCG concentrations measured on day 10 after blastocyst transfer were evaluated using receiver operating characteristic (ROC) curves to predict clinical pregnancy and live birth. Threshold values for predicting a clinical pregnancy were established in three different age groups: group A (21-29 years old, n = 360), group B (30-34 years old, n = 290) and group C (35-47 years old, n = 122).

RESULTS

The areas under the ROC curves for clinical pregnancy and live birth were 0.986 and 0.922, and the corresponding cut-off values were 113.28 and 146.37 mIU/ml, respectively. The optimal threshold values for clinical pregnancy as indicated by Youden index values for the three age groups were 145.15, 126.25 and 94.44 mIU/ml, respectively.

CONCLUSIONS

The study demonstrates that determination of initial serum β-HCG concentrations on day 10 after SBT in cryopreserved transfer cycles can help to predict cycle outcome in women of different ages. The optimal threshold value for clinical pregnancy for patients over 35 years of age was lower than that for the younger age groups.

Likelihood of live birth with extremely low β-hCG level 14 days after fresh embryo transfer

OBJECTIVE

To investigate the pregnancy outcomes of patients with low serum β-hCG level 14 days after day 3 embryo transfer.

METHODS

A retrospective study was performed with 723 patients with a serum β-hCG level between 5 and 100 mIU/ml 14 days after embryo transfer. Pregnancy outcomes (live birth, clinical pregnancy) were analyzed according to the female patients' age. ROC curves were plotted to indicate the threshold for prediction of clinical pregnancy and live birth.

RESULTS

Of the 723 patients with serum β-hCG level <100 mIU/mL, 85.6% (619) had biochemical pregnancy, and only 14.4% (104) had clinical pregnancy (including 4.3% with live birth, 3.7% with ectopic pregnancy, and 6.1% with early miscarriage). The rate of live birth was significantly lower in ≥38-year group ,compared with <38-year group (1.3% vs. 5.1%, p = 0.045). The rates of biochemical pregnancy in patients with serum β-hCG of 5-25 mIU/mL and 26-50 mIU/mL were 99.5% and 92.4%, respectively. The serum β-hCG level to predict clinical pregnancy was 44.8 mIU/ml (sensitivity, 90.4%; specificity, 82.1%). For live birth, the serum β-hCG level was 53.7 mIU/ml (sensitivity, 90.3%; specificity, 81.1%).

CONCLUSIONS

The likelihood of live birth was minimal with low serum β-hCG level 14 days after embryo transfer.

Initial maternal serum human chorionic gonadotropin levels in pregnancies achieved after assisted reproductive technology are higher after preimplantation genetic screening and after frozen embryo transfer: a retrospective cohort

PURPOSE

Few published articles have compared initial hCG values across all different types of ART cycles, including cycles with fresh or frozen embryo transfer. No articles have compared initial hCG values in cycles utilizing preimplantation genetic screening (PGS). The purpose of this study is to compare initial hCG values after fresh embryo transfer, frozen embryo transfer, and after PGS.

METHODS

This was a single-center retrospective cohort study at an academically affiliated private IVF center. All fresh and frozen embryo transfers between January 2013 and December 31, 2015 were included. We compared mean initial serum hCG values 14 days after oocyte retrieval for fresh cycles and 9 days after frozen embryo transfer. We examined cycles of single embryo transfer (SET) and double embryo transfer (DET).

RESULTS

Two hundred elven IVF (fresh embryo transfer), 128 FET (frozen embryo transfer cycles, no PGS), and 111 PGS cycles (ovarian stimulation with embryo cryopreservation, PGS, and frozen transfer in a subsequent estrogen-primed cycle) with initial positive hCG values were analyzed. In patients achieving a positive hCG after SET, initial hCG values were higher after PGS compared to FET (182.4 versus 124.0 mIU/mL, p = 0.02) and IVF (182.4 versus 87.1 mIU/mL, p < 0.001) as well as FET compared to IVF (124.0 versus 87.1 mIU/mL, p < 0.01). After DET, initial hCG values were higher after PGS (222.8 mIU/mL) compared to FET (182.1 mIU/mL, p = 0.02) and IVF (131.1 mIU/mL, p = 0.001).

CONCLUSIONS

Our study suggests that initial serum hCG values are higher after using PGS and higher after the transfer of a frozen embryo compared to a fresh embryo. This suggests that initial hCG values relate to the chromosomal status of embryos. Initial hCG values may help determine intervention and monitoring later in pregnancy.

Value of Post-transfer Day-12 Beta Human Chorionic Gonadotropin Levels for Pregnancy Outcome Prediction of Intracytoplasmic Sperm Injection Cycles

BACKGROUND

Several markers were studied previously in order to predict the pregnancy outcome of assisted reproductive techniques; however, serum beta human chorionic gonadotropin was found to be the most predictive marker.

AIMS

To evaluate the value of serum beta human chorionic gonadotropin levels in discriminating biochemical and clinical pregnancies 12 days after embryo transfer, while determining the factors predicting ongoing pregnancy was established as the secondary aim.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

A total of 445 pregnant cycles were retrospectively analysed in 2359 embryo transfer cycles. Patients were divided into two groups according to the outcome of pregnancy: biochemical and clinical.

RESULTS

The cut-off value of beta human chorionic gonadotropin levels on day 12 in predicting clinical pregnancies was 86.8 IU/mL with 65.1% sensitivity and 74.7% specificity [CI: 0.76 (0.71-0.81). Receiver operating characteristic curve analysis revealed different cut-off values for embryo transfer days (57 mIU/mL for day 3 embryo transfer CI: 0.59-0.79 and 87 mIU/mL for day 5 embryo transfer, CI: 0.74-0.86). Subgroup analysis of clinical pregnancies revealed a significant difference between ongoing pregnancies and early fetal losses regarding duration of infertility (81.3±54.4 vs. 100.2±62.2 months), serum oestradiol on hCG day (2667.4±1276.4 vs. 2094.6±1260.5 pg/mL), number of transferred embryos (1.9±0.8 vs. 1.5±0.7) and the prevalence of diminished ovarian reserve as an indication (2.3% vs 12.2%).

CONCLUSION

Beta human chorionic gonadotropin levels on day 12 following embryo transfer provide an important parameter for the prediction of clinical pregnancy; however, other stimulation parameters are indicated in the prediction of ongoing pregnancies.

Serum hCG-β levels of postovulatory day 12 and 14 with the sequential application of hCG-β fold change significantly increased predictability of pregnancy outcome after IVF-ET cycle

PURPOSE

To investigate hCG-β level on postovulatory day (POD) 12 and its fold increase as predictors for pregnancy outcome after in vitro fertilization (IVF) cycles.

METHODS

A retrospective cohort study was performed in total 1408 fresh and 598 frozen cycles between November 2008 and October 2011, which resulted in biochemical pregnancy, early pregnancy loss, or live birth of singleton pregnancy. The serum hCG-β levels of POD 12 and 14 were compared among biochemical pregnancy, early pregnancy loss, and live birth groups. The cutoff values of POD 12 and 14 hCG-β levels and the degree of hCG-β increase from POD 12 to 14 were determined for each pregnancy outcome.

RESULTS

POD 12 and 14 hCG-β levels stratified based on pregnancy outcomes were significantly different among the biochemical pregnancy, early pregnancy loss, and live birth in both fresh and frozen cycles. Serum hCG-β levels of POD 12 and 14 and the fold increase of hCG-β levels from POD 12 to 14 significantly predict pregnancy outcomes after fresh and frozen cycles. Among these, the cutoff value of POD 14 hCG-β had the highest sensitivity and positive predictive value (PPV). In fresh cycles, the cutoff values of POD 12 and 14 serum hCG-β levels for clinical pregnancies were 30.2 mIU/mL (sensitivity 81.3 %, specificity 79.6 %, and PPV 92.3 %) and 70.5 mIU/mL (sensitivity 88.4 %, specificity 85.2 %, and PPV 94.7 %). In pregnancies with POD 12 serum hCG-β levels ≥30.2 mIU/mL, the cutoff level of increase of hCG-β for clinical pregnancy was 2.56 (sensitivity 73.6 %, specificity 72.4 %, and PPV 97.8 %). Sequential application of cutoff values such as POD 12 hCG-β and fold increase of hCG-β improved predictability of pregnancy outcome as compared with that of POD 12 hCG-β alone. The cutoff values of POD 12 and 14 serum hCG-β levels for live birth were 40.5 mIU/mL (sensitivity 75.2 %, specificity 72.6 %, PPV 78.9 %) and 104.5 mIU/mL (sensitivity 80.3 %, specificity 74.1 %, PPV 80.8 %). In the frozen cycles, the cutoff values of POD 12 and 14 serum hCG-β level for clinical pregnancy were 31.5 IU/L (sensitivity 80.4 %, specificity 71.1 % and PPV 90 %) and 43.5 mIU/mL (sensitivity 72.6 %, specificity 71.7 %, PPV 77.2 %). In pregnancies with POD 12 serum hCG-β level ≥31.5 mIU/mL, the cutoff value for fold increase of hCG-β was 2.38 for clinical pregnancy (sensitivity 81.6 %, specificity 71.4 % and PPV 87.9 %). The cutoff values of POD 12 and 14 for live birth were 43.5 mIU/mL (sensitivity 72.6 %, specificity 71.7 %, PPV 77.2 %) and 101.6 mIU/mL (sensitivity 79.6 %, specificity 71.1 %, PPV 78.4 %). Sequential application of cutoff values for POD 12 hCG-β level and fold increase of hCG-β significantly increased PPV for live birth but not clinical pregnancy in frozen cycles.

CONCLUSIONS

Early prediction of pregnancy outcome by using POD 12 and 14 cutoff levels and sequential application of cutoff value of fold increase could provide appropriate reference to health care providers to initiate earlier management of high-risk pregnancies and precise follow-up of abnormal pregnancies.

How low is too low? Cycle day 28 estradiol levels and pregnancy outcomes

OBJECTIVE

To determine the utility of cycle day 28 estradiol (E2) levels in predicting pregnancy outcomes after IVF.

DESIGN

Retrospective, cohort study.

SETTING

Academic medical center.

PATIENT(S)

All IVF cycles resulting in a positive pregnancy test result at our center between January 2007 and December 2012 were included.

INTERVENTION(S)

In vitro fertilization with fresh embryo transfer.

MAIN OUTCOME MEASURE(S)

A total of 5,471 IVF cycles were identified. Cycles were stratified by day-28 E2 level (pg/mL) into three groups: A: ≤50; B: 51-100; and C: >100. Outcomes measured were live birth, clinical pregnancy, biochemical, ectopic, and spontaneous abortion rates.

RESULT(S)

There were 806, 588, and 4,077 IVF pregnancies in groups A, B, and C, respectively. Live birth rates were lower in groups A (15.4%) and B (41.2%) compared with group C (77.4%), representing decreased odds of live birth in patients with E2 levels of ≤50 pg/mL (odd ratio 0.05, 95% confidence interval 0.04-0.07) and in patients with levels of 51-100 pg/mL (odds ratio 0.20, 95% confidence interval 0.17-0.25) compared with patients with levels >100 pg/mL. Rates of biochemical and ectopic pregnancies were higher in groups A (66.5%, 6.20%) and B (30.7%, 3.57%) compared with group C (7.31%, 0.66%). An hCG level <50 mIU/mL was associated with increased odds of a biochemical pregnancy and decreased odds of a live birth.

CONCLUSION(S)

Low E2 levels early in IVF pregnancies are associated with poorer pregnancy outcomes. Estradiol can be used alone or in conjunction with hCG levels to predict the odds of a live birth.

Concentrations of human chorionic gonadotrophin in very early pregnancy and subsequent pre-eclampsia: a cohort study

STUDY QUESTION

Are low serum concentrations of human chorionic gonadotrophin (hCG) in very early pregnancy associated with pre-eclampsia risk?

SUMMARY ANSWER

Low hCG concentrations in very early pregnancy are associated with increased risk of severe pre-eclampsia.

WHAT IS KNOWN ALREADY

Low maternal serum concentrations of hCG early in pregnancy may indicate impaired proliferation or invasion of trophoblast cells, and thus low hCG concentrations may serve as a marker for impaired placental development. Impaired placental development is assumed to be a cause of pre-eclampsia, but there is little prospective evidence to support this hypothesis.

STUDY DESIGN, SIZE, DURATION

We performed a prospective cohort study of pregnancies after IVF at Oslo University Hospital 1996-2010 with linkage to the Medical Birth Registry of Norway to obtain information on pre-eclampsia development.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included 2405 consecutive singleton pregnancies and examined the association of maternal serum hCG concentrations (measured using Elecsys, Roche) on Day 12 after embryo transfer with the risk of any pre-eclampsia and of mild and severe pre-eclampsia.

MAIN RESULTS AND THE ROLE OF CHANCE

HCG concentrations were inversely associated with pre-eclampsia risk in a dose-dependent manner (Ptrend 0.02). Compared with women with hCG ≥150 IU/l, women with hCG <50 IU/l were at 2-fold higher overall risk of pre-eclampsia [absolute risk 6.4 versus 2.8%; odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2-4.7]. The inverse association was restricted to severe pre-eclampsia (Ptrend 0.01), thus, women with hCG <50 IU/l were at 4-fold higher risk of severe pre-eclampsia than women with hCG ≥150 IU/l (absolute risk 3.6 versus 0.9%; OR 4.2, 95% CI 1.4-12.2). For mild pre-eclampsia, there was no corresponding association (Ptrend 0.36).

LIMITATIONS, REASONS FOR CAUTION

Results for IVF pregnancies may not be generalizable to spontaneously conceived pregnancies.

WIDER IMPLICATIONS OF THE FINDINGS

Plausible causes of low maternal hCG concentrations very early in pregnancy include impaired placental development and delayed implantation. Thus, these results provide prospective evidence to support the hypothesis that impaired placental development may be associated with subsequent development of severe pre-eclampsia.

STUDY FUNDING/COMPETING INTEREST

The study was financially supported by the Research Council of Norway. None of the authors has any conflict of interest to declare.

Ectopic pregnancy after infertility treatment

Early pregnancy complications are more common in women who conceive after infertility treatment. Most of these occur before 12 weeks of gestation and include miscarriage, vaginal bleeding, intrauterine hematoma, vanishing twin, and ectopic pregnancy (EP). The incidence of EPs following infertility treatment is much higher compared with that in spontaneous pregnancies. The occurrence of an EP is very distressing to an infertile couple, who has lots of hopes pinned on the treatment outcome, especially because of the cost incurred and the physical and mental trauma both have gone through during the treatment process. The association between infertility and EP is complex, as it can be a consequence of infertility as well as a cause. The two principal risk factors for an EP are genital tract infections and tubal surgeries. Though several etiologies are proposed, but patients with tubal factor infertility are at an increased risk of an EP. Earlier diagnosis of EP helps to improve prognosis and optimize subsequent fertility. It is pivotal to evaluate the likelihood of subsequent occurrence of an EP and be too vigilant when treating. The correct choice of the treatment modality should be made to prevent the recurrence. The early prediction of the pregnancy outcome therefore has great importance for both the couple and clinician. Today with the help of sensitive beta human chorionic gonadotropin (β-hCG) assays and transvaginal sonography, one can diagnose an EP prior to symptoms, and conservative treatment for the preservation of the fallopian tube is possible. Conservative management in the form of expectant and medical management should be considered as a first-line treatment modality, provided that the overall clinical picture suggests that it is safe to do so. If not, laparoscopic management of EPs appears to be the favored approach of management as compared to laparotomy.

Early Maternal Serum β-human Chorionic Gonadotropin Measurements After ICSI in the Prediction of Long-term Pregnancy Outcomes: A Retrospective Cohort Analysis

Background

Initial low maternal serum β-human chorionic gonadotropin (β-hCG) is a good predictor of early pregnancy demise. Our objective was to determine its predictive value in determining the long-term outcome in ICSI pregnancies.

Methods

A retrospective cohort study was designed at the Saudi Center for Assisted Reproduction. Two hundred and sixty-one women with ICSI pregnancies were followed up from initial β-hCG level determination till the end of pregnancy. Accuracy of early β-hCG in predicting the occurrence of a live-birth, ongoing pregnancy, late miscarriage, ectopic pregnancy and early miscarriage following ICSI was measured.

Results

β-hCG levels were significantly different in pregnancies that reached the stage of an ongoing pregnancy and live-birth as compared to early pregnancy loss. The ROC curves demonstrated a high sensitivity for identifying patients with ectopic pregnancies and early miscarriage (100% and 93.33% respectively). The remaining results ranged from a sensitivity of 69% to 79% and specificity of 62% to 75%.

Conclusions

In ICSI pregnancies, a single early β-hCG may help to identify pregnancies that will reach full-term and delivery.

Keywords

ICSI; Human chorionic gonadotropin; Outcome; Pregnancy

Early serum β-human chorionic gonadotropin in pregnancies after in vitro fertilization: contribution of treatment variables and prediction of long-term pregnancy outcome

OBJECTIVE

Low initial serum beta hCG is a good predictor of early pregnancy failure. We sought to determine the contribution of treatment variables and the predictive value of early serum beta hCG after IVF on long-term pregnancy outcome.

DESIGN

A retrospective case-control study.

SETTING

An academic IVF unit.

PATIENT(S)

Five hundred thirty-three IVF cycles performed between 1999 and 2004, which resulted in a positive serum beta hCG level (> 10 mIU/mL) on day 13 after embryo transfer (ET).

INTERVENTION(S)

The study group included 281 pregnancies with initial beta hCG < or = 150 mIU/mL on day 13 after ET. Randomly selected 252 IVF cycles with initial beta hCG > 150 mIU/mL comprised the control group. Characteristics of the patients and the treatment protocols were analyzed using logistic regression, Pearson's chi-square, and Fisher's exact test.

MAIN OUTCOME MEASURE(S)

Primary pregnancy outcome was defined as favorable when a fetal pulse was detected, testifying to a viable gestation. Unfavorable outcome referred to chemical or ectopic pregnancies, as well as spontaneous abortions. Additionally, the two groups were followed throughout gestation. Secondary pregnancy outcome was based on the following parameters: gestational age at delivery, method of delivery, and birth weight.

RESULT(S)

Poor primary pregnancy outcome was encountered in 64.8% of the study group and in 22.2% of the control group. Predictors of unfavorable primary pregnancy outcome were older age, use of a short protocol, and shorter than anticipated crown-rump length. No difference was found in the secondary pregnancy outcome between the groups. Preterm labor was more prevalent in the study group, but the difference did not reach statistical significance.

CONCLUSION(S)

Pregnancy viability can be predicted by measuring serum beta hCG as early as on day 13 after ET. Older age, use of a short protocol, and shorter than anticipated crown-rump length are associated with early pregnancy loss. Of those who reach delivery, no significant adverse outcome is anticipated in IVF pregnancies with low initial serum beta hCG.

Highly specific and sensitive rise in Days 14–17 pro-αC inhibin with clinical pregnancy after frozen embryo transfer with ovulatory cycles

BACKGROUND

Pro-alphaC inhibins are luteal derived analytes peaking in the maternal serum as early as Day 16 after conception. We set out to verify a previous post hoc analysis which suggested that pro-alphaC levels measured this early are extremely sensitive in predicting clinical pregnancy success after unstimulated IVF with ovulatory cycles.

METHODS

Prospective observational study of 246 women undergoing frozen embryo transfer with ovulatory cycles. Serum pro-alphaC and beta-HCG levels at 14-17 days after conception were measured by enzyme-linked immunosorbent assay and grouped according to whether a clinical pregnancy occurred (demonstrable cardiac activity at > or =6 weeks' gestation).

RESULTS

Of 34 (13.8%) women who achieved a clinical pregnancy, median (25th-75th centile) Days 14-17 pro-alphaC levels were 995 pg/ml (758-1463), 6- to 7-fold higher than levels observed in the remainder who did not fall pregnant (112.8 pg/ml (104-121); P < 0.0001). At a fixed 95% specificity, pro-alphaC was 100% sensitive in predicting clinical pregnancy. The best specificities achieved at 100% sensitivity were; 94.8% for pro-alphaC, 96.7% for beta-HCG and 98.1% when both analytes were combined.

CONCLUSIONS

Clinical pregnancy is always associated with a release of luteal derived pro-alphaC 14-17 days after conception. Pro-alphaC may play a possible biological role and be a useful clinical biomarker of luteal health.

Optimizing hCG cut-off values: a single determination on day 14 or 15 is sufficient for a reliable prediction of pregnancy outcome

OBJECTIVE

Optimizing the cut-off level for a single serum hCG determination around day 15 after oocyte retrieval or ovulation.

STUDY DESIGN

Retrospective data analysis.

RESULTS

204 hCG samples >5 IU/L between March and October 1999 taken on day 14, 15 or 16 after oocyte retrieval in 204 patients undergoing IVF or ICSI were analyzed. ROC-curves and optimal cut-off levels to discriminate between viable and non-viable pregnancies were calculated for each day separately. Cut-off levels were found at 76, 142 and 223 IU/L for day 14, 15 and 16, respectively, and were verified by 487 hCG samples >5 IU/L taken between January 2000 and June 2004.

CONCLUSIONS

A single serum hCG determination on day 14 or 15 is sufficient to discriminate viable pregnancies accurately from non-viable pregnancies.

Serum oestradiol and β-HCG measurements after day 3 or 5 embryo transfers in interpreting pregnancy outcome

The aim of this study was to assess the clinical value of serum oestradiol concentration 8 days after embryo transfer (D8E2) and beta-human chorionic gonadotrophin (HCG-beta) concentration 12 days after embryo transfer (D12HCG-beta) in the prediction of pregnancy and the outcome of pregnancy following assisted reproduction, taking into account the day of transfer, which was either day 3 (D3) or day 5 (D5). The objective was to improve patient counselling by giving quantitative and reliable predictive information instead of non-specific uncertainties. A total of 2035 embryo transfer cycles performed between January 2003 and June 2005 were analysed retrospectively. Biochemical pregnancy, ectopic pregnancy and first-trimester abortions were classified as non-viable pregnancies; pregnancies beyond 12 weeks gestation were classified as ongoing pregnancies (OP). Significantly higher D8E2 and D12HCG-beta were obtained in D5 transfers compared with D3 transfers with regard to pregnancy and OP (P<or=0.001). For D3 embryo transfers, the cut-off value of D8E2 in predicting OP was 130 pg/ml (sensitivity 80%, specificity 72%), compared with 98 mIU/ml (sensitivity 89%, specificity 69%) for D12HCG-beta. For D5 embryo transfers, the values were 179 pg/ml (sensitivity 79%, specificity 84%) and 257 mIU/ml (sensitivity 78%, specificity 81%) respectively. It appears that serum post-embryo transfer D8E2 and D12HCG-beta concentrations provided clear information regarding pregnancy and the outcome of pregnancy following IVF-embryo transfer.

Serum hormones for predicting pregnancy outcome after assisted reproductive technology

Serum human chorionic gonadotrophin (HCG) in the second and third week after embryo transfer has been used for prediction of pregnancy outcome after assisted reproduction. There are few data on the clinical utility of HCG, progesterone and oestradiol, measured by contemporary immunoassay, in the fourth week after embryo transfer and later. Moreover, large inter-method differences have been described between automated immunoassays, making method-specific cut-off values mandatory. The main aim of this study was to determine assay-specific optimal cut-off values for serum HCG, progesterone and oestradiol for prediction of clinical pregnancy outcome in singleton pregnancies after assisted reproductive techniques, at days 11, 18 and 25 and at week 6 after embryo transfer. A retrospective study was performed on frozen serum samples of 67 singleton pregnancies after assisted reproduction techniques. HCG, oestradiol and progesterone were determined with the automated (random access) VIDAS immunoanalyser. Receiver operating characteristic curve analysis was performed to determine optimal cut-off values. Predictive values were calculated based on the prevalence of non-viable pregnancy after assisted reproduction. It was concluded that measurement of HCG by VIDAS at days 18 and 25, and at week 6 after embryo transfer yields high positive (70.5-100%) and negative (87.2-94.4%) predictive values for clinical pregnancy outcome.

Ectopic pregnancies after infertility treatment: modern diagnosis and therapeutic strategy

Ectopic pregnancy (EP) is a major event in a woman's reproductive life. It complicates infertility treatment and must be recognized early to simplify the treatment strategy, which must always be directed towards optimizing subsequent fertility. Epidemiological findings indicate that tubal history and smoking are the principal risk factors of those EP that are considered reproductive (rather than contraceptive) failures. Adding together the attributable risks for EP allows the construction of a risk scale to determine its probability for any given patient. This risk calculation makes it easier to establish a diagnostic strategy that uses abdominal and transvaginal ultrasound and hCG assays. Progesterone assays are useful only for determining the activity of the pregnancy but do not help to identify its site. Conservative treatment is to be preferred unless the EP occurs on a known hydrosalpinx. All the treatment trials and the Cochrane database meta-analysis show that medical treatment with methotrexate, preferably multidose, is equivalent in efficacy to conservative treatment with laparoscopy in the populations studied. Heterotopic pregnancies, which occur most often after assisted reproduction technology (1-3%), should preferably be treated by salpingectomy except in interstitial sites. There is no consensus that IVF is indicated after EP. The patient's age is probably the determining factor: fertility treatment should not be delayed to an age where the results would be altered, especially with the risk of a recurrent EP.

Serum HCG 12 days after embryo transfer in predicting pregnancy outcome

BACKGROUND

Assisted reproduction treatment (ART) entails a risk of ectopic pregnancy and early pregnancy loss. Serum HCG has been found to be predictive of pregnancy outcome. Our aim was to assess the clinical value of a single early HCG assay in ART pregnancies taking into account the aetiology and treatment of infertility.

METHODS

During 1994-1999, we studied 774 embryo transfer cycles resulting in pregnancy defined as a serum HCG concentration of > or =5 IU/l on day 12 following embryo transfer. The treatment included IVF in 518, ICSI in 119, and frozen embryo transfer in 137 cycles. Serum HCG concentrations were measured by fluoroimmunometric assay. Pregnancies were classified as viable (live fetus at > or =22 weeks gestation) or non-viable (biochemical pregnancy, miscarriage, ectopic pregnancy and molar pregnancy). Data on the outcomes were retrospectively retrieved from the records.

RESULTS

The median HCG concentration was 126 IU/l in viable pregnancies and 31 IU/l in non-viable pregnancies (P < 0.0001). The median HCG concentration was 115 IU/l in singleton pregnancies and 201 IU/l in multiple pregnancies (P < 0.0001). Male factor infertility was associated with viable pregnancies (P = 0.004) and tubal factor with non-viable pregnancies (P = 0.003); the lowest HCG level (88 IU/l) was observed in subjects with both male factor infertility and ICSI treatment (P = 0.001). An HCG value of 76 IU/l emerged as the most suitable cut-off point to predict viable pregnancy. Probabilities of each type of outcome related to the HCG level are given.

CONCLUSIONS

A single HCG reading on day 12 after embryo transfer helps to plan the subsequent follow-up. Male factor infertility and ICSI are associated with relatively low HCG values in viable pregnancies.

Endocrinology of the peri-implantation period

Current research suggests that the appearance of endometrial integrins and pinopode appearance signal the opening of the receptive phase of the endometrium. These integrins may be activated by the interleukin-1 system (IL-1). IL-1beta, expressed by the blastocyst, induces vascular endothelial growth factor (VEGF) which, in turn, promotes angiogenesis and integrin expression in endometrial cells. The IL-1 system also triggers the expression of gamma interferon (IFN-gamma) from T lymphocytes. Decidual natural killer (NK) lymphocytes interact with invading trophoblast to generate leukaemia inhibitory factor (LIF). LIF induces uPA and gelatinase, enzymes which play a crucial role in trophoblastic invasion. Progesterone is a potent inhibitor of LIF, while oestrogen is a potent inducer. Oestrogen in serum reflects follicular IL-1beta level and correlates with the outcome of embryo transfer after in vitro fertilization (IVF). Progesterone induces nitric oxide (NO) synthesis in the decidua, and NO promotes local vasodilatation and uterine quiescenceMeasurement of placental protein 14 (PP14, glycodelin-A) in serum may be of value as a screening test for implantation potential. However, human chorionic gonadotrophin (hCG) remains the most reliable predictor of successful implantation and pregnancy viability. An ovulation + 14 hCG level < 50 IU/l is often predictive of a non-viable outcome, while an ovulation + 21 hCG of < 200 IU/l always indicates a non-viable pregnancy. hCG secretion by invading trophoblast appears to be negatively modulated by endothelin-1 (ET-1) and prostaglandin F(2alpha)(PGF2alpha), while tissue growth factors and collagenases are positive modulators of hCG expression.ProalphaC, an inhibin pro-monomer, may have some value in monitoring corpus luteum function. Inhibin A, activin A and follistatin all rises throughout pregnancy and peak at 36 weeks of gestation. Relaxin is another ovarian hormone that may have a role in predicting implantation. Relaxin induces placental protein 14 (PP14, glycodelin-A) expression in a receptive endometrium, and measurement of serum PP14 may be of value as a screening test for implantation potential.