Gamete intrafallopian transfer: ethical considerations, historical development of the procedure, and comparison with other advanced reproductive technologies

The clinical efficacy of gamete intrafallopian transfer by minilaparotomy versus in vitro fertilization and embryo transfer

OBJECTIVE

To evaluate the clinical performance of gamete intrafallopian transfer (GIFT) and in vitro fertilization and embryo transfer (IVF-ET).

METHODS

Infertile women were divided into 2 groups: for GIFT, 239 patients (326 cycles) with at least 1 patent tube; and, for IVF-ET, 125 patients (210 cycles) with bilateral tubal occlusion. A specially designed retractor was developed to replace the gametes into an appropriate section of the Fallopian tube accurately and safely. Several parameters, including the pregnancy and delivery rates of each group, were compared.

RESULTS

The success rate per trial in the GIFT group was approximately 1.5 times higher than that in the IVF group (pregnancy rate: 44.2% vs. 31.0%, p < 0.01; delivery rate: 33.4% vs. 22.9%, p < 0.01). The pregnancy and delivery rates of GIFT decreased steadily with the number of trials. These apparent decreases were not observed up to the 3rd trial in IVF-ET cases.

CONCLUSIONS

GIFT with a minilaparotomy procedure yielded significantly higher success rates than IVF-ET. Accordingly, GIFT is considered to be the first treatment choice in infertility cases with at least 1 patent Fallopian tube.

Elevated serum progesterone values at the time of ovulation induction in luteal leuprolide acetate-down-regulated GIFT cycles are associated with decreased clinical pregnancy rates

PURPOSE

The effects of premature luteinization of ovarian follicles as detected by elevated progesterone values on the day of human chorionic gonadotropin induction of ovulation were evaluated in 38 consecutive gamete intrafallopian transfer (GIFT) retrieval cycles.

MATERIALS AND METHODS

All patients received leuprolide acetate beginning in the midluteal phase of their prior menstrual cycle, followed by gonadotropin stimulation of folliculogenesis. At least four oocytes were transferred in each cycle.

RESULTS

No significant differences in gonadotropin dosage, total number of days of gonadotropins, age, number of prior pregnancies, years of infertility since last pregnancy, total number of eggs retrieved, mature residual oocytes, fertilization of mature residual oocytes, or primary etiology of infertility were observed between groups; however, estradiol concentrations were significantly higher in the group with elevated progesterone values (2573 +/- 216 pg/ml) compared to the lower progesterone group (1925 +/- 202 pg/ml, P = 0.035) and the total number of oocytes transferred was greater in the high progesterone group (7.5 +/- 0.5) vs the low progesterone group (6.3 +/- 0.3, P < 0.038). P4 concentrations < or = 0.8 ng/ml were associated with significantly higher pregnancy rates (11/19; 57.9%) compared to progesterone concentrations > 0.8 ng/ml (5/19, 26.3%; P = 0.050).

CONCLUSIONS

Premature luteinization may occur in luteal leuprolide acetate-down-regulated patients and progesterone values > 0.8 ng/ml are associated with significantly lower pregnancy rates in GIFT cycles.

Gamete intrafallopian transfer

GIFT involves placement of a donor's oocyte into a surrogate's oviduct. Fertilization and embryo development occur within the recipient's reproductive tract. GIFT provides a viable method to obtain pregnancies from subfertile mares for which embryo transfer has been nonproductive. Currently, pregnancy rates after GIFT have been variable, although high success rates have been reported recently. Further refinement of techniques should allow GIFT to be used in research and commercial programs.

Factors associated with improving success rates with gamete intrafallopian transfer under thin-needle spinal anesthesia

PURPOSE

In order to reduce the risk of major anesthetic complications associated with laparoscopic gamete intrafallopian transfer procedures, we have exclusively used thin-needle spinal anesthesia over the years 1991 - 1994. This paper will review complication rates in order to further establish the safety profile of GIFT under thin-needle anesthesia and report the changes in our GIFT protocol from 1991 to 1994 which have been associated with a statistical improvement in the implantation rate from 11% to 23% (P = 0.01) and an increase in delivery rates from 29% to 42% per transfer procedure.

METHODS

Sixty-eight laparoscopic GIFT procedures were done in women with at least one patent oviduct and failure to respond to less invasive treatment. Clinical variables were analyzed to determine if similar patient populations had been treated over the study period.

RESULTS

The improved delivery rates and implantation rates could not be explained by patient selection. No major perioperative complications occurred. Minor perioperative complications and difficulties included one patient requiring general anesthesia, one patient developing a spinal headache which could be managed conservatively at home, and one patient requiring a minilaparotomy to complete the GIFT procedure. The more serious complications occurred as a result of the superovulation and multiple oocyte transfer rather than the surgical or anesthetic technique. These included two patients with severe ovarian hyperstimulation requiring hospitalization, and five delivered triplet pregnancies. Factors associated with improving success rates included improvements in semen and equipment preparation as well as an increase in the number of sperm transferred from 200,000 to 500,000.

CONCLUSIONS

GIFT can be performed with relative safety under thin needle spinal anesthesia with high implantation and delivery rates if care is made to optimize sperm and equipment preparation. GIFT under thin-needle spinal anesthesia may be an attractive alternative for treatment of longstanding nontubal infertility in couples willing to take the risk of ovarian hyperstimulation and multiple pregnancy.

Appraisal of gamete intrafallopian transfer

OBJECTIVE

To collect results of gamete intrafallopian transfer on a large scale in order to compare treatment indications, results, and factors which influence the success rates; to evaluate whether gamete intrafallopian transfer is well-established and what the real place of this procedure is among other assisted reproduction techniques.

DESIGN

Data relating to gamete intrafallopian transfer were collected from World Reports, national registries of different countries and meta-analysis of medical publications during the years 1986-1991.

SUBJECT

Official registries reported 47,200 treatment cycles and 18,759 treatment cycles were analysed from ten medical publications.

RESULTS

The procedure accounts for 13.5% of all assisted reproduction techniques but its popularity varies significantly among countries. The same indications for gamete intrafallopian transfer are followed by all countries, but great differences exist with regard to the proportional share of each etiology. Also, the share has changed considerably over the years. TREATMENT OUTCOME: 10,667 clinical pregnancies were reported which represent 24% of treatment cycles and 29% of ovum pick-up. The live birth rate was 23.3%; abortion rate, 22%; and ectopic pregnancy rate, 5.5%. The stillbirth rate was 2.3% and the malformation rate was 2.8%, not confined to specific organs or systems. There were 19.5% twins, 4.6% triplets and 0.3% quadruplets or more. The number of transferred oocytes influenced pregnancy rates: 28% for transfer of four oocytes and only 10% following transfer of one oocyte. The cause of infertility might influence the results and the poorest results are obtained for male factor infertility. In most cases correlation of success rates reported by leading units through medical publications closely resembles the overall national registries results. Indications for this treatment were broadened over the years, but its role among other assisted reproduction technologies is not agreed upon, especially for male factor and unexplained infertility.

CONCLUSIONS

Gamete intrafallopian transfer carries an overall higher pregnancy rate than in vitro fertilization. Quality control by professional or public associations should be established and more research employed over indications for treatment and results in order to establish when GIFT is the treatment of choice and when other modes of treatment should be preferred.

Endometrial receptivity in the light of modern assisted reproductive technologies

OBJECTIVE

To review the different aspects of endometrial receptivity as it is reflected in the various modalities of modern assisted reproductive technologies.

DESIGN

The importance of endometrial receptivity and the factors that affect it such as the type of treatment, age, and ovarian function are discussed in this review. Novel approaches to determine receptivity such as Doppler ultrasonography and molecular biology are considered; assisted hatching is also discussed.

CONCLUSIONS

Endometrial receptivity cannot, as yet, be directly assessed. Circumstantial evidence suggests that receptivity declines with age, is adversely affected by controlled ovarian hyperstimulation, and is possibly affected by ovarian function. Future studies will have to focus on molecular cell biology and physiology of the endometrium.