The incidence of multiple gestations after in vitro fertilization is dependent on the number of embryos transferred and maternal age

Morphokinetic parameters as auxiliary criteria for selection of blastocysts cultivated in a time-lapse monitoring system

Objective:

To describe embryonic profile up to blastocyst stage in a time-lapse system.

Methods:

A retrospective, longitudinal, analytical study of patients submitted to in vitro fertilization. The embryos were grouped according to the degree of expansion, internal cell mass and trophectoderm classification, the morphokinetic parameters were associated with the time periods stated in each evolution phase.

Results:

The appearance of a second polar corpuscle (CPap) occurred earlier in the embryos classified as excellent (2.99h; p<0.05), in relation to the embryos classified as good (3.40h), average (3.48h) and poor (3.55h). The embryos classified as excellent took less time for the pronuclei to disappear (PNbd) (21.80h; p<0.05), when compared to the good embryos (22.96h), the average (23.21h) and the poor (23.47h). As for the morphokinetic parameter, the end of the two-cell division (T2) occurred first in the excellent blastocysts (24.38h; p<0.05), when compared to the other groups: good (25.57h), average (25.53h) and poor (25.78h). With respect to synchronization with the division of three to four cells (S2), the poor embryos presented longer times for such division to occur (3.67h; p<0.05). When compared to the embryos from the groups excellent (1.97h), good (2.70h) and average (2.09h). At the time point of the blastocoel formation (TB), the excellent embryos (104.04h) did not differ from the good embryos (104.10h). However, when compared to average (107.27h) and poor (106.86h) embryos, there was statistical significance (p<0.05).

Conclusions:

Embryos of better quality had a shorter time in some morphokinetic parameters when compared to the other groups, thus increasing the possibilities to establish new parameters for the classification and selection of embryos.

Guidelines for the number of embryos to transfer following in vitro fertilization

OBJECTIVE

To review the effect of the number of embryos transferred on the outcome of in vitro fertilization (IVF), to provide guidelines on the number of embryos to transfer in IVF-embryo transfer (ET) in order to optimize healthy live births and minimize multiple pregnancies.

OPTIONS

Rates of live birth, clinical pregnancy, and multiple pregnancy or birth by number of embryos transferred are compared.

OUTCOMES

Clinical pregnancy, multiple pregnancy, and live birth rates.

EVIDENCE

The Cochrane Library and MEDLINE were searched for English language articles from 1990 to April 2006. Search terms included embryo transfer (ET), assisted reproduction, in vitro fertilization (IVF), ntracytoplasmic sperm injection (ICSI), multiple pregnancy, and multiple gestation. Additional references were identified through hand searches of bibliographies of identified articles.

VALUES

Available evidence was reviewed by the Reproductive Endocrinology and Infertility Committee and the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada and the Board of the Canadian Fertility and Andrology Society, and was qualified using the Evaluation of Evidence Guidelines developed by the Canadian Task Force on the Periodic Health Exam.

BENEFITS, HARMS, AND COSTS

This guideline is intended to minimize the occurrence of multifetal gestation, particularly high-order multiples (HOM), while maintaining acceptable overall pregnancy and live birth rates following IVF-ET.

Safety of drugs used in assisted reproduction techniques

Infertility may affect one in six couples; however, the development of the assisted reproduction technique (ART) created the opportunity for a large proportion of the infertile population to bear children. Pharmacological agents are routinely used in ART, and new ones are introduced regularly, with the aim of retrieving multiple oocytes to increase the prospect of pregnancy. The combinations of drugs that are used have specific adverse effects, but it is mostly the combined action of more than one agent that causes the greatest concern. The matter is complicated by the suspicion that some techniques in ART, for example intracytoplasmic sperm injection for severe male infertility problems (including azoospermia), may also contribute to the increase in adverse effects, especially congenital malformation. Gonadotropin releasing hormone (GnRH) agonists are widely used in controlled ovarian hyperstimulation. It may give rise to a short period of estradiol withdrawal symptoms and it may also lead to luteal phase deficiency. Similarly GnRHa antagonists, which have been recently introduced to control ovarian hyperstimulation, can lead to luteal phase deficiency and may cause some local injection site reactions. The more pure form of gonadotropin leads to less local injection site reactions and their main adverse effects are associated with the consequences of multiple ovulations. It has been proposed that gonadotropins may be a factor in the increasing risk of ovarian cancer and possibly breast cancer, but this has not been substantiated. Prion infection is another potential hazard, although no cases have been reported. Ovarian hyperstimulation syndrome is a well recognised complication of controlled ovarian hyperstimulation in ART. It is usually a result of recruitment of a large number of ovarian follicles. Efforts to minimise the incidence of this syndrome and its severity are now well developed. Congenital malformations are another possible adverse effect of fertility drugs, but it is more probable that the increase in congenital abnormality that is reported in ART is because of the population studied, i.e. patients already at high risk of congenital malformation, rather than the fertility drugs used or the technique employed. High order multiple pregnancy and its sequela is a well established complication of controlled ovarian hyperstimulation. This could be a result of multiple ovulations or more than one embryo replacement. Reducing the number of embryos transferred can reduce this more serious adverse effect for expectant mothers and for children conceived from ART.

Prevention of multiple pregnancy following IVF in Spain

Since the development of assisted reproduction techniques most countries have witnessed increased rates of multiple pregnancy. Despite the guidelines proposed by various scientific societies these rates continue to be abnormally high. In Spain, as in other Mediterranean countries, a greater number of embryos are transferred than in northern and central European countries and the incidence of multiple pregnancies is greater in comparison. Effective strategies must be established to prevent multiple pregnancy without reducing overall pregnancy rates. In the authors' institute, taking into account the authors' experience, the relevant literature, and despite the limitation of retrospective studies, it is recommended that a maximum of two embryos are transferred in young women with good quality embryos at the time of transfer. The transfer of three embryos is only recommended in women >or=38 years who have one or no good quality embryos available at the time of transfer. The responsibility for preventing multiple pregnancy lies with health professionals, who must be aware of the risks involved in twin and triplet pregnancy. Couples must be provided with objective information before starting an IVF cycle. Professional societies should highlight the problem and make suitable recommendations.

High rates of embryo wastage with use of assisted reproductive technology: a look at the trends between 1995 and 2001 in the United States

OBJECTIVE

To determine what percentage of embryos achieved through assisted reproductive technology (ART) do not result in a live birth and to examine the relationships among the number of embryos transferred, infants delivered, and embryos wasted.

DESIGN

Retrospective correlational study of the U.S. summary data of ART results for the years of 1995-2001.

PATIENTS

Fertility clinics reporting data to the Society of Assisted Reproductive Technology (SART).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Statistics for ART cycles using fresh, nondonor eggs and embryos were derived, and the percentage of embryos wasted each year was calculated. Trends over time were evaluated for percent embryos wasted, the average number of embryos transferred, and the delivery per transfer rate. Correlations between these variables were analyzed.

RESULT(S)

The percentage of embryos transferred that did not produce a live birth was 90.8 in 1995 and decreased to 84.9 in 2001. This trend significantly correlated with a reduction in the number of embryos transferred (from 3.9 to 3.1) and with an improvement in delivery rate per transfer (25% to 33.4%).

CONCLUSION(S)

The vast majority of embryos produced in vitro and transferred fail to develop into an infant, supporting the concept that only a small fraction of embryos has the capacity to become a live birth. Clinicians should strive to reduce embryonic wastage without an adverse effect on delivery rates by perfecting methods of ovarian stimulation and embryo screening, and by transferring fewer embryos.

Optimum number of embryos to transfer in women more than 40 years of age undergoing treatment with assisted reproductive technologies

OBJECTIVE

To determine whether increasing the number of embryos transferred beyond five increases pregnancy rates in women aged > 40 years.

DESIGN

Retrospective analysis of cycles performed between January 1998 and July 2003.

SETTING

University-affiliated teaching hospital.

PATIENT(S)

Women aged > 40 years undergoing a fresh cycle with a day-3 ET (n = 863).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy, chemical pregnancy, miscarriage rates, number of viable fetuses at 12 weeks' gestation, live birth rates, and number of babies delivered.

RESULT(S)

Compared with patients with fewer than five embryos transferred, those having five or more embryos transferred had significantly increased pregnancy rates and live birth rates, more viable fetuses at 12 weeks, and significantly decreased miscarriage rates. None of these outcome variables differed between the five-embryo and more-than-five-embryo groups. There were no differences in outcome when only five embryos were transferred, regardless of whether five or more than five embryos were available. The number of embryos transferred did not significantly influence multiple birth rates.

CONCLUSION(S)

The present study demonstrates that in women aged > 40 years, five embryos is the optimum number to transfer, and transferring more than five does not confer any additional benefit to clinical outcome.

Use of serum inhibin B levels at the start of ovarian stimulation and at oocyte pickup in the prediction of assisted reproduction treatment outcome

OBJECTIVE

To assess whether serum inhibin B levels before gonadotropin administration and at oocyte pickup (OPU) are associated with pregnancy.

DESIGN

Retrospective case-control study.

SETTING

University-based IVF program.

PATIENT(S)

Fifty-five IVF pregnancies and 55 control cycles matched by age, type of infertility, E(2) at ovulation induction, number of oocytes retrieved, and number of embryos replaced.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Association between serum inhibin B at stimulation day 1 (SD1) and OPU and pregnancy; correlation between inhibin B with clinical and endocrine parameters; predictive accuracy of inhibin B measurements at OPU.

RESULT(S)

Inhibin B on SD1 was similar between pregnant and nonpregnant subjects, whereas it was significantly higher at OPU in pregnant cycles, but did not allow differentiation between pregnancy outcomes. Inhibin B on SD1 was positively correlated with same-day E(2) in both groups and inversely with age in pregnant cycles. In both groups, inhibin B at OPU correlated positively with number of oocytes collected and with E(2) at ovulation induction.

CONCLUSION(S)

Higher inhibin B concentrations at OPU are predictive of clinical pregnancy, independently of age, peak E(2), number of oocytes retrieved and number of embryos replaced. Inhibin B on stimulation day 1 did not prove to be a useful predictor.

Single embryo transfer and IVF/ICSI outcome: a balanced appraisal

This review considers the value of single embryo transfer (SET) to prevent multiple pregnancies (MP) after IVF/ICSI. The incidence of MP (twins and higher order pregnancies) after IVF/ICSI is much higher (approximately 30%) than after natural conception (approximately 1%). Approximately half of all the neonates are multiples. The obstetric, neonatal and long-term consequences for the health of these children are enormous and costs incurred extremely high. Judicious SET is the only method to decrease this epidemic of iatrogenic multiple gestations. Clinical trials have shown that programmes with >50% of SET maintain high overall ongoing pregnancy rates ( approximately 30% per started cycle) while reducing the MP rate to <10%. Experience with SET remains largely European although the need to reduce MP is accepted worldwide. An important issue is how to select patients suitable for SET and embryos with a high putative implantation potential. The typical patient suitable for SET is young (aged <36 years) and in her first or second IVF/ICSI trial. Embryo selection is performed using one or a combination of embryo characteristics. Available evidence suggests that, for the overall population, day 3 and day 5 selection yield similar results but better than zygote selection results. Prospective studies correlating embryo characteristics with documented implantation potential, utilizing databases of individual embryos, are needed. The application of SET should be supported by other measures: reimbursement of IVF/ICSI (earned back by reducing costs), optimized cryopreservation to augment cumulative pregnancy rates per oocyte harvest and a standardized format for reporting results. To make SET the standard of care in the appropriate target group, there is a need for more clinical studies, for intensive counselling of patients, and for an increased sense of responsibility in patients, health care providers and health insurers.

Single or multiple embryo transfer following in vitro fertilisation for improved neonatal outcome: A systematic review of the literature

BACKGROUND

The aim of the current review was to determine if single versus two or more embryos, or double versus three or more embryos, transferred to the woman of a subfertile couple at in vitro fertilisation (IVF) maximises the likelihood of pregnancy, while minimising the likelihood of multiple pregnancy and adverse sequelae.

METHODS

Studies were identified that reported maternal, infant and cost outcomes following embryo transfer at IVF.

RESULTS

Three randomised trials and 17 cohort studies were included. From two randomised trials, single embryo transfer was found to result in decreased incidence of clinical pregnancy, multiple pregnancy and low birthweight. In the cohort studies for single embryo transfer compared with transfer of two or more embryos the incidence of live birth and singleton pregnancies was unchanged, and the incidence of multiple pregnancies and low birthweight was reduced. For double embryo transfer compared with the transfer of three or more embryos, the incidence of clinical pregnancy, live birth, preterm birth and low birthweight babies was reduced.

CONCLUSIONS

Information on neonatal and maternal outcomes following transfer of different numbers of embryos is limited. Transfer of one embryo does not alter the likelihood of a singleton pregnancy or birth when compared to transfer of two or more embryos. Transfer of one or two embryos decreases the risk of a multiple pregnancy, preterm birth and low birthweight. Further large, well-designed randomised trials are required to provide maternal and neonatal outcomes of relevance to a couple undergoing IVF.

Use of outcomes-based data in reducing high-order multiple pregnancies: the role of age, diagnosis, and embryo score

OBJECTIVE

To identify high-risk categories for high-order multiple pregnancy (HMP) in in vitro fertilization (IVF), establish clinic-specific HMP risk data for counseling use, and verify their utility in reducing HMP.

DESIGN

Before and after intervention study.

SETTING

Two IVF programs using the same embryology laboratory and IVF protocols.

PATIENT(S)

All IVF patients undergoing fresh embryo transfers.

INTERVENTION(S)

Use of clinic-specific age, diagnosis, and embryo score (ES) risk data in assessing individual HMP risk during informed consent.

MAIN OUTCOME MEASURE(S)

HMP and pregnancy outcomes.

RESULT(S)

In determining clinic-specific high risk categories and developing outcomes-based HMP risk data for counseling, the good outcome rate (GR) was defined as the percentage of singleton or twin deliveries per cycle and the bad outcome rate included no pregnancy or nondelivered pregnancies (miscarriages, multifetal reduction) and HMP per cycle. During 1995 to 1999, age <35 years, calculated morphologic ES, and donor egg (DE) cycles were factors shown by logistic regression to statistically significantly affect the GR. The optimal GRs for DE <35 and >or=35 years (donor age), and non-DE cycles <35 years were achieved with two (57.7%), three (43.2%), and three (43.2%) embryos transferred, respectively. A DE <35 years with >or=3 embryos transferred had the highest risk for HMP. The GR correlated (0.91) with the ES according to the formula: GR = 3.3 + 2.0 ES, when ES range was between 4 and 26. Clinic-specific risks for HMP based on age, diagnosis, and ES were developed and considered while counseling for ET during 2004. The clinic-specific HMP risk data made for a reduction in the HMP rate of 90.9% for DE-IVF (11.8% to 1%) and 53.8% for all IVF (9.1% to 4.2%), without decreases in clinical pregnancy or delivery rates. Physicians showing the greatest decline (64%) in HMP had no reduction in pregnancy or delivery rates.

CONCLUSION(S)

The use of clinic-specific HMP risk data in counseling based on age, diagnosis, and ES provided a 53% to 64% reduction in HMP without affecting rates of pregnancy or delivery. The clinic-specific ES system correlated closely with good outcomes. A standardized ES system may provide useful information for counseling during ET informed consent.

Role of fertility treatments in multiple pregnancy at National Women's Hospital from 1996 to 2001

OBJECTIVE

To determine the influence of fertility treatments on multiple pregnancy rates.

STUDY DESIGN

A retrospective audit of women with multiple pregnancies from 1996 to 2001 at National Women's Hospital (NWH), Auckland, New Zealand was conducted. Information was collected regarding the demographics, fertility treatment, outcome of the pregnancy and complications experienced by women discharged with multiple births as an discharge diagnosis.

RESULTS

For the years 1996-2001 there were 1136 multiple births at NWH. Of these births, 201 (18%) were conceived following fertility treatment. Seventeen percent of twin births and 44% of triplet births were conceived following fertility treatment. There was a statistically significant increase in the number of births conceived following fertility treatment, from 9%, in 1996 to 24%, in 2001, although the proportion of births that were multiple overall did not change (20% in 1996 and 2.3%, in 2001). Sixty-three percent of all fertility conceived multiple births were following in vitro fertilization/intracytoplasmic sperm injection treatment. Sixty percent of these women had two embryos transferred and 31% had three embryos transferred. Ovulation induction with follicle-stimulating hormone accounted for 19% of all fertility conceived multiple births. Nineteen percent of fertility conceived multiple births followed clomiphene treatment alone.

CONCLUSIONS

The proportion of multiple pregnancies as a result of fertility treatments has increased over the 6 years studied.

Avoiding multiple pregnancies in ART: a plea for single embryo transfer

It has been generally accepted that triplets after IVF/intracytoplasmic sperm injection (ICSI) can and should be avoided by adopting a standard strategy of replacing no more than two embryos. However, there is an increasing awareness of the risks and costs and of the epidemic size of twin pregnancies after IVF/ICSI. This has resulted in efforts to replace no more than one embryo. However, this approach has been hampered by our relative inability to identify embryos with a very high implantation potential. To identify such embryos, a number of strategies are being considered, both at the two pronuclear (2PN), early cleavage and the blastocyst stages. At the 2PN stage, the polarity characteristics of the nucleoli have been shown to be correlated with a high implantation rate. Similarly, the morphological characteristics at day 2 and 3 have been used to describe top quality embryos in approximately 75% of all IVF/ICSI cycles. Blastocyst culture has resulted in very high implantation rates in the hands of some authors. No approach has shown its superiority at present, but initial experience with single embryo transfer (SET) at the early cleavage stage by Scandinavian and Belgian groups shows that an ongoing pregnancy rate of 35% and more can be achieved. Proper identification of patients at risk of a twin pregnancy after double embryo transfer is equally important. It is clear that mainly young patients (aged <34 years) during their first, perhaps first two, IVF/ICSI cycles constitute the main population at risk (responsible for >80% of all twins) and are the main target group for twin prevention by SET of a top quality embryo at whatever stage. Therefore, in our opinion, although a further fine-tuning of both embryo and patient characteristics relating to a high risk for (twin) pregnancy is desirable, SET should be introduced carefully and progressively in each IVF/ICSI programme from now on. Correct counselling is very important and both public and private insurers will have to join in the discussion.

Prenatal diagnosis in multiple pregnancy

Fetal abnormality is more common in multiple than in singleton pregnancies. This, together with the requirement to consider the risks with at least two babies to sample correctly each fetus and to undertake accurately-targeted selective termination, amounts to a major challenge for obstetricians involved in prenatal diagnosis. Early determination of chorionicity should be routine, since this influences not only the genetic risks but also the invasive procedure chosen for karyotyping or genotyping. Assessment of nuchal translucency identifies individual fetuses at risk of trisomy. Contrary to expectation, invasive procedures in twins appear to have procedure-related miscarriage rates that are similar to those in singletons. Instead, contamination remains a concern at chorionic villus sampling. Elective late karyotyping of fetuses may have a role in some countries. Whereas management options for discordant fetal abnormality are relatively straightforward in dichorionic pregnancies, monochorionic pregnancies are at risk of co-twin sequelae after any single intrauterine death. Techniques have now been developed to occlude completely the cord vasculature by laser and/or ultrasound guided bipolar diathermy. Given the complexities associated with prenatal diagnosis, all invasive procedures in multiple pregnancies should be performed in tertiary referral centres.

The influence of supernumerary embryos on the clinical outcome of IVF cycles

PURPOSE

To assess the influence of the presence of quality supernumerary embryos on the clinical outcome and risk of multiple conception in patients having their first in vitro fertilization (IVF) cycle.

METHODS

Retrospective cohort study of 1448 women having their first IVF treatment cycle who received 4004 embryos where at least six embryos were available for transfer treated in an Assisted Conception Unit based in a large teaching hospital.

RESULTS

The replacement of three rather than two embryos to women under 35 years who had good-quality supernumerary embryos resulted in a higher twin (12.5 vs. 11.9%) and triplet birth rates (2.1 vs. 0%), without significantly improving the clinical pregnancy (50.5 vs. 45.2%) or total live birth rates (38.9 vs. 35.7%). In the absence of quality spare embryos, these women who had three rather than two embryos replaced had a significantly higher clinical pregnancy rate (39.3 vs. 28.8%; P = 0.04), total live birth (32.7 vs. 19.4%; P = 0.02) and singleton birth rate per cycle (20.8 vs. 14.4%; P = 0.04), without significantly influencing the multiple birth rate. In women over 35 years, the replacement of three instead of two embryos in the presence or absence of quality supernumerary embryos led to a significant improvement in clinical outcome, without being associated with a concurrent increase in the multiple birth rate. Women in both age groups who had either two or three embryos replaced in the presence of quality supernumerary embryos had a notably better clinical outcome compared with their counterparts who had the same number of embryos replaced, but with no quality embryos to spare.

CONCLUSIONS

The presence of good-quality supernumerary embryos can be used as a reference to determine the optimal number of embryos to transfer and as an indicator of the probability of success of an individual couple in a given cycle. Optimal pregnancy rates and simultaneous reduction of multiple gestation can be achieved with a flexible embryo replacement policy that is based on embryo quality, maternal age, and the presence or absence of surplus quality embryos.

Prevention of twin pregnancy after in-vitro fertilization or intracytoplasmic sperm injection based on strict embryo criteria: a prospective randomized clinical trial

A prospective randomized study comparing single embryo transfer with double embryo transfer after in-vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) was carried out. First, top quality embryo characteristics were delineated by retrospectively analysing embryos resulting in ongoing twins after double embryo transfer. A top quality embryo was characterized by the presence of 4 or 5 blastomeres at day 2 and at least 7 blastomeres on day 3 after insemination, the absence of multinucleated blastomeres and <20% cellular fragments on day 2 and day 3 after fertilization. Using these criteria, a prospective study was conducted in women <34 years of age, who started their first IVF/ICSI cycle. Of 194 eligible patients, 110 agreed to participate of whom 53 produced at least two top quality embryos and were prospectively randomized. In all, 26 single embryo transfers resulted in 17 conceptions, 14 clinical and 10 ongoing pregnancies [implantation rate (IR) = 42.3%; ongoing pregnancy rate (OPR) = 38.5%] with one monozygotic twin; 27 double embryo transfers resulted in 20 ongoing conceptions with six (30%) twins (IR = 48.1%; OPR = 74%). We conclude that by using single embryo transfer and strict embryo criteria, an OPR similar to that in normal fertile couples can be achieved after IVF/ICSI, while limiting the dizygotic twin pregnancy rate to its natural incidence of <1% of all ongoing pregnancies.

One thousand initiated cycles of in vitro fertilization in women > or = 40 years of age

OBJECTIVE

To evaluate the results of IVF in women > or = 40 years of age using their own oocytes.

DESIGN

Retrospective study.

SETTING

Wolfson and Royal Masonic in vitro fertilization units, London, United Kingdom.

PATIENT(S)

A total of 1,087 IVF cycles were started in women > or = 40 years of age.

INTERVENTION(S)

Medical records of patient outcomes were reviewed.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy, miscarriage, and delivery rates.

RESULT(S)

Of the 1,087 cycles started in 471 women > or = 40 years of age, 842 reached oocyte retrieval (77.5%) and 702 had embryos transferred (64.6%). The pregnancy rate (PR) was significantly lower in women > or = 40 years of age than in a control group of women <40 years of age (11.3% versus 28.2%). It decreased sharply in women >42 years of age, and no women >45 years of age had a child. Women > or = 40 years of age were more likely to miscarry (27% versus 12.7%). When only one embryo was available for transfer, the PR was 3.3%. When >2 embryos were available for transfer, the PR was similar whether 2 or 3 embryos were replaced. No triplet pregnancy occurred. Women > or = 40 years of age achieved a cumulative PR of 30% after three cycles with a cumulative "take home baby" rate of 21%.

CONCLUSION(S)

In vitro fertilization is a reasonable treatment for women <45 years of age using their own gametes. Those with a "good response" in their first attempt may be encouraged to complete three cycles with an acceptable chance of conception.

Maximizing pregnancy rates and limiting higher-order multiple conceptions by determining the optimal number of embryos to transfer based on quality

OBJECTIVE

To define statistical thresholds for the number of embryos to be transferred to achieve an optimal pregnancy rate and keep higher-order multiple conceptions (pregnancy with more than two fetal sacs with cardiac activity) within an acceptable limit.

DESIGN

A retrospective review of patient records.

SETTING

Private practice assisted reproductive technology (ART) facility.

PATIENT(S)

Seven hundred fifty-four consecutive patients who underwent IVF-ET from 1994-1996.

INTERVENTION(S)

Embryo grading and score system used on day 3 of embryo transfer.

MAIN OUTCOME MEASURE(S)

Implantation, pregnancy, and multiple conception rates.

RESULT(S)

For women < or =35 years old, transfer of up to four poor-quality, two fair-quality, or two good-quality embryos is optimal to eliminate any risk of higher-order multiple pregnancies. Transfer of four poor-quality, three fair-quality, or two good-quality embryos is recommended for women 36 to 39 years old. In women who are > or =40 years old, five embryos need to be transferred regardless of embryo quality.

CONCLUSION(S)

The mean cumulative embryo score can be used as a reference to determine an optimal number of embryos to transfer and to predict pregnancy outcome.

A new assisted hatching technique using a piezo-micromanipulator

OBJECTIVE

To estimate the efficacy of a new assisted hatching technique using a piezo-micromanipulator to support embryonic implantation.

DESIGN

Sibling spare embryos from human cycles of IVF were allocated to either a treated group for assisted hatching by a piezo-micromanipulator or a nontreated control group.

SETTING

The Infertility and IVF unit of the Kyoto University Hospital.

PATIENT(S)

Sixty-eight women undergoing conventional IVF treatment.

INTERVENTION(S)

One hundred ten spare 4- or 8-cell embryos from 68 patients undergoing IVF were treated with the new assisted hatching technique, and the results were compared with those obtained for 112 sibling embryos without the treatment. In the assisted hatching procedure, zona thinning combined with drilling was performed by the vibration of a microneedle produced by the piezo-micromanipulator unit.

MAIN OUTCOME MEASURE(S)

The rates of partial hatching and completely hatched blastocysts.

RESULT(S)

The rates of hatching and of hatched blastocysts per total developing blastocysts were significantly higher in the treated group (86.7% and 33.3%, respectively) than in the control group (15.3% and 2.8%, respectively).

CONCLUSION(S)

These results demonstrate that the newly devised zona thinning and drilling technique using a piezo-micromanipulator is useful for assisted hatching.

Strategies to prevent multiple pregnancies in assisted conception programmes

All assisted conception techniques are associated with an increase in the multiple pregnancy rate. Iatrogenic multiple births are increasing as the use of these technologies expands. The cornerstone of safe ovulation induction is careful ultrasound monitoring, with cancellation of cycles if excessive ovulation is expected. In in vitro fertilization (IVF) cycles, the main determinant of multiple pregnancy risk is the number of embryos replaced. The current move in IVF clinics is to reduce the risk of multiple pregnancy by reducing the number of embryos transferred. We would suggest a maximum of two embryos transferred to women under, for example, 39 years of age. Women of 39 years or over have a reduced chance of embryo implantation; they should be allowed the transfer of up to three embryos (the UK legal maximum).

Fertility options after vasectomy: a cost-effectiveness analysis

OBJECTIVE

To evaluate cost per delivery using two different initial approaches to the treatment of postvasectomy infertility.

DESIGN

Model of expected costs and results in the United States in 1994.

SETTING

Men with postvasectomy infertility, evaluated and treated at centers with experience in vasectomy reversal or sperm retrieval and ICSI.

PATIENT(S)

Men with postvasectomy infertility, with a female partner < or = 39 years of age.

INTERVENTION(S)

Initial microsurgical vasectomy reversal was compared with retrieved epididymal or testicular sperm. Actual treatment charges, complication rates, and pregnancy and delivery rates obtained in the United States were used for cost per delivery analysis.

MAIN OUTCOME MEASURE(S)

Cost per delivery, delivery rates.

RESULT(S)

Cost per delivery with an initial approach of vasectomy reversal was only $25,475. (95% confidence interval $19,609 to $31,339), with a delivery rate of 47%. However, the cost per delivery after sperm retrieval and ICSI was $72,521. (95% confidence interval $63,357 to $81,685), with an average of $73,146 for percutaneous or testicular sperm retrieval and $71,896 for surgical epididymal sperm retrieval. The delivery rate after one cycle of sperm retrieval and ICSI was 33%.

CONCLUSION(S)

The most cost-effective approach to treatment of postvasectomy infertility is microsurgical vasectomy reversal. This treatment also has the highest chance of resulting in delivery of a child for a single intervention.