Early pregnancy wastage after gamete manipulation

MPA given orally during the first trimester for threatened miscarriage carries no specific risk for foetal abnormalities albeit the rate is higher than non-threatened pregnancies

This observational study examines the outcomes of pregnancies arising in women referred for infertility, where those who experienced threatened miscarriage were treated with medroxyprogesterone acetate (MPA) tablets. The 14-year study period covers comprehensive real-time data entries into the validated electronic database including details of the infertility management, pregnancy outcomes and any foetal anomalies among the infants, each being tracked and recorded. Of 4057 clinical pregnancies, 1343 received MPA for threatened miscarriage; 934 (69.6 %) of which continued to livebirths. These were compared with the remaining 2714 clinical pregnancies without threatened miscarriage or MPA and which resulted in 2075 (76.5 %) livebirths. There were 134 developmental abnormalities recorded among the 3009 livebirths of which 78 (2.6 %) were categorised appropriate for the Western Australian Developmental Abnormalities Register; WARDA. These comprised 55 in the MPA group, 36 of which were categorised as serious (being 2.7 % of clinical pregnancies and 3.9 % of births). In the group without MPA, there were 79 abnormalities, of which 42 were categorised as serious (being 1.7 % of clinical pregnancies and 2.2 % of births). Specifically, there were no cases of androgenisation noted among the female infants. The abnormality rates were low overall and well within the annual WARDA ranges. We cautiously suggest that oral MPA can be considered for studies throughout pregnancy including the early first trimester to assess a potential role in reducing miscarriage, as well as advanced pregnancies to evaluate a potential role in reducing stillbirths and preterm delivery.

Assisted hatching is more effective when embryo quality was optimal in previous failed IVF/ICSI cycles

Assisted hatching (AH) was developed as a possible solution to repeated implantation failure. The aim of this analysis was to examine the relationship between the morphology of embryos in a previous cycle on outcome in a subsequent cycle with AH. A total of 175 AH cycles performed after previous failed ART without hatching were divided into group A with optimal and group B with suboptimal embryos transferred previously. The groups were similar in terms of demographic and cycle characteristics. In group A, there was a significant improvement (p<0.001) in implantation (28.8 vs 5.1%), clinical pregnancy (41.9 vs 12.1%) and live birth rate (38.5 vs 8.6%) compared with group B. The data suggest that the prognosis for treatment is better if AH is performed after failure despite optimal embryos compared with failure associated with suboptimal embryos and embryo quality is the most significant factor affecting outcome.

Placental isoferritin as a marker of early abortion in pregnancies induced by in vitro fertilization

The relatively high rate of early pregnancy loss in artificial reproductive technology-induced conceptions has driven researchers to seek for an efficient diagnostic tool for estimating the gestational risk in these cases. Monitoring early gestation normalcy using serial beta-human chorionic gonadotrophin (beta hCG) measurements requires several days before diagnosis can be established. The objective of this study was to determine whether placental isoferritin (PLF) can be used as a predictive marker of normal pregnancy development during early stages of in vitro fertilization (IVF)-induced pregnancy. Ninety-three consecutive IVF cycles were investigated. Blood samples for PLF (enzyme linked immunosorbent assay; ELISA) and beta hCG (radio-immunoassay; RIA) determination were obtained from all women on days 11, 13 and 15 following embryo transfer. Placental isoferritin was detectable in the serum 11 days after embryo transfer in IVF conception cycles. These levels were significantly higher in normally developing pregnancies (n = 18) than in cases which eventually aborted spontaneously (n = 9) during the first trimester (mean +/- s.d.; 33 +/- 28 U/mL as compared with 1 +/- 2 U/mL; P = 0.0004; Wilcoxon test; sensitivity 94.5 per cent, specificity 88.9 per cent, positive predictive value 89.9 per cent, negative predictive value 94.5 per cent). Moreover, in those patients who later aborted, lower than normal PLF levels were detected long before the decline in beta hCG titres was evident. Considering its suppressor activity, it is expected that PLF levels would be high at the initiation of normal pregnancy. This may explain the present finding of low PLF levels in abnormally developing IVF-induced pregnancies. These preliminary data suggest that PLF can be used as a sensitive marker for detecting those cases destined to abort at a very early stage. However, further studies are still required on spontaneous conceptions, before this test can be recommended for routine clinical application.

Developmental failure in preimplantation human conceptuses

The majority of human conceptuses fertilized normally in vitro fail to establish a pregnancy following their replacement in utero. However, since conceptuses are usually transferred after only one or two cell divisions, their developmental outcome is not known. It has been found that a significant number of human oocytes which can be fertilized carry chromosomal abnormalities, even in the absence of ovarian stimulation. After fertilization, preimplantation-stage conceptuses developing in vitro display a high incidence of cellular abnormalities. Similar disruptions of cellular organization have also been noted in conceptuses fertilized in vivo. Thus, developmental abnormalities and the demise of the conceptus prior to the stage of implantation may stem from the poor quality of the oocyte. The conditions encountered in vitro have also been proposed to cause or contribute to the early demise of human conceptuses.

Potential use of embryo coculture with human in vitro fertilization procedures

PURPOSE

This review was designed to outline potential uses of an embryo co-culture system in human assisted reproduction programs to improve embryo quality and pregnancy rates.

RESULTS

The various cell types used in embryo co-culture were reviewed in addition to the use of co-culture for both animal and human embryos. Co-culture provides a method to enhance embryo development in an inadequate in vitro environment without compromising embryo quality. Human IVF laboratories have used various types of "helper cells" to improve rate of development, reduce cell fragmentation rate and in some instances increases pregnancy and implantation rates.

CONCLUSION

In conjunction with several assisted reproduction procedures such as IVF, microsurgical fertilization, cryopreservation and genetic evaluation, co-culture may increase the number of viable embryos for replacement and improve pregnancy rates.

In vitro fertilisation and gamete intrafallopian transfer: an integrative analysis of research, 1987-1992

OBJECTIVE

To provide a statistically integrated analysis and review of all published outcome studies of in vitro fertilisation (IVF) and gamete intrafallopian transfer (GIFT) occurring in English language journals between 1987 and 1992; to provide information regarding outcome of assisted reproduction not otherwise available from national registers; and to assess correspondence of these outcomes with outcome data presented in the national registers of the Fertility Societies of Australia and the United States.

DESIGN

Computer literature review and manual search of major infertility journals to identify all papers reporting clinical pregnancy rates for IVF and GIFT. A secondary analysis of three factors, including 1. treatment (IVF vs GIFT), 2. stimulation protocol [combinations using clomiphene citrate (CC), combinations using gonadotrophin agonists (GnRHa), and combinations using neither clomiphene citrate nor gonadotrophin agonists, (designated by the symbols and acronyms approximately CC approximately GnRHa throughout this article)], and 3. cause of infertility, assessed their impact upon three clinical pregnancy rates: 1. cycles commenced, 2. cycles reaching retrieval and 3. cycles reaching oocyte/embryo transfer, via a series of one-way analyses of variance with either planned contrasts or post hoc comparisons.

SUBJECTS

The unit of observation was the published study. Data were obtained from 31 journals and 216 papers, containing 509 samples and 39,754 per cycles commenced. Data from the national registers of the Fertility Societies of Australia and the United States were used for comparison of literature-based outcomes, where appropriate.

RESULTS

The concordance between the outcomes reported in the national registers of Australia and the United States and the amalgamated literature-based data was such that cautious confidence was placed in the results of the subsequent analyses of the literature-based data which provided information not otherwise available. GIFT resulted in significantly more clinical pregnancies than IVF for each stage of the treatment cycle. Differences in pregnancy rates between IVF and GIFT were 8.6% more pregnancies for GIFT for cycles commenced, 14.2% for cycles reaching retrieval, and 7.5% for cycles reaching oocyte or embryo transfer. Stimulation protocols using gonadotrophin agonists (GnRHa) resulted in more clinical pregnancies than protocols using clomiphene citrate for each stage of the treatment cycle: from commencement (10.22%), to retrieval (8.36%), and to transfer (9.36%). Interaction effects indicated that GIFT-GnRHa combinations were superior to IVF-clomiphene citrate combinations for all rates. For cycles reaching retrieval and transfer, GIFT-GnRHa resulted in significantly more clinical pregnancies than IVF-GnRHa. GIFT-clomiphene citrate was better than IVF-clomiphene citrate and IVF-GnRHa was better than IVF-clomiphene citrate. Women with endometriosis (Stages I or II) achieved higher rates of clinical pregnancy than participants with other causes of infertility.

CONCLUSIONS

Significantly higher pregnancy rates for GIFT and GnRHa were demonstrated in this study. It was argued that since the differences in clinical pregnancy rates were smaller between IVF and GIFT when a GnRHa protocol was employed, the apparent superiority of GIFT may in fact be due, at least in part, to GnRHa. This question needs further prospective investigation. Women with endometriosis (Stage I or II) achieved higher pregnancy rates than those with other causes of infertility. Overall, this study provides confirmation that well-held clinical conclusions have a true basis in the published literature and that the published literature reflects population data reported in national registers. Further prospective research is needed to clarify the unique probabilities of a live birth for individual couples.

Chromosome abnormalities detected in chorionic villus biopsies of failing pregnancies in a subfertile population

OBJECTIVE

To determine the range and prevalence of chromosomal abnormalities occurring in failing pregnancies in subfertile women.

DESIGN

Prospective biochemical and ultrasound monitoring of all pregnancies conceived between 1988 and 1990 in a subfertile population.

SETTING

A single-centre specialist fertility clinic in Perth, Western Australia.

SUBJECTS

Tissue from 50 early pregnancy losses was successfully cultured for chromosomal analysis from 46 pregnancies comprising 29 anembryonic pregnancies, 9 miscarriages and 8 ectopic pregnancies.

MAIN OUTCOME MEASURES

Impending pregnancy loss was identified at an early stage. Chromosomal analysis was performed on chorionic villi obtained before the diagnosis became clinically evident.

RESULTS

Significant chromosomal abnormalities were identified in 54% (14/26) of early pregnancy losses where gamete manipulation was involved and 45% (9/20) of those following spontaneous conception. The most common abnormalities were trisomies (12 pregnancies, mainly trisomy 16), triploidies (3 pregnancies) and monosomy X (3 pregnancies). An excess of female fetuses was noted with only 24% of conceptuses (11/46) bearing a Y chromosome.

CONCLUSIONS

The data indicate a similar rate of chromosomal abnormalities underlying pregnancy losses at earlier stages of pregnancy and after infertility treatments as that reported from the general population. Gamete manipulation does not appear to confer a higher rate of chromosomal abnormalities in ensuing pregnancies.