Mid-luteal phase injection of subcutaneous leuprolide acetate improves live delivered pregnancy and implantation rates in younger women undergoing in vitro fertilization-embryo transfer (IVF-ET)

PURPOSE

To determine if a single injection of one-mg leuprolide acetate three days after embryo transfer (ET) in younger women causes an increase in pregnancy rates, and if so, is it associated with a higher initial serum hCG level?

MATERIALS AND METHODS

A prospective study was initiated where women aged ≤ 35 years were offered the option of taking the leuprolide or not.

RESULTS

Though a significant difference was not found, there was a trend for higher live delivered pregnancy rates in those taking the leuprolide supplement (47.8%) vs. those not taking it (38.6%). There was no difference in the first serum beta hCG level.

CONCLUSIONS

The trends is interesting enough to continue with a higher powered study.

Failure to increase the thickness of thin endometria with intrauterine infusion of granulocyte colony stimulating factor (G-CSF)

PURPOSE

To corroborate or refute a previous study suggesting that intrauterine infusion of granulocyte colony stimulating factor (G-CSF) could significantly improve endometrial thickness into more fertile levels when the endometrial thickness was ≤ five mm.

MATERIALS AND METHODS

Three women whose endometrial thickness never exceeded five mm on the in vitro fertilization-embryo transfer (IVF-ET) cycle or subsequent attempted frozen ETs using graduated estradiol had intrauterine infusion of G-CSF to the estradiol regimen.

RESULTS

Not one of the three women improved the endometrial thickness beyond five mm and none conceived on the G-CSF cycle. One woman had a subsequent pregnancy following a frozen ET with only a four-mm thickness with no infusion of G-CSF.

CONCLUSIONS

These data do not confirm the efficacy of intrauterine infusion of G-CSF for poor endometrial thickness. Perhaps only certain cases will respond. A larger series could take time to accumulate since other studies have shown that only 0.3% of women with ≤ five mm endometrial thickness in the late proliferative phase during an IVF-ET cycle will not improve the endometrial thickness > five mm using graduated estradiol protocols.

A prospective comparison of outcome following cryopreservation using vitrification vs. a modified slow-freeze protocol of 2 pronuclear (2PN) and day 3 multi-cell embryos

PURPOSE

To compare the efficacy of vitrification of 2 pronuclear and day 3 cleavage stage embryo vs. a modified slow freeze protocol that historically has achieved good survival and pregnancy rates at these stages.

MATERIALS AND METHODS

Embryos were randomly assigned by day to freezing at the 2 proncular stage or day 3 cleavage stage embryos by either vitrification or a modified slow freeze protocol. Comparisons were made for survival rate, cleaveage rate, and pregnancy rate.

RESULTS

The results were comparable with a slight edge to vitrification. Only the implantation rates of day 3 cleavage staged embryos (75% vs. 30.4%) showed a significant difference.

CONCLUSIONS

Vitrification seems to be equally or possibly slightly superior to freezing embryos at the 2 pronuclear or day 3 cleavage stage vs. a modified slow freeze protocol that had been previously found to be superior to the slow freeze method of LaSalle-Testart.

Mid-luteal phase injection of subcutaneous leuprolide acetate improves live delivered pregnancy and implantation rates in younger women undergoing in vitro fertilization-embryo transfer (IVF-ET)

PURPOSE

To see if the single injection of one mg of the gonadotropin releasing hormone agonist (GnRHa) leuprolide acetate given in the mid-luteal phase can increase live delivered pregnancy and implantation rates. Furthermore the purpose was to determine if improvement was found, did the mechanism involve increased secretion of human chorionic gonadotropin (hCG).

MATERIALS AND METHODS

A prospective study was conducted in women aged 35 who were undergoing in vitro fertilization-embryo transfer (IVF-ET). They were advised of data from Tesarik et al. and a previous pilot study conducted in the present IVF center showing improved pregnancy rates with the injection of a GnRHa three days after embryo transfer. They were offered the option of returning for a one-mg injection s.c. of leuprolide acetate or not. Clinical and live delivered pregnancy rates were compared according to those taking or not the leuprolide acetate one-mg injection. Chi-square analysis was used for statistical comparisons. Serum beta-hCG levels were compared between those conceiving with or without the extra injection of leuprolide.

RESULTS

There was a non-significant trend for higher live delivered pregnancy rates in those taking leuprolide (47.8%, 64/134) vs. those not taking it (38.6%, 76/197). For those pregnant there was no difference in hCG levels according to taking the GnRHa or not.

CONCLUSIONS

The 25% increased live delivered pregnancy rate per transfer was insufficiently powered to detect a significant difference. The results do justify continuing the study. Perhaps the difference could be wider using a slightly older age group whose embryos are frequently less hearty.

The effect of oocyte reserve on pregnancy rates per oocyte harvest in women aged 36-39

PURPOSE

To determine the relative effect of diminished oocyte reserve on clinical viable and live delivered pregnancy rates per transfer and live delivery pregnancy rate per oocyte harvest in women aged 36-39.

MATERIALS AND METHODS

A retrospective comparison of pregnancy outcome was performed over a ten-year time period in women with normal oocyte reserve (day 3 serum FSH ≤ 11 mIU/mL) vs. diminished reserve (day 3 serum FSH ≥ 12 mIU/mL). Pregnancy rate per oocyte harvest equals the odds of conceiving with fresh or frozen embryos from a given retrieval before proceeding to another oocyte retrieval.

RESULTS

The clinical and viable (at end of first trimester) pregnancy rate per transfer was only 20% lower for the group with diminished oocyte reserve, but was 50% lower for the pregnancy rate per oocyte harvest.

CONCLUSIONS

Mild stimulation for women with diminished oocyte reserve allows a higher percentage of chromosomally normal embryos in women with diminished oocyte reserve, leading to only a 20% lower clinical and viable pregnancy rate per transfer. However, overall, there are less normal total number of normal embryos leading to a pregnancy rate per oocyte harvest only half as good in the group with lower reserve vs. normal.

The effect of conventional vs. mild ovarian hyperstimulation on the total number of live babies born from a given oocyte retrieval

PURPOSE

To compare pregnancy outcome in women with normal oocyte reserve according to whether they received conventional or mild follicle stimulating hormone (FSH) controlled ovarian hyperstimulation (COH) further stratified by age.

MATERIALS AND METHODS

A ten-year retrospective study including all cycles (even multiple in given patients) was performed. Mild stimulation including all cycles initiated and continued with 150 IU FSH or less from early follicular phase. Everything else was considered conventional stimulation. Mild stimulation included natural cycles or those with just a boost of 75 IU FSH from the mid to late follicular phase. Only women with normal oocyte reserve were selected--serum FSH < 12 mIU/mL and serum E2 < 50 pg/mL. Live delivered pregnancy rates within three age groups (≤ 35, 36-39, and 40-42 years) were compared per embryo transfer and per embryo retrieval, i.e., the percentage of women having a live baby without proceeding to another IVF-ET cycle. Also compared were the average number of babies born from one retrieval.

RESULTS

For aged ≤ 35 there were no differences in pregnancy rates per transfer but a trend for higher pregnancy rates per retrieval with conventional stimulation. For all other age groups both pregnancy rates per transfer and retrieval were significantly higher with conventional stimulation. This was reflected with a higher average number of babies born per retrieval with conventional.

CONCLUSIONS

For women with normal oocyte reserve in general, there is no advantage of mild vs. conventional COH other than cost saving. Of course there are exceptions, e.g., ovarian hyperstimulation with conventional COH.

The effect of a rise or fall of serum estradiol the day before oocyte retrieval in women aged 40-42 with diminished egg reserve

PURPOSE

To determine the effect of a drop in serum estradiol the day after injection of human chorionic gonadotropin (hCG) in in vitro fertilization-embryo transfer (IVF-ET) cycles in women aged 40-42 with diminished oocyte reserve.

MATERIALS AND METHODS

Retrospective study with further requirement that the female partner had a day 3 serum follicle stimulating hormone (FSH) of ≥ 12 miU/mL and ≥ five antral follicles.

RESULTS

A drop in serum estradiol the day after hCG injection is not associated with a lower chance of pregnancy compared to those women whose serum estradiol increases. However, their chances of releasing the oocyte before retrieval is significantly higher.

CONCLUSIONS

A drop in serum estradiol in women of advanced reproductive age with diminished oocyte reserve should not signal the need to cancel the retrieval.

Effect of taking a one time injection of one mg leuprolide acetate three days after embryo transfer on pregnancy outcome and level of first beta human chorionic gonadotropin (beta-hCG) level

PURPOSE

To determine if the injection of a gonadotropin releasing hormone agonist (GnRHa) three days after embryo transfer will improve pregnancy and implantation rates.

MATERIALS AND METHODS

One mg s.c. of leuprolide acetate was randomly given based on patient decision three days after embryo transfer to some patients undergoing in vitro fertilization-embryo transfer (IVF-ET).

RESULTS

For women aged ≤ 43 the clinical pregnancy rate for those not taking the GnRHa was 39.5% (68/122) vs. 54.5% (42/77) for those taking leuprolide acetate (Chi-square, p = 0.0275). The respective implantation rates were 22.6% vs. 30.2% (p = 0.0495). There was no difference in first serum beta human chorionic gonadotropin (beta-hCG) levels according to whether leuprolide was used or not.

CONCLUSIONS

Leuprolide acetate similar to other GnRH agonists can improve implantation rates following IVF-ET when injected once in mid-luteal phase. The beneficial effect may be on GnRH receptors in the endometrium rather than the embryo (which had been hypothesized to direct increased placental production of hCG).

Failure to improve a thin endometrium in the late proliferative phase with uterine infusion of granulocyte-colony stimulating factor

PURPOSE

To determine if the treatment with uterine infusion of granulocyte colony-stimulating factor (G-CSF) can improve endometrial thickness in an infertile woman with a double uterus, who consistently showed a thin endometrium in the late proliferative phase either in controlled ovarian hyperstimulation (COH) IVF-ET cycles or with graduated estrogen/sildenafil protocols for frozen embryo transfer (ET).

MATERIALS AND METHODS

A single uterine infusion of G-CSF was performed in the late proliferative phase in a woman who only attained a five-mm thickness despite a high dose vaginal and oral estradiol regimen plus sildenafil.

RESULTS

No increase was found within a couple days.

CONCLUSIONS

A previous four-case study in another center found 100% improvement in the endometrial thickness in women with consistently thin endometria. Perhaps the uterine anomaly in the present case prevented the response of the endometrium.

Effect of triple line vs isoechogenic endometrial texture on pregnancy outcome following embryo transfer according to use of controlled ovarian stimulation (COH) or estrogen/progesterone replacement

PURPOSE

To determine if pregnancy rates following embryo transfer are reduced if the endometrial echo pattern in the late proliferative phase is isoechogenic (IE) vs triple line (TL).

METHODS

Pregnancy and implantation rates were compared according to TL vs IE pattern in the late proliferative phase in women having in vitro fertilization-embryo transfer (IVF-ET), frozen ET, and transfer of embryos derived from donor oocytes.

RESULTS

There was no difference in pregnancy rates with IE vs TL pattern with fresh or frozen ET or in donor egg recipients. The degree of ovarian reserve did not affect the pregnancy rates according to endometrial echo pattern.

CONCLUSIONS

The presence of an IE pattern in the late proliferative phase should not influence the treating physician to either cancel the cycle and withhold human chorionic gonadotropin (hCG) injection or freeze all embryos and defer transfer.

A study to determine the efficacy of controlled ovarian hyperstimulation regimen using a gonadotropin releasing hormone agonist versus antagonist in women of advanced reproductive age with varying degrees of oocyte reserve on outcome following in vitro fertilization-embryo transfer

PURPOSE

To determine if the use of gonadotropin releasing hormone (GnRH) agonists (a) or antagonists (ant) allow better pregnancy rates when used in controlled ovarian hyperstimulation protocols in women of advanced reproductive age. Furthermore the study aimed to determine if the status of ovarian oocyte reserve has a confounding effect.

MATERIALS AND METHODS

A 12-year retrospective review was performed on all in vitro fertilization-embryo transfer (IVF-ET) cycles in women aged 40-44. Pregnancy rates were determined according to whether a GnRH-a or GnRH-ant was used. The data were also stratified according to normal or low oocyte reserve.

RESULTS

There was no significant difference in pregnancy rates according to whether a GnRH-a or GnRH-ant was used in women with normal oocyte reserve. Though a large majority of the women used a GnRH-ant, there was a 9% live pregnancy rate vs 0% in the women using a GnRH-a.

CONCLUSION

Since it is unlikely that a larger study will ever be conducted, it is probably wise to use a GnRH-ant for the controlled ovarian hyperstimulation regimen in women aged 40-44 with diminished oocyte reserve.

The sharing of eggs by infertile women who are trying to conceive themselves with an egg recipient for financial advantages does not jeopardize the donor's chance of conceiving

PURPOSE

To determine if the sharing of oocytes by an infertile woman with an egg recipient for financial advantages has any negative impact on the success rate for the donor.

METHODS

A matched controlled study was performed comparing pregnancy outcome of women undergoing in vitro fertilization-embryo transfer (IVF-ET) but sharing half of their eggs with a recipient vs women undergoing IVF-ET but not sharing oocytes.

RESULTS

Even though more women sharing oocytes deferred fresh transfer and cryopreserved the embryos because of a greater likelihood of ovarian hyperstimulation syndrome, there was no difference in pregnancy rates between the two groups after their first embryo transfer whether it was with fresh or frozen-thawed embryos.

CONCLUSIONS

Sharing of oocytes by a woman undergoing IVF-ET does not jeopardize her chance of a successful outcome following embryo transfer.

Pregnancy outcome following fresh vs frozen embryo transfer into gestational carriers using a simplified slow freeze protocol

PURPOSE

To compare pregnancy rates following fresh vs frozen embryo transfer into gestational carriers.

METHODS

Choice of deferring fresh embryo transfer and cryopreserving the embryos vs fresh transfers was not randomized but based on circumstances. The cryopreservation protocol used a simplified slow cool technique avoiding the planar programmable freezer and using a one-step removal of the cryoprotectant.

RESULTS

The live delivered pregnancy rate was 51.0% (49/96) for fresh embryo transfer vs 34.3% for transfers of frozen thawed embryos in gestational carriers not having a fresh embryo first.

CONCLUSIONS

Using the simplified slow cool cryopreservation protocol with a one-step removal of cryoprotectants pregnancy rates are comparable to what is found in women of similar ages undergoing controlled ovarian hyperstimulation followed by IVF-ET. However, when transferring to a gestational carrier the live delivered pregnancy rates are 50% higher with fresh embryo transfer.

Comparison of pregnancy rates following frozen embryo transfer according to the reason for freezing: risk of ovarian hyperstimulation vs inadequate endometrial thickness

PURPOSE

To determine the relative pregnancy rates following frozen embryo transfer according to the reason for deferring fresh embryo transfer and freezing all embryos.

METHOD

A retrospective review over a 10-year time period of all in vitro fertilization (IVF) cycles that deferred fresh transfer and cryopreserved all embryos related to risk of ovarian hyperstimulation syndrome or if there was inadequate endometrial thickness. Pregnancy rates according to the reason for freezing were then compared.

RESULTS

The clinical and live delivered pregnancy rates following frozen embryo transfer in women < or = age 39 was 42.8% and 31.9%, respectively for women deferring for risk of ovarian hyperstimulation syndrome vs 28.7% and 21.8% for those freezing for inadequate endometrial thickness (p = 0.01 and p = 0.07, respectively).

CONCLUSION

Embryo cryopreservation may not be a complete panacea for problems of inadequate endometrial thickness.

Effect of multiple source vs single source of donor embryos on pregnancy and implantation rates per transfer

PURPOSE

To evaluate whether using donated embryos from more than one source has a negative impact on pregnancy rates compared to a single source.

METHODS

Retrospective review of all donor embryo transfers that occurred in our IVF center over a 10-year period. Embryos were all from our own patient pool.

RESULTS

There were no differences in clinical or live delivered pregnancy rates.

CONCLUSIONS

The willingness to choose multiple sources allows a marked reduction in the waiting time for donated embryos which are scarce. This also reduced the financial burden for couples who for religious or for ethical reasons cannot destroy the embryos and have to pay continuous embryo storage charges.

Evidence that the main adverse effect of ganirelix on pregnancy and implantation rates is on the embryo rather than the endometrium

PURPOSE

To compare pregnancy rates following the transfer of thawed frozen embryos according to the type of GnRH antagonist or agonist used during controlled ovarian hyperstimulation (COH).

METHODS

Retrospective review of frozen embryo transfers according to whether a GnRH agonist or antagonist was used. Furthermore to determine if a specific antagonist/agonist resulted in higher pregnancy rates than the other.

RESULTS

The pregnancy rates in two different age categories were similar whether the COH regimen used the GnRH agonist leuprolide acetate or the GnRH antagonist cetrorelix. However, lower pregnancy rates were found with the GnRH antagonist ganirelix.

CONCLUSIONS

These data reached similar conclusions as was found comparing these three agents in fresh embryo transfer.

Blastomere number and pregnancy rates in the succeeding in vitro fertilization cycle in women who formed all embryos with < or = 5 blastomeres

PURPOSE

To determine the likelihood of pregnancy following the transfer of embryos all with slow cleavage to day 3. Furthermore to determine the likelihood that if slow cleavage happens once, it is likely to repeat.

METHODS

A 10-year retrospective review of in vitro fertilization-embryo transfer (IVF-ET) cycles was performed to identify day 3 embryo transfers where none of the embryos had > 5 blastomeres. The pregnancy rate was then determined. If pregnancy did not occur and another IVF-ET cycle was performed it was determined what percentage of those cycles also showed 100% slow cleavage.

RESULTS

The ongoing delivered pregnancy rate was 22.3% and the implantation rate was 15.6%. Of the 90 women trying another cycle 82.2% had at least one embryo with six blastomeres. The implantation rate for cycle number 2 for those with at least one 6-cell embryo was 18% (34/187) but was zero (0/17) for those not having at least a 6-cell embryo in cycle number 7.

CONCLUSIONS

These data can help a couple decide whether to pursue a second cycle following an IVF-ET cycle with 100% slow cleavage embryos.

Matched controlled study to evaluate the effect of endometrial polyps on pregnancy and implantation rates following in vitro fertilization-embryo transfer (IVF-ET)

PURPOSE

To determine if endometrial polyps negatively effect outcome following in vitro fertilization-embryo transfer (IVF-ET) and whether hysteroscopic resection improves pregnancy and implantation rates and/or decreases miscarriage rates.

METHODS

Retrospective study with two matched controlled groups (polyps vs no polyps) based on age and previous number of IVF failures. The polyp group was further stratified by whether polypectomy was performed or not.

RESULTS

There was no difference or even trend for lower pregnancy rates or higher miscarriage rates with the presence of endometrial polyps.

CONCLUSIONS

These data do not support the recommendation for hysteroscopic resection of endometrial polyps to aid conception rates.

Effect of serum progesterone level on the day of human chorionic gonadotropin injection on outcome following in vitro fertilization-embryo transfer in women using gonadotropin releasing hormone antagonists

PURPOSE

To determine if there is any association of serum progesterone (P) level at the time of human chorionic gonadotropin (hCG) injection and pregnancy outcome in in vitro fertilization (IVF) cycles using gonadotropin releasing hormone (GnRH) antagonists for controlled ovarian hyperstimulation (COH).

METHODS

A retrospective analysis of IVF cycles over a six and a half-year period where either cetrorelix or ganirelix was used with COH and at least two embryos were transferred. Female partners were < or = 35. Four different serum progesterone (P) ranges were evaluated from < or = .5 ng/ml to 1.9 ng/ml; P was measured by ELISA.

RESULTS

There was no significant difference in pregnancy rates or even a trend in that direction with increasing serum P levels with either GnRH antagonist.

CONCLUSIONS

At least with COH cycles using GnRH antagonists and where serum P is measured by ELISA there does not seem to be any disadvantage of higher serum P levels up to 2 ng/ml at the time of hCG in IVF-ET cycles.

Evaluation of the importance of late follicular phase endometrial echo patterns and pregnancy outcome following embryo transfer by evaluating infertile donor/recipient pairs

PURPOSE

To investigate if the late follicular phase echo pattern is associated with pregnancy outcome in donors vs recipients.

METHODS

Infertile donors sharing eggs with recipients were retrospectively evaluated. The endometrial echo pattern was evaluated on the day of human chorionic gonadotropin injection in donors and on the day before progesterone was given to recipients.

RESULTS

Almost twice as many donors conceived when the triple-line pattern was found compared to isoechogenic (IE) (51.5% or 52/101 vs 27.3% or 6/22) but there were inadequate numbers in the IE group to show a significant difference. There was not even a trend for a difference in recipients (55.2%, 37/67 vs 53.8%, 14/26).

CONCLUSIONS

The trend in this study for higher pregnancy rates in COH cycles with triple-line isoechogenic pattern in the late follicular phase will prompt a study of a larger group of patients undergoing IVF-ET in the modern era. If confirmed one treatment option would be to freeze and defer transfer to an estrogen/progesterone cycle.

Successful pregnancy following a single fresh embryo transfer in a 45-year-old woman whose early follicular phase serum follicle stimulating hormone was 29 mIU/ml

PURPOSE

To determine if a successful pregnancy is possible following in vitro fertilization embryo transfer (IVF-ET) in a woman of advanced reproductive age with diminished egg reserve.

METHODS

In vitro fertilization-embryo transfer with intracytoplasmic sperm injection (ICSI) was performed for a 45-year-old woman with a peak serum follicle stimulating hormone (FSH) level of 29 mIU/ml and a history of failing to conceive in five previous IVF-ET cycles at a younger age. A minimal FSH stimulation protocol was used.

RESULTS

A fresh transfer of a 7-cell embryo was performed on day 3. A successful pregnancy and delivery ensued.

CONCLUSION

This case report establishes a precedent that a successful pregnancy following IVF-ET is possible in a woman whose serum FSH is > 15 mIU/ml, and is age 45. Of course, there is no implication that accomplishing this again in another woman with similar circumstances would be likely.

Evidence that high serum progesterone (P) levels on day of human chorionic gonadotropin (hCG) injection have no adverse effect on the embryo itself as determined by pregnancy outcome following embryo transfer using donated eggs

PURPOSE

To determine if too high of a level of progesterone at the time of peak follicular maturation of donors adversely affects pregnancy or implantation rates of recipients.

METHODS

A retrospective cohort analysis was performed on donor egg recipients. Pregnancy rates were calculated according to ranges of five serum progesterone (P) levels based on two standard deviations before and above the mean.

RESULTS

No adverse effect was found in recipients whose donors had serum P levels between 2.47 and 3.41 ng/ml. There may have been a slightly lower pregnancy rate in recipients whose donors had seen P levels over 3.41 but there were only seven patients in that group and there still was a live delivered pregnancy rate of 28.6% per transfer.

CONCLUSIONS

The main adverse effect of a premature rise of progesterone in women making multiple follicles with gonadotropin stimulation seems to be on the endometrium. There appear to be enough follicles not affected by the progesterone to recommend proceeding with oocyte retrieval in the donor so as not to waste money on expensive medication and monitoring.

Increasing the dosage of progesterone (P) supplemention from the mid-luteal phase in women not attaining a mid-luteal homogeneous hyperechogenic (HH) pattern with sonography improves pregnancy rates (PRS) following frozen embryo transfer (ET)

PURPOSE

To determine if a mid-luteal phase non-homogeneous hyperechogenic (HH) endometrial echo pattern may lower pregnancy rates following frozen embryo transfer and to determine if raising the dosage of progesterone improves pregnancy outcome.

METHODS

Women not attaining an HH pattern at the mid-luteal phase following estrogen-progesterone replacement were randomly given (or not) an increase in progesterone dosage.

RESULTS

Increasing the progesterone dosage in those not attaining an HH pattern significantly improved the pregnancy rate relative to controls not attaining an HH pattern and showed a trend for higher pregnancy rates than those with an HH pattern.

CONCLUSIONS

The mid-luteal phase echo pattern should be evaluated for a non-HH pattern so that an increase in progesterone dosage could be provided possibly resulting in higher pregnancy rates.

The effect of endometriosis on pregnancy outcome following in vitro fertilization-embryo transfer (IVF-ET) in women with decreased egg reserve

PURPOSE

To determine the effect of the presence of endometriosis on the delivered pregnancy rate following in vitro fertilization-embryo transfer.

METHODS

A retrospective cohort analysis of fresh or frozen embryo transfer in women with diminished egg reserve having IVF-ET and who also had had a laparoscopy. The data was analyzed as to whether endometriosis was present or not.

RESULTS

The data demonstrated that women with diminished egg reserve can achieve pregnancies following IVF-ET. The presence of endometriosis did not have any negative effects on pregnancy rates.

CONCLUSIONS

At least in women with diminished egg reserve the presence of endometriosis did not impair outcome following IVF-ET.

A novel method to assess the effect of uterine senescence by comparing pregnancy outcome in younger donors vs older recipients who are sharing a common pool of oocytes

PURPOSE

To evaluate uterine senescence by comparing pregnancy rates in older recipients vs their younger donors who were actually trying to conceive themselves.

METHODS

A retrospective analysis comparing clinical and delivered pregnancy rates in all infertile donors < or = age 35 sharing their eggs with a recipient age > or = 40 over a 6-year time span. These parameters were also evaluated in the first frozen embryo transfer from these couples (if they had one).

RESULTS

The clinical and delivered pregnancy rates were similar in younger donors vs older recipients following fresh embryo transfer. There was a non-significant trend for lower implantation rates in the younger donors. No differences were found when comparing frozen embryo transfers.

CONCLUSIONS

These data support conclusions that the uterus of women > or = 40 does not inhibit embryo implantation.

Association of the change in serum estradiol (E2) levels from the day of to the day after human chorionic gonadotropin (hCG) injection and pregnancy outcome following in vitro fertilization-embryo transfer (IVF-ET) in less than average responders

PURPOSE

To determine if the change in serum estradiol (E2) from the day of human chorionic gonadotropin (hCG) injection to the day after predicts pregnancy and implantation rates following in vitro fertilization-embryo transfer (IVF-ET) in less than average responders.

METHODS

A retrospective cohort analysis was performed in women with less than average follicular response as defined by a peak serum E2 on the day of hCG of < 1500 pg/ml despite a maximum stimulation gonadotropin protocol. Pregnancy and implantation rates were compared in five groups based on standard deviation (SD) below or above the mean.

RESULTS

No differences were found in outcome in any groups including those that were 1-2 SD below the mean or within 1 SD below the mean or up to 2 SD above the mean. The group that was 2 SD above the mean seemingly had higher pregnancy and implantation rates but there were insufficient numbers to allow statistical comparisons. There did not appear to be any confounding variables among these groups.

CONCLUSIONS

A drop in serum E2 in a group of women that were less than average responders was not associated with a lower chance of conception following IVF-ET.

Effect of the length of time that donated embryos are frozen on pregnancy outcome

PURPOSE

To determine if the longer length of time that embryos donated to an anonymous couple have been frozen has a negative effect of subsequent successful pregnancy following thawing and transfer to the recipients.

METHODS

Retrospective determination of pregnancy rates according to the length of cryopreservation time has on pregnancy outcome following transfer of embryos designated for donation.

RESULTS

Longer time of freezing did not adversely affect subsequent pregnancy rates following frozen embryo transfer.

CONCLUSIONS

Donated embryos frozen for over five years (the time when some countries demand that the embryos be discarded) contributed to one-fourth of the donor embryo pool and one-third of the live deliveries.

A comparison of pregnancy rates following fresh and frozen embryo transfer according to the use of leuprolide acetate vs ganirelix vs cetrorelix

PURPOSE

To determine if controlled ovarian hyperstimulation (COH) regimens using the gonadotropin releasing hormone (GnRH) agonist leuprolide acetate result in higher pregnancy and implantation rates than COH regimens using the GnRH antagonists cetrorelix or ganirelix following fresh and frozen embryo transfer.

METHODS

Retrospective analysis was performed evaluating the pregnancy rates with the first fresh and first frozen embryo transfer cycles according to which protocol was used. A haphazard decision was made on which protocol to use. Women were required to be < 40 years of age and have had > or = 5 eggs retrieved.

RESULTS

Significantly lower implantation rates were seen with ganirelix compared to leuprolide acetate or cetrorelix.

CONCLUSIONS

These data should hopefully encourage interest in a prospective study to determine if conclusions about the inferiority of ganirelix are not merely fortuitous.

A prospective comparison of in vitro fertilization (IVF) outcome following controlled ovarian hyperstimulation (COH) regimens using follitropin alpha exclusively or with the addition of low dose human chorionic gonadotropin (hCG) and ganirelix

PURPOSE

To determine if the addition of luteinizing hormone (LH) activity to a controlled ovarian hyperstimulation regimen for purposes of in vitro fertilization adds any additional benefit to the exclusive use of recombinant (r) FSH in antagonist protocols.

METHODS

Women with normal endogenous gonadotropin levels were randomly assigned to receive either follitropin alpha exclusively or have the addition of 25 IU human chorionic gonadotropin (hCG) daily. Ganirelix was used when a 14 mm follicle was attained. The data would be analyzed after 70 women were selected for the study and divided into two groups.

RESULTS

There were 22 women in each group who proceeded with embryo transfer (some purposely cryopreserved all embryos because of risk of ovarian hyperstimulation syndrome). There were no trends for differences in clinical or delivered pregnancy rates or implantation rates.

CONCLUSIONS

There does not appear to be any clinical advantage of adding exogenous LH activity to the drug regimen for stimulation of multiple follicles for purposes of in vitro fertilization when using follitropin alpha in an antagonist protocol.

The effect of cetrorelix vs. ganirelix on pregnancy outcome using minimal gonadotropin stimulation in women with elevated day 3 serum follicle stimulating hormone levels

PURPOSE

To determine if the choice of gonadotropin releasing hormone antagonist influences subsequent pregnancy rates in women with diminished egg reserve.

METHOD

Retrospective determination of pregnancy rates following embryo transfer in women with day 3 FSH >12 mIU/ml using lower dose gonadotropin stimulation regimen.

RESULTS

Though no significant differences were found there was a trend for lower pregnancy rates with ganirelix vs cetrorelix.

CONCLUSIONS

The trend for lower pregnancy rates with ganirelix vs. cetrorelix seen in women with diminished egg reserve is consistent with the findings of a study performed in women with normal egg reserve using a normal gonadotropin stimulation regimen. It is not clear if the adverse effect is on the endometrium or the embryo.

Donor-recipient pairs to evaluate the effect of day 3 embryos having at least six blastomeres on pregnancy outcome

PURPOSE

To determine if having all embryos transferred with at least six blastomeres improves pregnancy rates compared to women having an embryo transfer with at least one embryo with less than six cells.

METHODS

Donor-recipient pairs were used to help remove the confounding effect of egg quality. Four donor-recipient pair types were evaluated: (1) both donor and recipient had all embryos with at least six cells, (2) neither donor nor recipient had all embryos with > or =6 cells, (3) donor but not recipient had all > or = six cell embryos, (4) recipient but not donor had all embryos with > or = six cells. Combining donor and recipients there was a significantly higher pregnancy rate per transfer when all embryos had at least six blastomeres (50/92 or 54.3%) vs. the group with at least one embryo with <6 cells (46/121 or 38.8%). Similarly the implantation rate was significantly higher (37.8% vs. 20.3%).

CONCLUSIONS

These data corroborate conclusions made by evaluating single embryo transfer in women with diminished egg reserve that the presence of at least six blastomeres is associated with a better chance of a given embryo to implant

The effect of length of the follicular phase on pregnancy outcome following single embryo transfer (ET) in hypergonadotropic women

OBJECTIVE

To evaluate whether a short follicular phase adversely affects pregnancy rates following in vitro fertilization-embryo transfer in women with diminished egg reserve similarly to women with short follicular phases and normal egg reserve.

METHODS

A retrospective review of women with day 3 serum FSH > 12 mIU/ml having only a single embryo transfer. Pregnancy rates were determined according to length of follicular phase, i.e., until day of egg retrieval.

RESULTS

The ongoing/delivery pregnancy rates for women having oocyte retrievals on day 10 or earlier was 20.0% (20/63) compared to 16.1% (34/210) for those having retrievals on day 11 or later (p = NS).

CONCLUSIONS

Either length of the follicular phase is not an important factor for achieving a pregnancy in women with diminished egg reserve or the use of ethinyl estradiol in the follicular phase negates the adverse effect of the short follicular phase even if it fails to lengthen this phase to at least ten days.

Septoplasty allows successful delivery in a primary aborter with six previous first trimester miscarriages

PURPOSE

To demonstrate that septoplasty can correct a problem of recurrent miscarriage.

METHODS

The patient was a primary aborter with a history of six consecutive miscarriages. Septoplasty by hysteroscopy/laparoscopy was performed. The septum was diagnosed by 3D sonohysterography.

RESULTS

She delivered a healthy live baby at 36 weeks.

CONCLUSION

This case clearly demonstrates that sometimes the uterine septum plays an important role in recurrent miscarriage and that septoplasty can improve the chances of successful delivery. The case also shows that a definitive diagnosis of a bicornuate uterus by HSG and/or MRI can not be made.

Pregnancy rates per embryo transfer (ET) may be improved by conventional oocyte insemination for male factor rather than intracytoplasmic sperm injection (ICSI)

PURPOSE

To determine if intracytoplasmic sperm injection (ICSI) for mild male factor may create embryos less likely to implant.

METHOD

A retrospective analysis of pregnancy outcome following oocyte fertilization with ICSI vs conventional egg insemination was performed.

RESULTS

Though there were many less cases using conventional oocyte insemination compared to ICSI so that a meaningful comparison of outcome could not be made, the data could suggest the fertilization by ICSI might result in embryos less likely to implant.

CONCLUSIONS

This pilot study should encourage IVF centers to consider conventional oocyte insemination for mild male factor instead of ICSI. Only by evaluating a larger series can it be determined with certainty that fertilization by ICSI may lower the implantation potential of the embryo that is formed.

Relationship of serum progesterone (P) level the day after human chorionic gonadotropin (hCG) injection on outcome following in vitro fertilization-embryo transfer (IVF-ET)

PURPOSE

To determine if either too little or too much of a rise in serum progesterone (P) on the day after human chorionic gonadotropin (hCG) injection has any negative impact on pregnancy outcome following in vitro fertilization-embryo transfer (IVF-ET).

METHODS

Retrospective review. Three progesterone groups established--low, normal and high.

RESULTS

There was a significantly higher clinical pregnancy rate in the normal P group vs low or high. There were no significant differences in ongoing delivered pregnancy rates but a trend for higher implantation rates in the normal P group.

CONCLUSIONS

These data are consistent with the hypothesis that either too little or too much P can adversely effect implantation. However, the differences are not of sufficient magnitude to warrant a clinical intervention, e.g., deferring fresh transfer and freezing the embryos for future transfer.

Successful pregnancy with frozen embryo transfer into a gestational carrier from eggs obtained from a woman in premature menopause

PURPOSE

To describe a unique case of a successful gestational carrier pregnancy in a woman with premature ovarian failure using her own oocyte.

METHODS

Despite amenorrhea, failure to have menses to progesterone withdrawal and resistance to gonadotropin stimulation, ovulation induction was attempted by restoring down-regulated follicle stimulating hormone (FSH) receptors by lowering the elevated serum FSH and allowing stimulation by endogenous or exogenous gonadotropins. Oocyte retrieval was attempted if a mature follicle was obtained. GnRH antagonist was used to prevent premature oocyte release. Tapering prednisone was used for the first five days of the cycle due to patient's history of autoimmune disease (vasculitis and Crohn's disease). IVIG was given 8/2003 for vasculitis.

RESULTS

The patient underwent a total of 19 attempted retrievals during continuous natural cycles from 3/2003 to 2/2007. Oocyte retrieval required traversing the uterus with the retrieval needle because of ovarian position after multiple surgeries for bilateral endometriomas and Crohn's disease. Empty follicle syndrome was encountered in four retrieval attempts. In 15 attempts, an oocyte was obtained. The sole attempt at natural fertilization failed. ICSI and assisted hatching were used in all subsequent attempts, and were successful in all but one attempt which led to a 3 pronuclei embryo which was discarded. The first four single embryos retrieved (7, 4, 6 cells and morula) were all A1 or A2 and transferred fresh to the patient, but no pregnancy resulted. All subsequent embryos were cryopreserved. The transfer of four embryos (6-cell and 7-cell and 3-cell and 8-cell) in two cycles to two different gestational carriers resulted in a successful delivery of a full-term healthy female infant 3.3 kg. Genetic testing confirmed maternal identity to be the patient, not the carrier.

CONCLUSIONS

This is the first reported case of a successful gestational carrier pregnancy after reversing ovarian failure, inducing ovulation, and transferring a frozen-thawed embryo.

Pregnancy outcome following in vitro fertilization-embryo transfer (IVF-ET) in women of more advanced reproductive age with elevated serum follicle stimulating hormone (FSH) levels

PURPOSE

To present data on the chances of pregnancy following in vitro fertilization embryo transfer, according to day 3 serum FSH and age groups in women > or = age 36.

MATERIALS AND METHODS

Data were analyzed according to three age groups (36-39, 40-42, > or = 43) and five serum FSH ranges (< or = 10, 11-12, 13-14, 15-16, > or = 17).

RESULTS

No live pregnancies were found in women aged > or = 40 with serum FSH > or = 15 mlU/ml but they were seen in women aged 36-39. Live deliveries were seen in women even > or = 43 with serum FSH 13-14 mlU/ml.

CONCLUSIONS

The higher the serum FSH and the greater the age, the lower the chances of successful conception. However, reasonable pregnancy rates are found in women aged > or = 36 with serum FSH > or = 15 mlU/ml and a live delivered pregnancy rate of about 10% can occur even in women aged > or = 43 with mild FSH elevations.

Improved pregnancy outcome for women with decreased ovarian oocyte reserve and advanced reproductive age by performing in vitro fertilization-embryo transfer

OBJECTIVE

To compare the pregnancy rates with IVF-ET vs non-assisted reproductive technology in women of more advanced reproductive age with decreased egg reserve as manifested by elevated day 3 serum FSH.

METHODS

A retrospective evaluation was made in women aged > or = 38 with a day 3 serum FSH of degrees 15 mIU/ml with > or = 1 year of infertility. Another inclusion criterion was three cycles (unless a pregnancy occurred before that time) of either IVF-ET or non-assisted reproductive therapy which as a minimum included luteal phase support with progesterone.

RESULTS

The clinical pregnancy rates in three cycles for non-IVF were 11.7% vs 27.2% for IVF. Delivery rates were 2.9% vs 15.1%. For ages 40-42 the clinical pregnancy rates were 37.5% vs 0.0% (p = .02).

CONCLUSIONS

Live deliveries are possible in women > or = age 38 with marked decreased egg reserve. In vitro fertilization is more effective than non-IVF when follicle stimulation with gonadotropins is mild.

A matched controlled study to evaluate the efficacy of acupuncture for improving pregnancy rates following in vitro fertilization-embryo transfer

PURPOSE

To determine if acupuncture performed during the follicular phase and luteal phase but not on the day of embryo transfer could improve the outcome following IVF-ET compared to controls.

METHODS

Acupuncture was started biweekly from day 5 of the follicular phase through the luteal phase but not on the day of the transfer. Controls were matched according to age, same number of previous failed IVF cycles and same type of embryo transfer (fresh or frozen).

RESULTS

The clinical and ongoing (delivered pregnancy rates per transfer) for 32 women undergoing IVF-ET and acupuncture was 40.6% and 37.5%, respectively vs 53.1% and 43.7% for controls. The median number of previous failed IVF cycles was three.

CONCLUSIONS

Acupuncture performed twice weekly during the follicular and luteal phase does not seem to improve pregnancy rates following IVF-ET.

A reassessment of comparative pregnancy and implantation rates following embryo transfer in recipients vs their infertile donors also trying to conceive in the background of performing salpingectomy for hydrosalpinx

PURPOSE

To compare pregnancy and implantation rates in egg donors trying to conceive vs their recipients in the background of salpingectomy for hydrosalpinx prior to IVF-ET.

METHODS

A retrospective six-year review of all donor egg cycles where the eggs are supplied by an infertile donor trying to conceive herself was carried out. Salpingectomy for hydrosalpinx was performed prior to IVF-ET.

RESULTS

Clinical and delivered pregnancy rates (PRs) following fresh ET were not significantly different in donors vs recipients (60.0%, 45.8% vs 56.8%, 50.8%). Implantation rates were 27.3% vs 32.6%. The respective implantation rates following frozen ET were 13.8% and 14.4%.

CONCLUSIONS

In the background of salpingectomy for hydrosalpinges the much higher PRs in recipients vs donors is no longer seen. The trend for higher implantation rates in recipients (about 20%) following fresh but not frozen transfer could still reflect some adverse effect of the controlled ovarian hyperstimulation regimen in a minority of women.

A novel method to evaluate pregnancy rates following in vitro fertilization to enable a better understanding of the true efficacy of the procedure

PURPOSE

To propose a new method of evaluating in vitro fertilization (IVF)-embryo transfer (ET) outcome so that statistics are not biased against IVF centers that have strong cryopreservation programs.

METHODS

A retrospective review was made of all patients undergoing IVF-ET in a four and a half year time period having at least two embryos transferred. There were no other exclusions. All types of problems and controlled ovarian hyperstimulation protocols were used. Data were analyzed according to four age groups: < or =35, 36-39, 40-42, > or =43. Pregnancy rates were calculated according to a given oocyte harvest where a pregnancy was counted if the woman conceived on the fresh transfer or any succeeding frozen ET from embryos obtained from oocytes retrieved on that harvest. Also pregnancy rates per transfer and retrieval were evaluated.

RESULTS

For women < or =35 to age 39 the new category of clinical pregnancy rate per oocyte harvest was significantly higher than the pregnancy rate per transfer. The pregnancy rate per transfer was significantly higher than the pregnancy rate per retrieval in women up to age 42.

CONCLUSIONS

We propose that calculating pregnancy rate per harvest is the best method to evaluate the true efficacy of IVF-ET especially from programs with a strong emphasis on cryopreservation.

Ectopic pregnancy is not more likely following fresh vs frozen embryo transfer

PURPOSE

To determine if the risk of ectopic pregnancy is greater following frozen vs fresh embryo transfer (ET).

METHODS

Retrospective review of pregnancy outcome from January 1, 1997 to November 30, 2003. Cryopreservation was used as a simple freezing method and one-step removal of cryoprotectant. The cycles consisted mostly of graduated estradiol and progesterone supplementation.

RESULTS

The ectopic pregnancy rate in 1,445 clinical pregnancies from fresh ET was 2.6% vs 2.0% of 975 clinical pregnancies resulting from frozen ET.

CONCLUSION

In contrast to the conclusions of two previous studies, the present study evaluating twice as many clinical pregnancies than the two aforementioned studies combined failed to show any greater risk of ectopic pregnancy when transfers were performed on day 3.

Leukocyte immunotherapy improves live delivery rates following embryo transfer in women with at least two previous failures: a retrospective review

PURPOSE

To determine whether leukocyte immunotherapy (LIT) could improve live delivery rate following embryo transfer (ET) in women who were not successful in prior attempts.

METHODS

Paternal leukocytes were intradermally injected in some women who had failed to have a successful pregnancy following at least two prior ETs approximately two weeks prior to fresh or frozen ET and repeated at the time of the 3rd rising serum beta human chorionic gonadotropin level and at eight weeks if a pregnancy occurred. Clinical pregnancy and live pregnancy rates (PRs) were compared to those women having ETs during the same time period not receiving LIT.

RESULTS

Thirty-six of 94 (38.3%) patients receiving LIT (group 1) conceived following fresh or frozen ET vs 98 of 341 (28.7%) for women not receiving LIT (group 2) (p = NS). The live delivery rate per ET cycle was 30.8% (39/94) vs 19.7% for group 2 (p = .02). For the subset of women failing despite five previous ETs 17 of 37 (45.9%) group 1 women had a clinical pregnancy vs 18 of 64 (28.1%) group 2 women (p = .07%) and live delivery rates were 35.1% (13/37) vs 15.6% (10/64) (p = .024).

CONCLUSIONS

These retrospective data encourage a prospective study of LIT combined with progesterone vs controls receiving progesterone only for recalcitrant patients having ETs.

A comparison of luteal phase support in graduated estradiol/progesterone replacement cycles using intramuscular progesterone alone versus combination with vaginal suppositories on outcome following frozen embryo transfer

PURPOSE

To compare pregnancy outcome following frozen embryo transfer according to type of progesterone (P) support given in the luteal phase.

METHODS

Retrospective cohort analysis of frozen embryo transfer (ET) cycles in which ovulation was suppressed by graduated estradiol in the follicular phase. Two P regimens in the luteal phase were compared: P vaginal suppositories and intramuscular P vs intramuscular alone.

RESULTS

The clinical and viable pregnancy rates were significantly higher for the women receiving only intramuscular P (57.6% and 43.7%) vs those receiving combined therapy (45.9% and 35.6%, respectively). The implantation rates were not significantly different (22.6% vs 19.5%).

CONCLUSION

The increased pregnancy rates with intramuscular P may have been related to a higher number of embryos transferred (3.69 vs 3.26). Nevertheless, intramuscular P alone is at least as effective, if not more effective, than combined therapy for frozen embryo transfers.

Non-homogeneous hyperechogenic echo pattern three days after frozen embryo transfer is associated with lower pregnancy rates

OBJECTIVE

To evaluate the association of mid-luteal phase echo patterns and pregnancy rates (PRs) following frozen embryo transfer (ET).

METHODS

Sonographic evaluation of endometrial echo patterns was performed three days after ET in the first frozen ET cycle of women < 40 years of age who used their own oocytes as well as all donor oocyte recipients.

RESULTS

The distribution of echo patterns and clinical PRs were similar in women using their own eggs and women who used donor oocytes; therefore all data was combined. The clinical PR was 49.5% with a hyperechogenic echo pattern vs 38.8% with a non-hyperechogenic pattern, p = .007.

CONCLUSION

A larger study of frozen ET and mid-luteal echo pattern now demonstrates conclusions similar to the data from fresh ET in hyperstimulated in vitro fertilization (IVF)-ET cycles in that failure to attain a hyperechogenic echo pattern three days after ET is associated with lower pregnancy rates.