Profiling assisted reproductive technology: outcomes and quality of infertility management

OBJECTIVE

To critically appraise the content of the American Society for Reproductive Medicine (ASRM)/Society for Reproductive Technology (SART) Registry.

DESIGN

English-language literature review.

PATIENT(S)

Women undergoing treatment with assisted reproductive technology (ART).

INTERVENTION(S)

Current ART treatments, including IVF, GIFT, zygote intrafollopian transfer (ZIFT), oocyte micromanipulation, and cryopreserved embryo transfers.

MAIN OUTCOME MEASURE(S)

Compliance with clinical practice guidelines, and casemix-adjusted rates of live delivery, clinical pregnancy, ectopic pregnancy, miscarriage, birth defects, implantation, fertilization, and retrieval.

RESULT(S)

Outcomes should be adjusted for variation in patient characteristics known to affect prognosis, including maternal age, the duration of infertility, the presumed cause(s) of infertility, the patient's prior history of treatment for infertility, and diethylstilbestrol exposure. Outcome rates should be reported using the patient as the denominator, as well as cycle, retrieval, and transfer. The statistical significance of observed differences in events rates should be indicated. Because widely accepted clinical practice guidelines related to performance of ART procedures are not available, compliance with practice guidelines cannot currently be assessed.

CONCLUSION(S)

Reports based on ASRM/SART Registry data can be enhanced by refined casemix adjustment, assessing outcome rates per patient, as well as per component of ART procedure, and by providing an indication of the statistical significance of observed differences in event rates. In addition, a critical appraisal of available evidence related to particular aspects of infertility management would help clarify the areas in which there is an evidentiary basis for formulation of practice guidelines, as well as topics requiring additional clinical research.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assisted conception and immunological infertility

Our work with a group involved in Assisted Conception (AC) has provided us with a perfect opportunity for making an assessment of the efficiency of the techniques used for the treatment of Male Antisperm Autoimmunization (MAA) and Female Antisperm Isoimmunization (FAI). The aim of this study is to present all the most important methods of AC used by our group for the treatment of immunological infertility, such as intrauterine insemination, intraperitoneal insemination, intrafallopian gamete transfer, in-vitro insemination and intrauterine embryo transfer, intrafallopian zygote transfer, intrafallopian embryo transfer, and gamete micromanipulation. In-vitro fecundation would appear to be particularly efficient in cases of FAI, while MAA would seem to benefit more from the use of gamete micromanipulation.

Appraisal of gamete intrafallopian transfer

OBJECTIVE

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

DESIGN

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

SUBJECT

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

RESULTS

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

CONCLUSIONS

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

Current management of unexplained infertility

During the last decade, numerous studies have evaluated the effectiveness of various treatments for unexplained infertility. Few studies employ a design that allows for appropriate comparison with an untreated control group. This article reviews the efficacy of clomiphene citrate, human menopausal gonadotropin, intrauterine insemination, superovulation with intrauterine insemination, and gamete intrafallopian transfer in the treatment of unexplained infertility. Treatment for patients with unexplained infertility with superovulation or gamete intrafallopian transfer is promising, but the incremental contributions of intrauterine insemination, superovulation, or gamete intrafallopian transfer beyond untreated controls await appropriately designed trials. When counseling patients regarding treatment options, both the expected increase in cycle fecundity and treatment expense should be considered.

Current technology of oocyte retrieval

Transvaginal follicle puncture under sonographic control has become the method of choice for ovum retrieval worldwide. Because it is the current technology of the 1990s, there are very few reports in the literature on other methods of oocyte retrieval. Furthermore, perhaps because of the simplicity of transvaginal follicle puncture under sonographic control, there are only a few reports on the technique itself in the current literature. This review classifies the papers on hand according to general studies of the subject, appropriate anesthesia, necessity of follicle flushing for oocyte retrieval, vaginal disinfection and the evaluation of the risk following transvaginal oocyte retrieval, and new techniques in connection with the harvesting of oocytes.

Gamete and zygote intrafallopian transfers and related techniques

Until recently, most authors reported superior results (ie, higher implantation and pregnancy rates) with gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) compared with results using in vitro fertilization-embryo transfer (IVF-ET). According to these investigators, the advantages of tubal over uterine transfer are related mainly to a stable tubal environment and a more appropriate arrival time of the embryo into the uterine cavity. However, more recently, the use of IVF-ET has been increasingly extended to etiologies other than tubal infertility. Indeed, the recent simplification of this technique and the achievement of pregnancy rates comparable to those obtained with tubal transfers have seriously questioned the value of ZIFT and any other type of tubal embryo transfer. As discussed in this review, the results obtained with various transfer procedures in nontubal infertility must still prove ZIFT to be a more effective procedure than IVF-ET. Efforts to develop transcervical methods of transfer to the tube have not translated into higher pregnancy rates than those with IVF-ET. On the other hand, laboratory conditions appear to affect embryos in ways not corrected by the tubal milieu. Negative effects of laboratory conditions on embryos are confirmed by differences in results between GIFT and ZIFT that are accentuated with age. The results obtained with GIFT in patients 40 years of age and older seem to emphasize not only the high compliance of the endometrial receptivity but also the relevance of the biologic potential of the embryos in the process of implantation at this age.

Assisted reproductive technology

Several aspects of reproductive technology are discussed. In tubal infertility, the choice between surgery or in vitro fertilization and embryo transfer (IVF-ET) is addressed. In cases with bilateral distal occlusion or otherwise bad prognosis, IVF is probably more successful and less expensive. IVF in unstimulated cycles has given promising results, with pregnancy rates comparable to the results from the National IVF-ET Registry. If these results can be confirmed by more studies they will probably have a great impact on the choice of treatment in tubal infertility. The results obtained with various transfer procedures in nontubal infertility have still to prove tubal transfer to be a more effective procedure than IVF. Finally, studies on microinsemination in male infertility or unexplained infertility with previous fertilization failure in IVF show promising results with the subzonal insemination and partial zona dissection procedures.

Microsurgery and in vitro fertilization/embryo transfer for infertility resulting from distal tubal lesions

The live birth rates were analyzed after 688 microsurgical operations for infertility resulting from distal tubal lesions and after 885 in vitro fertilization cycles for tubal factor infertility at the Ljubljana University Department of Obstetrics and Gynecology. The cumulative live birth rate five years after surgery was 31% (17% cases lost to follow-up). The cumulative live birth rate after four in vitro fertilization cycles for tubal infertility was 40% (8% per treated cycle). With two options for treatment, operable cases had a better prognosis than did the inoperable ones. If pregnancy did not occur two to three years after surgery, the patients underwent in vitro fertilization. The complementary use of microsurgery and in vitro fertilization has substantially improved the prognosis for infertility resulting from distal tubal lesions.

[Intratubal transfer of an embryo or a zygote. (TET or GIFT) Past, present and future? Comparative study of tubal embryo transfer (TET) versus in vitro fertilization]

The pregnancy rate per transfer does not appear to be increased if the embryos are placed in the Fallopian tube rather than using in-vitro fertilization or inserting the gametes into the tubule ampulla. Consequently, the indications are specific to particular cases.

Gamete intrafallopian transfer: the effect of the number of eggs used and the depth of gamete placement on pregnancy initiation

The role of the fallopian tube in initiating pregnancy was examined in 246 consecutive gamete intrafallopian transfer (GIFT) cycles. Before actual transfer, the ampulla of each tube was measured to determine the depth at which gametes could be placed. Fifty-seven transfers were made with four oocytes into a single tube; of these, when gametes were deposited deeper than 4 cm, the pregnancy rate was higher than when they were placed at between 3 to 4 cm (69.6% compared with 41.2%). Presumably, a deeper placement is more secure and decreases the likelihood of gamete displacement. The pregnancy rate also rose with the number of oocytes used: from 0% with a single oocyte to 42.9% with four oocytes.