Successful Pregnancy and Live Birth from Oocytes Retrieved After 50 Hours of Human Chorionic Gonadotropin Injection: A Case Report

BACKGROUND

The timing of human chorionic goadotropin (hCG) injection and oocyte retrieval in women undergoing in vitro fertilization and intracytoplasmic sperm injection is crucial. If not properly timed, premature spontaneous luteinizing hormone surge or even premature ovulation may lead to cancellation of the treatment cycle. Commonly, oocyte retrieval is planned 32-36 hours after hCG injection. This time interval is of relevance because a number of essential processes, including the start of luteinization and resumption of the reduction division of the oocytes, should be well established before oocyte retrieval.

CASE

We present a rare case in which, due to patient misunderstanding of timing of hCG injection, oocytes were retrieved 50 hours after hCG injection. On the morning of the oocyte retrieval at 08.00 hours it became apparent that, by mistake, the patient had taken the hCG injection at 09.15 hours rather than at 21.15 hours, 12 hours earlier than advised. It was therefore already 48 hours post-hCG injection. Nineteen good- quality, mature oocytes were retrieved, resulting in 11 good-quality embryos. A single expanded blastocyst was transferred, resulting in pregnancy and delivery of a healthy female infant.

CONCLUSION

This is the first reported case of successful pregnancy after oocyte retrieval 5o hours after hCG injection. This case could be a stimulus for others to conduct further studies of prolonged exposure of hCG to oocyte retrieval to show the improved outcome of assisted reproduction treatment.

What is the best treatment option for infertile women aged 40 and over?

PURPOSE

To summarise the causes of decreased fecundity with age and review chronological vs biological ovarian ageing. To explore the clinician's means of assessing a woman's ovarian reserve. To review the recent literature on the effectiveness of different assisted reproductive technology (ART) techniques for women aged 40 and over and offer a single best treatment option.

METHODS

Pubmed and google scholar were searched for relevant articles using key words. Data were extracted based on authors, year, aims, sample and results.

RESULTS

Success rates for women aged 40 or over with clomiphene, IUI, IUI with FSH are all extremely low, at less than 1% live birth per cycle. However, IVF offers a success rate of around 13.7% per cycle.

CONCLUSION

An exploration of the effectiveness of available treatment options for older infertile women using their own gametes suggests that IVF offers the best prospects of success. Attempting treatments other than IVF will delay conception unnecessarily.

Impact of Chlamydia trachomatis in the reproductive setting: British Fertility Society Guidelines for practice

Chlamydia trachomatis infection of the genital tract is the most common sexually transmitted infection and has a world-wide distribution. The consequences of infection have an adverse effect on the reproductive health of women and are a common cause of infertility. Recent evidence also suggests an adverse effect on male reproduction. There is a need to standardise the approach in managing the impact of C. trachomatis infection on reproductive health. We have surveyed current UK practice towards screening and management of Chlamydia infections in the fertility setting. We found that at least 90% of clinicians surveyed offered screening. The literature on this topic was examined and revealed a paucity of solid evidence for estimating the risks of long-term reproductive sequelae following lower genital tract infection with C. trachomatis. The mechanism for the damage that occurs after Chlamydial infections is uncertain. However, instrumentation of the uterus in women with C. trachomatis infection is associated with a high risk of pelvic inflammatory disease, which can be prevented by appropriate antibiotic treatment and may prevent infected women from being at increased risk of the adverse sequelae, such as ectopic pregnancy and tubal factor infertility. Recommendations for practice have been proposed and the need for further studies is identified.

The effect of diclofenac and paracetamol on pregnancy and implantation rates in infertile women undergoing IVF treatment

We set out to assess the effect of diclofenac on implantation rates, when administered as analgesia following transvaginal oocyte recovery. This was a prospective study of infertile women undergoing IVF treatment in a University Hospital. Subjects (n = 74) were divided in two groups (A and B). Group A (n = 38) received 1 g paracetamol and 100 mg diclofenac and group B (n = 36) received 1 g paracetamol only. All the medication was administered rectally immediately after the oocyte retrieval. Pregnancy and implantation rates were compared between group A and B using the chi2 test. In groups A and B, the implantation rates were 12.4% and 9.6% (p = 0.5) and the pregnancy rates were 28.9% and 19.4%, respectively (p = 0.67). Neither pregnancy nor implantation rates differed significantly between the two groups. Administration of diclofenac to patients at the time of egg collection does not appear to affect implantation or pregnancy rates, while it could be effective in reducing discomfort and pain associated with oocyte retrieval.

Early Pregnancy Assessment Units

The advent of a 1-stop approach to managing women with early pregnancy problems led to the development of early pregnancy clinics. Such clinics progressed to providing a patient centered approach, minimising inpatient admissions while providing women with an early diagnosis of miscarriage or extrauterine pregnancy by a multiprofessional group of individuals with expertise in this area. The clinic structure, referral process, and ongoing challenges are discussed.

Does training in obstetric emergencies improve neonatal outcome?

OBJECTIVES

To determine whether the introduction of Obstetrics Emergency Training in line with the recommendations of the Clinical Negligence Scheme for Trusts (CNST) was associated with a reduction in perinatal asphyxia and neonatal hypoxic-ischaemic encephalopathy (HIE).

DESIGN

A retrospective cohort observational study.

SETTING

A tertiary referral maternity unit in a teaching hospital.

POPULATION

Term, cephalic presenting, singleton infants born at Southmead Hospital between 1998 and 2003 were identified; those born by elective Caesarean sections were excluded.

METHOD

Five-minute Apgar scores were reviewed. Infants that developed HIE were prospectively identified throughout this period. The study compared the period 'pre-training' (1998-1999), with the period 'post-training' (2001-2003).

MAIN OUTCOME MEASURES

Five-minute Apgar scores and HIE.

RESULTS

Infants (19,460) were included. Infants born with 5-minute Apgar scores of <or=6 decreased from 86.6 to 44.6 per 10,000 births (P<0.001) and those with HIE decreased from 27.3 to 13.6 per 10,000 births (P=0.032) following the introduction of the training courses in 2000. Antepartum and intrapartum stillbirth at term rates remained unchanged, at about 15 and 4 per 10,000 births, respectively.

CONCLUSION

The introduction of obstetric emergencies training courses was associated with a significant reduction in low 5-minute Apgar scores and HIE. This improvement has been sustained as the training has continued. This is the first time an educational intervention has been shown to be associated with a clinically important, and sustained, improvement in perinatal outcome.

Levonorgestrel hormone releasing intrauterine system (Mirena) as a contraceptive in egg donors: case report

We report the safe use of levonorgestrel hormone releasing intra uterine system (Mirena) as a contraceptive in egg donors during a treatment cycle. In the first case report, a 29-year-old egg donor using the Mirena coil for contraception and two egg recipients, aged 41 years and 32 years respectively underwent standard IVF treatment, oocyte retrieval in the egg donor and in vitro fertilization followed by embryo transfer in the recipient. The outcome of IVF cycle using donor eggs was satisfactory with successful pregnancy in the egg recipient. The second case involved a 34-year-old egg donor using the Mirena coil and a 44-year-old recipient. Our findings suggest that egg donors can safely use the (Mirena) as a contraceptive device during treatment, without compromising follicular development and oocyte quality.

Tubal pelvic damage: prediction and prognosis

Tubal pelvic damage is a common cause of infertility, and laparoscopy is the accepted gold standard for its diagnosis. However, laparoscopy is both costly and invasive. Chlamydia is now recognized as the most common cause of tubal pelvic damage. In contrast to laparoscopy, evidence of past chlamydial infection using serology is readily available, and the test is simple and quick to perform. As such, serology can be used as a screening test in infertile women. It is accepted that screening tests may have higher margins of error and may be less accurate than diagnostic tests. Screening is most valuable when detecting a disease for which the treatment is more effective when undertaken at the earliest opportunity. Because there are justified constraints to the indiscriminate use of laparoscopy, there is a need to minimize the number of patients who do not have disease (false positives) who are subjected to this diagnostic investigation. An appropriate Chlamydia antibody titre that would distinguish women at risk of tubal pelvic damage should be determined using diagnostic test analysis and clinical judgement. Identification by serology of women who are likely to have damage would enable these women to undergo a diagnostic test such as laparoscopy sooner, allowing treatment to be provided earlier. However, the severity of tubal pelvic damage varies, and the need to distinguish women with a favourable or unfavourable prognosis after treatment using a simple classification system is discussed.