P–251 To collapse or not to collapse blastocysts before vitrification? A matched case-control study on single vitrified-warmed blastocyst transfers

Study question

Does laser-induced artificial blastocoel collapse result in better blastocyst cryopreservation survival and higher live birth rate (LBR) in comparison with intact counterparts?

Summary answer

Compared to vitrification of intact blastocysts, collapsed blastocysts resulted in higher survival and for 5% higher LBR. Neonatal outcomes were comparable in both groups.

What is known already

Blastocysts have long been considered a stage that is suboptimal for freezing-thawing procedures due to their high fluid content and different cell types. The development of a modified vitrification technique has enabled blastocysts to better survive cryopreservation compared to a slow freezing procedure. Many studies on the optimization of cryopreservation of blastocysts have mentioned the need for artificial collapsing of the blastocoel prior to cryopreservation, thereby reducing the risk of intracellular ice-crystals formation. However, the effectiveness of artificial collapsing on blastocyst survival rate, single vitrified-warmed blastocyst transfer (SVBT) outcome and on safety of such intervention remains to be confirmed.

Study design, size, duration

A retrospective matched case-control study of transfers of single blastocysts being artificially collapsed (case) or intact (control) before vitrification. A sample size of 306 cycles in both arms was needed to achieve 80% power to detect a difference between the groups of 10% with P < 0.05. Controls were matched to cases on a 1:1 ratio by female age, parity, fresh and frozen cycle protocol, blastocyst age and quality, getting 309 pairs of cases and controls.

Participants/materials, setting, methods

Artificial collapsing was introduced into clinical practice gradually. In fresh IVF cycles (performed in university clinic from 2012 until 2014) with supernumerary blastocysts, half of the blastocysts were randomly selected before vitrification for laser-induced artificial collapsing. The other half was vitrified in intact form. Only the first transfers of a single vitrified-warmed blastocyst (n = 818) were included in the study. By matching, 309 pairs of collapsed (study) and intact (control) SVBTs were identified.

Main results and the role of chance

Both groups were comparable by their characteristics in indications, female age, type and length of ovarian hyperstimulation, insemination method in fresh cycle, protocol for warmed blastocyst transfer, blastocyst quality and day of blastocyst vitrification. Survival rates in case and control group ((309/316) 97.8% and (309/323) 95.7%; P = 0.13) were comparable, but optimal survival rates (100% survival and re-expansion after warming) was significantly higher in artificial collapse group ((247/316) 78.2% and (225/323) 69.7%; P = 0.01). Clinical pregnancy rates ((120/309) 38.8% and (110/309) 35.6%; P = 0.4), miscarriage rates ((15/120) 12.5% and (24/110) 21.8%; P = 0.06) and LBR per transfer ((100/309) 32.4% and (85/309) 27.5%; P = 0.19) or LBR per warmed blastocyst ((100/316) 31.6% and (85/323) 26.3%; P = 0.14) were not statistically different between case and control groups. Since the study was powered to detect a 10% difference, the possibility of type 2 error cannot be excluded. Perinatal outcomes were available for 175 live births. There were 10.5% (10/95) preterm births in the study group vs. 16.3% (13/80) in control group (P > 0.05). Birth weights (3,308 g (SD 592 g) vs 3,308 g (SD 738 g) and sex ratio (50.7% vs 49.2% boys) were also comparable between both groups (P > 0.05). There were no major malformations detected in the study population.

Limitations, reasons for caution

The research is retrospective, but the cycles from both groups were performed in the same time period. The groups were balanced according to all possible confounders. Blastocysts for vitrification were first categorized by quality groups and embryos from each category were randomized for collapsing or for remaining intact.

Wider implications of the findings: No significant difference was found in live births by this sample size. Nevertheless, increasing the success by 5% with the introduction of artificial collapsing can be an important step towards optimizing of blastocyst cryopreservation. To confirm a 5% improvement in results, a sample size of > 2500 cases would be needed.

Trial registration number

The study has been approved by the National Ethics Committee of the Republic of Slovenia (0120–204/2016–2).

Health related QoL in celiac disease patients in Slovenia

BACKGROUND

Measurements of health-related quality of life (HRQoL) among celiac disease patients using a validated questionnaire have been lacking in Slovenia. This study aims to measure HRQoL in celiac disease (CD) patients using EQ-5D internationally validated questionnaire and comparing it to the HRQoL of the general population.

METHODS

In this cross sectional analysis all of the approximately 2000 members of the Slovenian Celiac Society were invited to take part. We used a 3 step approach for recruitment and data collection. HRQoL was evaluated through the EuroQoL EQ-5D-5L instrument (Slovenian version) and analysed using the ordinal logistic regression.

RESULTS

Out of 321 patients who gave their consent, 247 celiac patients were included in the study (77%). 68% of the participants were female and 53% of them lived in an urban setting. Most patients originated from North-East Slovenia, whereas approximately 30% of patients came from other Slovenian regions. The EQ-5D respondents' self-reported health status at the time of the study show that most patients have slight or no problems when living with CD. The duration of the gluten-free diet, academic education and rare (< 1 × year) doctor visits affect EQ-5D in a positive way. On the other hand, higher age and chronic rheumatic disease were negatively associated with EQ-5D also when compared to the general population.

CONCLUSION

This is the first Slovenian study to measure the HRQoL of Slovenian CD patients, using an internationally validated questionnaire. The results of our study show that HRQoL is slightly impaired among Slovenian patients with CD. Clinical characteristics are better determinants of their HRQoL than socio-demographic factors. Greater awareness of the impact of CD on patients' HRQoL would improve the holistic management of CD patients.

Public database for validation of follicle detection algorithms on 3D ultrasound images of ovaries

BACKGROUND AND OBJECTIVE

Automated follicle detection in ovarian ultrasound volumes remains a challenging task. An objective comparison of different follicle-detection approaches is only possible when all are tested on the same data. This paper describes the development and structure of the first publicly accessible USOVA3D database of annotated ultrasound volumes with ovarian follicles.

METHODS

The ovary and all follicles were annotated in each volume by two medical experts. The USOVA3D database is supplemented by a general verification protocol for unbiased assessment of detection algorithms that can be compared and ranked by scoring according to this protocol. This paper also introduces two baseline automated follicle-detection algorithms, the first based on Directional 3D Wavelet Transform (3D DWT) and the second based on Convolutional Neural Networks (CNN).

RESULTS

The USOVA3D testing data set was used to verify the variability and reliability of follicle annotations. The intra-rater overall score yielded around 83 (out of a maximum of 100), while both baseline algorithms pointed out just a slightly lower performance, with the 3D DWT-based algorithm being better, with an overall score around 78.

CONCLUSIONS

On the other hand, the development of the CNN-based algorithm demonstrated that the USOVA3D database contains sufficient data for successful training without overfitting. The inter-rater reliability analysis and the obtained statistical metrics of effectiveness for both baseline algorithms confirmed that the USOVA3D database is a reliable source for developing new automated detection methods.

Reproductive complications in celiac disease patients in Slovenia

OBJECTIVE

Celiac disease is associated with higher risk of infertility, recurrent abortions, and adverse outcomes in pregnancy and in puerperium. The aim of the study was to analyse the association between celiac disease and reproductive disorders in the group of celiac patients and compare these to healthy controls.

METHODS

A retrospective case-control matched study. The association between celiac disease and menstrual cycle, gyneco-obstetrical complications was assessed with a questionnaire specifically developed for the study. 144 celiac women and 61 celiac men, members of Slovenian Celiac Society, together with 71 healthy women and 31 healthy men participated in the study.

RESULTS

A higher percentage of celiac women (27.1%) had difficulties in conception of the first child when compared to healthy controls (12.7%) (p = 0.042). In addition, celiac women experienced more complications than healthy controls during the pregnancy, such as abortions or intrauterine growth retardation (p < 0.005). In our study, the prevalence of reproductive problems was not the same in celiac males and females. Altogether 2 celiac men (3.3%) reported having fertility problems, however, the difference between male cases and controls was not statistically significant (p = 0.548).

CONCLUSION

Physicians should examine women with unexplained infertility, recurrent abortions or intrauterine growth retardation for undiagnosed celiac disease. Compared with healthy women, women with celiac disease have increased risk of spontaneous abortions, preterm delivery and fewer successful pregnancies.

Could polymorphisms of some hormonal receptor genes, involved in folliculogenesis help in predicting patient response to controlled ovarian stimulation?

PURPOSE

The aim of this study was to investigate whether single nucleotide polymorphisms (SNPs) in selected genes, responsible for hormonal regulation of folliculogenesis, are associated with response to controlled ovarian hyperstimulation (COH) and clinical characteristics of women enrolled in in vitro fertilization (IVF) programs.

METHODS

In a cross-sectional study, 60 (IVF) patients underwent COH by using gonadotropin-releasing hormone (GnRH) antagonist and recombinant follicle-stimulating hormone (rFSH) protocol. Patients were classified into three groups: poor-responders (according to Bologna criteria), normo-responders (≤ 15 oocytes), and hyper-responders (> 15 oocytes). Genotyping of SNPs AMH rs10407022, AMHR rs3741664, FSHR rs1394205 and rs6166, and ESR1 rs2234693 was performed using high-resolution melting analysis (HRMA). Basal FSH (bFSH), estradiol (E2), and anti-Müllerian hormone (AMH) were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Patients with GG genotype of FSHR rs1394205 had significantly lower AMH level (P = 0.016) and required higher rFSH dose per oocyte compared to women with AA or AG genotype (P = 0.036). We also found higher frequency of GG genotype of FSHR rs1394205 in poor- (76.5%) than in hyper-responders (37.5%, P = 0.002). Patients with AA genotype of FSHR rs6166 had higher level of measured bFSH compared to those with AG or GG genotypes (P = 0.043). Women with GG genotype of AMHR rs3741664 required higher rFSH dose in comparison with patients carrying genotypes AA or AG (P = 0.028).

CONCLUSIONS

The GG genotype at position rs1394205 is associated with poor ovarian response to COH. Patients with this genotype may require higher doses of rFSH for ovulation induction.

Onset of menarche is not delayed in Slovenian patients with celiac disease

Objective

Celiac disease (CD) is an autoimmune disorder associated with numerous health problems, including reproductive disorders. This study was performed to analyze the association between CD and the menstrual cycle in a group of patients with CD and compare these patients’ characteristics with those of healthy women.

Methods

The study included 145 patients with CD (age, 15–51 years) and 162 healthy women (age, 18–55 years). Age at menarche and characteristics of the menstrual cycle were obtained by an anonymous questionnaire developed for the study.

Results

The age at onset of menarche was 12 to 14 years in 72.9% of the patients with CD and 77.3% of the healthy controls. For most patients (74.2%), the length of the menstrual cycle was around 27 to 28 days with 4 to 5 days of bleeding. Furthermore, 8.4% of patients versus 5.9% of controls experienced bleeding between cycles.

Conclusions

Our results suggest that in Slovenia, the age at menarche in patients with CD is 12.7 years, which is comparable with that in healthy women. We conclude that CD (treated or untreated) may not be associated with late menarche.

Cumulative live birth rate after GnRH agonist trigger and elective cryopreservation of all embryos in high responders

Elective embryo cryopreservation after using gonadotrophin-releasing hormone (GnRH) antagonist protocols and GnRH agonist triggering is becoming an increasingly important part of medically assisted reproduction. We designed a single-centre retrospective study to assess the cumulative probability of achieving a live birth through consecutive transfers of vitrified-warmed blastocysts after elective embryo cryopreservation in high-responding patients. Hence, 123 women identified to be at high risk for developing ovarian hyperstimulation syndrome were included. They were stimulated using GnRH antagonist protocol, and GnRH agonist was used to trigger final oocyte maturation. All embryos were vitrified at the blastocyst stage and transferred in the subsequent menstrual cycles. Using the Kaplan-Meier survival analysis, a total of 65.9% (95% CI 57.5 to 74.3) women achieved a live birth after a maximum of six embryo transfer cycles using the 'conservative' approach. Applying the 'optimistic' approach, presuming that women who still had cryopreserved embryos and did not return for embryo transfer had the same chance of achieving a live birth as those returning for transfer, the cumulative live birth rate estimated in six embryo transfer cycles was 76.6% (95% CI 69.1 to 84.1). No cases of severe ovarian hyperstimulation syndrome were recorded.

What is the value of anti-Müllerian hormone in predicting the response to ovarian stimulation with GnRH agonist and antagonist protocols?

BACKGROUND

Anti-Müllerian hormone (AMH) is a marker of the ovarian reserve with promising prognostic potential in reproductive medicine. We aimed to evaluate the prognostic ability of AMH for predicting excessive or poor responses to ovarian stimulation using gonadotrophin-releasing hormone (GnRH) agonist and GnRH antagonist protocols in patients undergoing medically assisted reproduction (MAR) procedures.

METHODS

This retrospective analysis included 623 women who underwent ovarian stimulation for medically assisted reproduction. AMH level measurements were acquired from all couples within six months of the initiation of ovarian stimulation.

RESULTS

AMH was significantly correlated with the number of retrieved oocytes, and age was not relevant in a multivariate regression analysis (unstandardized regression coefficient of 1.130, 95 % confidence interval 0.977-1.283). AMH was a better predictor of both excessive (>19 oocytes) and poor (<4 oocytes) ovarian response than age (areas under the curve (AUCs) of 0.882 and 0.816, respectively). When stratified according to the stimulation protocol (a long GnRH agonist versus a GnRH antagonist protocol), AMH retained its high predictive value for excessive and poor responses in both groups. Serum AMH levels exhibited a strong correlation with the level of the response to ovarian stimulation.

CONCLUSIONS

AMH is an independent and an accurate predictor of excessive and poor responses to GnRH agonist and GnRH antagonist protocols for ovarian stimulation.

The use of time lapse photography in an in vitro fertilization programme for better selection for embryo transfer

The time lapse photography is not a new method for assessing the dynamics of early embryo development in vitro. It has been used many times in the past for studying cleavages and blastulation of embryos of various animal species. However, this technique became available for routine use in an human in vitro fertilization (IVF) programme only a couple years ago and it becomes more and more popular today. The new time lapse systems are using modified microscopes which are positioned within the incubators. The observation of embryos does not need the opening of incubators. By sequential photographing of each embryo separately with camera of low intensity illumination, more than 1400 pictures of embryo are made. All these pictures are collected together and transformed into a short movie with software. This system offers the observation of dynamics of embryo development. The studies, which have used a time lapse technique for studying embryo development, revealed that the timing between different events can be used for predicting its developmental potential. In this paper the advantages and drawbacks of time lapse photography is precisely described. An overview through the published papers analyzing the dynamics of human embryo development from the zygote toward blastocyst is done and new timing parameters for grading zygotes, early embryos and blastocysts are analyzed.

Simultaneous determination of phthalates, their metabolites, alkylphenols and bisphenol A using GC-MS in urine of men with fertility problems

A GC-MS method was successfully applied to measure simultaneously the concentrations of endocrine disrupting compounds (5 dialkyl phthalates, 9 phthalate monoesters, 3 alkylphenols and bisphenol A) in 136 male urine samples. In the present study the method was validated and concentrations of EDCs were determined. The results were compared with results from other studies. Correlations between endocrine disrupting compounds and also correlations of endocrine disrupting compounds with two semen quality parameters are presented and evaluated. Significant positive correlations were found between almost all the endocrine disrupting compounds. The parameter sum of DEHP (SUM DEHP) was positively correlated to all the endocrine disrupting compounds but negatively to two semen quality parameters. Negative correlations between the endocrine disrupting compounds and the semen quality parameters could indicate that endocrine disrupting compounds could cause reproductive problems by decreasing the semen count and quality. This research will have helped to evaluate human exposure to endocrine disrupting compounds.

Comparison of embryo transfer strategies and assisted reproduction outcome in Slovenian and cross-border patients

A reduction in the number of embryos transferred is the most important step in decreasing multiple gestation rates after medically assisted reproduction. Slovenia has implemented insurance company regulations that regulate single-embryo transfer in selected good-prognosis couples. The aim of the present study was to evaluate its effects on the Slovenian population compared with cross-border patients, who are not affected by the insurance company policy. Ultimately, 2403 couples undergoing IVF or intracytoplasmic sperm injection were included in the retrospective analysis. Patients were classified according to their origin. The decision about the number of embryos transferred and the treatment success were evaluated. The implementation of the policy favouring single-embryo transfer resulted in a significant decrease in the twin birth rate in Slovenian patients (24.4% before policy versus 6.7% after policy implementation, P<0.001). Although in cross-border patients twin birth rates have declined through the study period, they remained significantly higher compared with Slovenian patients (23.1% versus 6.7%, P<0.001). The data demonstrate that insurance company policies favouring single-embryo transfer are an effective tool in decreasing multiple gestation rates. Similar mechanisms should be implemented in the cross-border patient population.

Evaluation of coagulation abnormalities among women with vaginal bleeding in the first trimester of pregnancy

OBJECTIVE

To compare blood coagulation parameters between pregnant women with vaginal bleeding in the first trimester of pregnancy and pregnant women with normal pregnancy in the first trimester.

METHODS

A prospective controlled study of 98 women in the first trimester of vital pregnancy was conducted at the University Medical Centre Maribor, Slovenia. The study group comprised women with vaginal bleeding (n=50) while the control group women with normal pregnancy, admitted for artificial abortion (n=48). Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen concentration, number of platelets, hemogram, coagulation factor VIII (FVIII) and von Willebrand factor (VWF) activity were compared between the 2 groups.

RESULTS

No significant between-group differences were detected in mean PT, fibrinogen concentration, FVIII, and VWF activity. Mean aPTT was significantly higher in the control group than the study group (32.47 versus 30.46 seconds; P<0.05). The mean number of platelets was significantly lower in the study group than the control group (181.69 versus 203.52×10(9)/L; P<0.05). All measured coagulation parameters, except VWF activity, were within normal ranges.

CONCLUSION

Coagulation abnormalities are rarely the cause of vaginal bleeding in the first trimester of pregnancy among women with no previous symptoms of bleeding disorders.

An observational study of assisted reproductive technology outcomes in new European Union member states: an overview of protocols used for ovarian stimulation

BACKGROUND

The development of new fertility treatment options has facilitated individualized assisted reproductive technology (ART) protocols to improve outcomes. Manufacturing improvements to recombinant human follitropin alfa have allowed precise dosing based on mass (filled-by-mass; FbM) rather than bioactivity (filled-by-bioassay; FbIU). Continued monitoring and reporting of follitropin alfa treatment outcomes in routine clinical practice is essential.

OBJECTIVE

To provide an overview of the frequency of different controlled ovarian-stimulation protocols used in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles in new European Union member states, and to provide post-registration efficacy and safety data on follitropin alfa.

RESEARCH DESIGN AND METHODS

A 2-year, prospective, observational, multicentre, Phase IV study conducted at ART clinics in the Czech Republic, Estonia, Latvia, Lithuania, Poland, Slovakia and Slovenia. Women aged 18-47 years undergoing ovarian stimulation with follitropin alfa for conventional IVF or ICSI were eligible for inclusion. The main treatment outcome was cumulative clinical pregnancy rate. Data were analysed descriptively.

RESULTS

Clinical pregnancy outcomes were available for 4055 of 4085 (99.3%) patients. In total, 1897 (46.8%) patients used follitropin alfa FbIU; 2133 (52.6%) used follitropin alfa FbM. Clinical pregnancy was achieved by 39.5% (1603/4055) of patients. A greater proportion of patients with polycystic ovary syndrome achieved a clinical pregnancy than those with endometriosis (41.8% vs 37.8%, respectively). A higher cumulative pregnancy rate was observed with the use of follitropin alfa FbM than follitropin alfa FbIU (41.3% vs 37.8%, respectively; p = 0.02).

CONCLUSIONS

This study represents the most comprehensive audit of individualized ART in clinical practice in Central and Eastern Europe. Overall, clinical pregnancy was achieved by 39.5% of patients after stimulation with follitropin alfa. The use of follitropin alfa FbM resulted in a higher cumulative pregnancy rate than did the FbIU formulation. However, limitations of the study include the observational and non-comparative study design, and descriptive nature of statistical analyses; furthermore, the study was not designed to make direct comparisons between the success rates of different ovarian-stimulation protocols.

Sperm morphological abnormalities as indicators of DNA fragmentation and fertilization in ICSI

PURPOSE

To determine the relationship between sperm morphological abnormalities, DNA fragmentation and fertilization rate in intracytoplasmic sperm injection (ICSI).

METHODS

Sperm samples from 20 ICSI cycles were analysed. Morphology was assessed according to strict criteria, and DNA fragmentation was measured by terminal deoxynucleotidyl transferase (TdT)-mediated fluorescein-dUTP nick end labelling (TUNEL) using flow cytometry.

RESULTS

A negative correlation was found between the percentage of spermatozoa with elongated heads and fertilization rate. There was a significant difference in the amount of morphological abnormalities between sperm samples with low and high degree of DNA fragmentation. The percentages of amorphous heads and overall head abnormalities were significantly higher in sperm samples with elevated degree of DNA fragmentation. No correlation was found between sperm DNA fragmentation and fertilization rate.

CONCLUSIONS

Head abnormalities, especially amorphous heads, are related to elevated degree of DNA fragmentation. Elongated heads, when detected as predominant abnormal form in sperm samples, may affect fertilization in ICSI.

Influence of atmospheric versus reduced oxygen concentration on development of human blastocysts in vitro: a prospective study on sibling oocytes

Numerous studies show the beneficial effect of reduced oxygen on the culture of animal embryos in vitro. However, few similar studies have been carried out in humans, and the conclusions from these were contradictory. Using sibling human oocytes, a prospective study was carried out to analyse the effect of 5 and 20% oxygen on prolonged development of embryos. The outcomes measured were fertilization rate and proportion of morphologically optimal embryos, blastocysts and optimal blastocysts developing on day 5. The results were analysed separately for the group of IVF (n = 988 oocytes) and ICSI (n = 928 oocytes) cycles. It was found that low oxygen did not influence fertilization, but in comparison with 20% oxygen, it resulted in a significantly higher proportion of embryos being optimal on day 3 after IVF (59 versus 43.2%; P < 0.001) as well as after ICSI cycles (51.2 versus 28.5%; P < 0.001). In both methods, the lower oxygen concentration improved the blastulation rate (73.2 versus 63.1%; P < 0.05 and 67.4 versus 54.7%; P < 0.001) and increased the proportion of embryos reaching the stage of expanded blastocyst with normal inner cell mass on day 5 (31.1 versus 14.6%; P < 0.001 and 18.9 versus 11.4%; P < 0.01). The ratio of successful embryo development to optimal blastocyst stage on day 5 of culture, calculated for two oxygen concentrations, was 2.1 for IVF and 1.7 for ICSI, in favour of lower oxygen tension.

How safe is germinal vesicle stage oocyte rescue? Aneuploidy analysis of in vitro matured oocytes

OBJECTIVE

To evaluate the rate and type of aneuploidies of chromosomes 13, 16, 18, 21 and 22, with respect to the length of in vitro maturation (IVM) period, and to compare the results to previously published studies on aneuploidy rates of unfertilized, uninseminated mature oocytes and first polar bodies.

STUDY DESIGN

Two hundred and twelve immature germinal vesicle stage oocytes were assigned to two groups. After successful IVM, depending on their maturational period of 24h (Group A) or 36h (Group B), chromosomal analysis was performed by five color fluorescence in situ hybridization (FISH). In Groups A and B the rates of aneuploid oocytes were calculated and compared by chi-square test. Also the rates of hyperhaploidy, hypohaploidy, disomy and nullisomy were determined and compared by chi-square test. The difference was considered statistically significant at p-value of <0.05.

RESULTS

The prolonged IVM did not significantly affect the aneuploidy rate compared to the shorter maturation period (48.1% and 45.0%, respectively). Regarding the unbalanced premature chromatid separation, no statistically significant difference was found between hyperhaploidy and hypohaploidy (14.8% versus 8.3%). For chromosome nondisjunction, higher frequency of disomy than nullisomy was observed (30.6% versus 14.8%; p<0.05). The estimated global aneuploidy rate was between 42% and 63%.

CONCLUSIONS

The aneuploidy rate of IVM GV-oocytes is comparable to the aneuploidy rate of in vivo matured oocytes and first polar bodies, regardless of the length of maturation period. This suggests that the immature oocytes can be used in infertility treatment after they complete maturation.

Multinucleation and cleavage of embryos derived from in vitro-matured oocytes

In patients with polycystic ovary syndrome (PCOS), the proportion of optimal embryos-blastomere number and fragmentation rate-derived from in vitro-matured oocytes after the hCG priming protocol was higher (43.3%) than the proportion of optimal embryos derived from oocyte in vitro maturation with the FSH priming protocol (11.1%). The embryos derived from in vitro-matured oocytes after the hCG priming protocol also showed a lower incidence of multinucleated blastomeres. Pregnancies were recorded only in the hCG primed patients.

Measurement of perifollicular blood flow of the dominant preovulatory follicle using three-dimensional power Doppler

OBJECTIVE

To establish whether we might predict the outcome of unstimulated in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles with quantitative indices of perifollicular blood flow assessed with three-dimensional (3D) reconstruction of power Doppler images.

METHODS

This prospective study included an analysis of 52 unstimulated cycles. Color and power Doppler ultrasound examinations of a single dominant preovulatory follicle were performed on the day of oocyte pick-up. With 3D reconstruction and processing, quantitative indices were obtained i.e. the percentage of volume showing a flow signal (VFS) inside a 5-mm capsule of perifollicular tissue and the percentage of VFS of each of the three largest vessels in this capsule. These indices as well as pulsed Doppler indices were compared between the groups of cycles with different outcomes using a one-way ANOVA test.

RESULTS

In nine cycles no oocyte was retrieved (Group A), in seven cycles no fertilization occurred (Group B) and in 30 cycles no implantation occurred (Group C). Six cycles resulted in pregnancy (Group D). There were no statistically significant differences in pulsed and power Doppler indices between these groups. However, the percentage of VFS in the capsule was higher than average in cycles with implantation (19.22 +/- 16.82 vs. 12.42 +/- 8.89, NS) and the percentage of VFS in the main vessel exhibited lower than average values in cycles with implantation (20.66 +/- 10.05 vs. 39.84 +/- 20.15), but only reached borderline statistical significance (F = 2.457, P = 0.074).

CONCLUSION

It can be hypothesized that the follicles containing oocytes able to produce a pregnancy have a distinctive and more uniform perifollicular vascular network.

Clinical outcome of day 2 versus day 5 transfer in cycles with one or two developed embryos

OBJECTIVE

To determine whether extended culture of embryos to blastocysts has any benefit in cycles with only one or two created embryos.

DESIGN

Retrospective analysis of cycles comparing outcomes of day 2 and day 5 transfers. Our day 2 group was from the year 1999 and our day 5 group, from the year 2000.

SETTING

Assisted reproductive technology program of a teaching hospital.

PATIENT(S)

All patients, irrespective of age, who had developed one or two embryos.

INTERVENTION(S)

Stimulated IVF, intracytoplasmic sperm injection, or testicular sperm extraction and intracytoplasmic sperm injection cycles with 2-day culture in universal IVF medium (n = 133) or 5-day culture in BlastAssist media (MediCult, Jyllinge, Denmark; n = 132).

MAIN OUTCOME MEASURE(S)

Pregnancy, implantation, and take-home baby rates.

RESULT(S)

In the groups of 2-day and 5-day culture, embryo transfer was performed in 98% and in 57% of cycles, respectively. However, the total implantation rate per created embryo (18% vs. 18%), the pregnancy rate per cycle (23% vs. 21%), and the take-home baby rate (69.4% vs. 71.4%) did not differ between the day 2 and day 5 groups.

CONCLUSION(S)

Extended culture of embryos does not improve or decrease their capacity for implantation but only allows for better selection and is therefore not necessary in cycles with fewer than three embryos.

Results of intracytoplasmic sperm injection of single oocyte in 362 unstimulated cycles

PURPOSE

The purpose was to test the adequacy of unstimulated cycles for intracytoplasmic sperm injection (ICSI) and to evaluate implantation and pregnancy rates in three different age groups.

METHODS

ICSI was performed in 362 unstimulated cycles in women up to 45 years old. All cycles were monitored by serum estradiol, urinary LH, and ultrasound.

RESULTS

The delivery rate per started cycle was higher in patients younger than 36 (9.4%) than in cycles with patient's age between 36 and 39 years (4.8%) or older than 40 (4.6%) but the difference was not statistically significant. In all groups, the fertilization rate was similar (70.4, 77.6, and 84.8%, respectively). The pregnancy rate per cycle and the pregnancy rate per puncture was similar in the group of patients in age between 36 and 39 years (8.3 and 9.7%) and those older than 40 (7.7 and 9.3%).

CONCLUSIONS

Unstimulated cycles monitored by serum estradiol, urinary LH, and ultrasound can produce an acceptable pregnancy rate after ICSI procedure only in patients younger than 36.

Is there any benefit from the culture of a single oocyte to a blastocyst-stage embryo in unstimulated cycles?

BACKGROUND

The aim of the study was to test the influence of 2- and 5-day cultivation of a single oocyte on the pregnancy rate in a non-stimulated cycle.

METHODS

A retrospective chart review of 391 consecutive patients undergoing IVF and intracytoplasmic sperm injection in unstimulated cycles was performed. The embryos were kept in MediCult universal IVF medium for day 2 transfers and in BlastAssist System for day 5 transfers.

RESULTS

The oocyte recovery rate in the group for 2-day cultivation and in the group for 5-day cultivation was similar, being 79.4 (162/204) and 83.6% (154/187) respectively. The same is true of the fertilization rate (73.8 versus 77.7%). The blastulation rate was 52.8%. The embryo transfer rate per cycle was higher when day 2 embryos were transferred: 64.8% (105/162) compared with 35.7% (55/154) if blastocyst-stage embryos were transferred. The pregnancy rate per transferred embryo was higher when a blastocyst was transferred (40.0%) instead of a day 2 embryo (23.8%).

CONCLUSION

The expected pregnancy rate calculated per embryo available on day 2 of cultivation was similar in both groups (23.8 versus 22.2%) and it was not affected by oocyte culture to the blastocyst stage.

Three protocols for monitoring follicle development in 587 unstimulated cycles of in vitro fertilization and intracytoplasmic sperm injection. A comparison

OBJECTIVE

To test the adequacy of unstimulated cycles for intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF) and to evaluate implantation and pregnancy rates in three monitoring protocols.

STUDY DESIGN

A retrospective chart review of 587 patients undergoing IVF and ICSI in unstimulated cycles was performed. In the first group (protocol A), all cycles were monitored by ultrasound only. Human chorionic gonadotropin (hCG) was given when the mean follicle diameter reached 18 mm. In protocol B, hCG was given when serum estradiol (E2) or follicle diameter reached the critical value (0.91 nmol/L and 18 mm). With a smaller follicle diameter, the E2 level had to be higher, and vice versa. In protocol C, hCG was administered when the serum E2 was > 0.49 nmol/L and follicle diameter at least 15 mm. Cycles with positive luteinizing hormone in urine before hCG was given were cancelled.

RESULTS

The cancellation rate was lower in protocol C (33/335, 9.8%) than protocol B (42/151, 27.8%) and A (41/101, 40.5%). In protocol C the pregnancy rate per cycle was higher with IVF (n = 219) and ICSI (n = 116) cycles (10.5% and 12.1%) than when protocol B was used (3.8% and 4.3%). The pregnancy rate per transfer was highest when protocol C was used in the IVF (23/105, 21.9%) and ICSI group (14/53, 26.4%).

CONCLUSION

Unstimulated cycles monitored by serum E2, urinary luteinizing hormone and ultrasound can produce an acceptable pregnancy rate after IVF and ICSI.

Dependence of the in-vitro fertilization capacity of the oocyte on perifollicular flow in the preovulatory period of unstimulated cycles

BACKGROUND

One method to economize on monitoring cycles for IVF and improving its outcome is follicular selection. The purpose of our study was to determine whether quantitative indices of perifollicular blood flow allow the prediction which follicles contain a fertilizable oocyte and which do not.

METHODS

This prospective study included 178 unstimulated cycles for IVF in patients treated for tubal infertility, endometriosis and unknown causes of infertility that ended with follicular aspiration. All male partners had a normal spermiogram. Cycles were monitored using ultrasound folliculometry and estimation of serum estradiol concentrations. On the day of hCG administration (day 0), day +1 and prior to follicular aspiration (day +2), perifollicular blood flow was measured using color and pulsed Doppler. The pulsatility index (PI), resistance index (RI) and peak systolic velocity (PSV) between the group in which fertilization occurred (group A) and that in which no fertilization occurred (group B) were compared. Student's t-test and ANOVA were used for statistical analysis.

RESULTS

The oocyte recovery rate was 71.5% and the fertilization rate 74.8%. Comparison of RI and PI between group A (N = 95) and group B (N = 32) revealed a decline in PI and RI after hCG administration in both groups. Only on day 0 was PI in group A significantly lower than that in group B. The difference in RI and PSV between the two groups was not statistically significant. ANOVA showed that there was no significant difference in serial Doppler measurements between the two groups.

CONCLUSION

We confirmed an increased perifollicular blood flow in the preovulatory period. Quantitative indices of perifollicular blood flow are of limited value as parameters for cycle monitoring and decision-making in unstimulated cycles for IVF.

Simplification of the clinical phase of IVF and ICSI treatment in programmed cycles

OBJECTIVE

To evaluate the success of a protocol for controlled ovarian hyperstimulation allowing patient self-selection into groups for ovulation stimulation planned 8 weeks and more in advance following cycle synchronization, drug self-administration as well as a reduced number of folliculometries.

METHODS

A total of 714 patients received the same stimulation protocol. In 260 cases GnRH-a was applied daily and in 454 as depot. In all patients FSH-HP was self-administered subcutaneously for ovarian stimulation. In 316 patients IVF and in 398 patients ICSI was performed.

RESULTS

The delivery rate per started cycle was higher in patients receiving depot GnRH-a in the IVF and ICSI group (30.2 vs. 23.4) than in those receiving subcutaneous GnRH-a (20.2 vs. 22.1).

CONCLUSION

Programming of the IVF/ICSI cycle greatly simplifies treatment. A comparison of pregnancy rate and delivery rate per cycle between depot and subcutaneous daily application of GnRh-a did not confirm any statistically significant difference.

The preovulatory serum estradiol pattern in natural IVF/ICSI cycles

PURPOSE

The aim of the study was to find whether inferences to the possible success of natural IVF/ICSI cycles could be drawn from the estradiol (E2) pattern.

METHODS

Sixty-eight women who underwent oocyte recovery in 98 natural cycles were recruited for the study. Daily serum E2 was measured in the preovulatory phase (-3 to +2 day). The E2 pattern was compared among four groups: Group A, unsuccessful egg retrieval; Group B, no fertilization; Group C, no implantation; and Group D, implantation.

RESULTS

There was no difference in mean E2 levels between groups. Only the ratio of E2 on day +1/E2 on day 0 was significantly lower in conception cycles in comparison with nonconception cycles. In cycles with a decreased E2 level on day +1, only the implantation rate was significantly higher in comparison with cycles with an increasing E2 level.

CONCLUSIONS

From the E2 pattern it is possible to make inferences about the likelihood of implantation but not the fertilization or oocyte recovery success.

Number of oocytes retrieved and resulting pregnancy. Risk factors for ovarian hyperstimulation syndrome

OBJECTIVE

To test whether the risk of developing clinically significant ovarian hyperstimulation syndrome (OHSS) is related to the number of oocytes retrieved by puncture and the resulting pregnancy and to determine the most suitable cutoff limit of the number of oocytes in predicting OHSS.

STUDY DESIGN

The study included 973 patients who underwent ovarian stimulation for in vitro fertilization or intracytoplasmic sperm injection. Using the classification of Schenker and Weinstein, we identified patients who developed moderate and severe OHSS. By multiple logistic regression we established the risk of moderate or severe OHSS development in relation to the number of oocytes retrieved and the resulting pregnancy. A receiver operator characteristic curve was constructed to describe the relation between sensitivity and the false positive rate for the number of oocytes retrieved in the prediction of OHSS.

RESULTS

We identified 35 (3.6%) patients who developed OHSS, 8 (0.8%) severe and 27 (2.8%) moderate. The risk of developing OHSS increased with the number of oocytes retrieved (odds ratio = 1.14) and with pregnancy (odds ratio = 1.14). The most suitable limit for predicting OHSS was 10 oocytes, with 81.9% specificity and 48.6% sensitivity. The risk of OHSS development in cycles with < or = 10 oocytes and no conception was 1.31% and, with conception, 5.12%. The risk of OHSS development in cycles with > 10 oocytes and no conception was 4.43% and with conception, 15.93%.

CONCLUSION

The risk of OHSS development increases with the number of oocytes retrieved and with pregnancy. The most suitable limit for predicting OHSS is 10 oocytes; however, due to low sensitivity, it is also necessary to consider other factors when establishing the increased risk of OHSS.

Treatment of varicocele and male fertility

Ninety-six patients with varicocele were followed for 4 years in a prospective randomized study. Seventeen patients were excluded from the study in accordance with exclusion criteria. In 26 patients varicocele was treated surgically and 12 patients were treated either by sclerosation or embolization. Forty-one patients with varicocele had no therapy. In 54 patients oligoasthenozoospermia and in 25 normozoospermia was certified. In the group of patients without treatment, the pregnancy rate in the women was higher (22/41, or 53.7%) than in the group receiving treatment (13/38, or 34.2%). The difference was not statistically significant. After therapy, sperm concentration increased and sperm motility improved also. The differences were not statistically significant. The study showed that varicocele therapy bears no influence on male fertility.

Selective reduction after gamete intrafallopian transfer

Selective reduction was performed in a patient with triplet pregnancy in the 9th week of gestation. Selective reduction of the fetuses to two was performed by puncture using vaginal ultrasound probe. No complications occurred and the patient was delivered of healthy twins.

[Evaluation of embryotoxicity of materials used in the IVF laboratory]

It has been established that the quality of water for the preparation of culture media has an essential influence on the percentage of two cell-stage mouse embryos developing successfully until the blastocyst stage. The quality of media prepared with bidistilled water (p less than 0.001) is inferior to that prepared with bidestilled demineralized water (p less than 0.02). Best results were attained by using the medium prepared with Nanopure water (Barnstead), in which 73.2% of embryos developed into blastocysts. There was no statistically significant difference between this medium and the commercial liquid medium (Sigma), in which 83.1% of embryos developed into blastocysts. The age of the medium and the percentage of added serum have no statistically significant influence on the outcome of the test. Contact of the medium with the syringe containing a black rubber piston proved explicitly embryotoxic (p less than 0.001).

[Results of the IVF/GIFT program in Maribor]

The results of the IVF/GIFT programme for 1989 in Maribor are presented. During this period 4 clinical pregnancies were attended by the IVF procedure and one by GIFT and ZIFT each. In the IVF procedure the highest percentage of pregnancies was obtained in the group of women with the tubal factor of infertility (n = 34) where 4 clinical pregnancies on 22 ET were registered (18.1%). Cycle synchronisation with contraceptives, followed by stimulation with CC-HMG proved to be the most successful protocol for the cycle stimulation. With this protocol, pregnancy was attained in 4 of 19 stimulated cycles (21.0%). In the spontaneous cycles (n = 17) no pregnancy was registered.

[Diagnosis of breast cancer in the gynecology department]

Breast examinations were performed in 4199 women by a simultaneous carrying out of clinical investigation, thermography and mammography, and, if needed, also by ultrasonic examination and aspiration cytology. A total of 169 women were referred to treatment and biopsy. Among them, 78 had breast cancer. In 6 patients ca in situ intraductale was discovered, while the disease was limited to the breast with negative lymph nodes in the axilla in 48 (61.5%) patients. Mammography proved more successful than clinical investigation. Its sensitivity amounted to 92% and that of clinical investigation only to 69%. The cost of a complete diagnostic process (on the first of April, 1986) was 5.717 dinars, which means that the cost of a diagnosed carcinoma was 307.765 dinars.

[Breast cysts--diagnosis and therapy]

The authors present the results of the diagnosis of 1405 cases of macroscopically evident breast cysts. Only 15% patients were younger than 40 and only 6% older than 55 years. All lesions were cytologically analysed. The results were classified as negative in 1120 (79.9%), suspect in 27 (1.9%) and positive in 6 (0.4%) of cases. In 18% (n = 252) of cases aspirates were not adequate for cytologic evaluation. During a five-year follow-up period no new cyst was confirmed in 69.2% of cases, while in 30.8% of cases new cysts were diagnosed in yearly examinations during the observed period. Five (2.6%) intracystic proliferations were selected from the 190 cysts studied by means of pneumocystography. In the group presented three intracystic cancers were diagnosed by the combination of different diagnostic methods. The authors conclude that the introduction of ultrasound in breast cyst diagnostic work has reduced indications for pneumocystography and the cytologic evaluation of aspirates.

[Sex hormone binding globulin in stimulated cycles]

Ovulation was stimulated in 56 cycles, namely in 16 cycles with clomiphene, in 19 with clomiphene and HCG, and in 16 cycles with clomiphene, HMG and HCG. In three women there was no LH or estradiol increase following ovulation stimulation with clomiphene, but in two women stimulated by the two remaining methods there was a spontaneous LH peak before the application of HCG. Using the radioimmunologic method once a day the concentrations of LH, estradiol and SHBG in serum were determined. The concentrations of SHBG in serum do not change in all three methods of ovulation stimulation. The mean concentrations of SHBG vary between 47 and 54 mumol/l during the entire preovulatory phase of the stimulated cycle. All of these cycles were ovulatory since the preovulatory E2 peak is clearly expressed in all three methods of ovulation stimulation.

[Analysis of the levels of gonadotropins and testosterone in the serum and sperm of patients with varicocele]

In 26 patients with clinical varicocele, in 20 patients with "subclinical" varicocele, and in 90 clinically normal patients, measurements of the plasma follicle stimulating hormone (FSH), luteinising hormone (LH), prolactin (PRL) and testosterone were made. In 13 patients pre-operative and post-operative measurements were also performed. The difference in the serum testosterone values in patients with varicocele and in those without varicocele was not statistically significant. The level of FSH and LH markedly higher in the group of patients with subclinical varicocele than in the group with clinically expressed varicocele (p less than 0.05). The difference in the values of FSH, LH, PRL and testosterone in the serum and seminal plasma of clinically normal patients with thermographically verified scrotal hyperthermia due to the reflux into the pampiniform plexus and in those with euthermia was not statistically significant if the quality of the semen was similar.

[Ultrasonically guided puncture of nonpalpable breast cysts]

The technique and the success of ultrasonically guided punctures of nonpalpable breast cysts are presented. A total of 43 cysts were punctured. The average lesion diameter (means +/- SD) was 16.4 +/- 5.4 mm. The puncture was not successful in 20.9% of cases. The cell material obtained by puncture was adequate for analysis in 32 (74.4%) cases, in 11 (25.6%) cases the aspirates were not suitable for the setting of a diagnosis because of an insufficient number of cells or the absence of the cell material. Inflammation as a complication of the intervention was registered twice (4.6%).

[Results of prospective cytological diagnoses of cervical intraepithelial neoplasia]

The value of prospective cytologic diagnosis in cervical intraepithelial neoplasia (CIN) is analysed by means of ROC (receiver operating characteristic) curves. Examined was a group of 160 women with subsequent cone biopsies. The result of a prospective cytologic diagnosis in moderate dysplasia, severe dysplasia and carcinoma in situ is analysed separately, taking into consideration the particular frequencies in the studied group. The most reliable prospective cytologic diagnosis is in moderate dysplasia, followed by carcinoma in situ a slightly more reliable prospective diagnosis than that in severe dysplasia.

[Analysis of receiver operating characteristic in the echographic diagnosis of breast tumors]

The echographic characteristics of 215 breast tumours were analysed. The validity of echomammography (EM) in the diagnosis of breast tumours was assessed by the analysis of receiver operating characteristic curves. The dependence of the success of the diagnosis on the rigour of the chosen diagnostic criteria is presented. In the same manner the successfulness of the evaluation of the nature of tumour was tested with various combinations of echographic diagnostic signs. By using the ROC curves of the prior and posterior probability of the disease and the detectability index, the degree of applicability of EM was compared in the diagnosis of carcinomas, cysts, and benign breast tumours.

[Diagnosis of breast cancer (author's transl)]

The authors draw attention to the frequency of breast carcinoma and the importance of its early detection. They critically evaluate the advantages and disadvantages of X-ray diagnosis, thermography, ultrasound, radioisotope diagnosis, cytology, and histological diagnosis.