Multivariate analysis of factors predictive of successful live births in in vitro fertilization (IVF) suggests strategies to improve IVF outcome.

PURPOSE: Our purpose was (1) to identify characteristics correlated with pregnancy outcome, (2) to use these characteristics to predict in vitro fertilization (IVF) outcome, and (3) to develop strategies that might improve IVF success. METHODS: Maternal age, cause for IVF, donor insemination, rank of attempt, serum estradiol and luteinizing hormone levels on the day of human chorionic gonadotropin administration, flexible vs rigid catheter, number of embryos transferred of each morphologic type, and cell number were analyzed by logistic regression. RESULTS: Variables positively correlated with success are as follows: (1) for pregnancy, endometriosis and 2-, 3-, and 4-cell good and 4-cell excellent embryos; (2) for live births, 2-, 3-, and 4-cell good and 4-cell excellent embryos and donor insemination; and (3) for multiple births, 2- and 4-cell good and 4-cell excellent embryos. Maternal age was negatively correlated with live births. CONCLUSIONS: Embryos derived from IVF have different potentials for implantation, live births, and multiple births. Transferring one additional good-quality embryo for each 5 years of incremental increase in maternal age is predicated to improve live birth rates without increasing multiple births.

The sperm stress test: a novel test that predicts pregnancy in assisted reproductive technologies.

OBJECTIVE: To develop a reliable sperm test that would predict pregnancy rate in assisted reproductive technologies. DESIGN: Blind prospective cohort study. SETTING: Tertiary-care, university hospital-affiliated IVF program. PATIENTS: One hundred nineteen sperm samples were obtained from 110 males from couples undergoing IVF or GIFT (ART). Sperm samples were washed by Percoll, incubated at 24 degrees C for 4 hours, and an aliquot of the same sperm suspension was used for ART incubated at 40 degrees C for 4 hours (stress test). Stress test scores are expressed as the ratio of final to initial motility. RESULTS: Of 119 ART cycles, 24 resulted in pregnancy. Of 24 pregnancies, 23 occurred in cycles that used sperm samples with stress test scores > or = 0.75 and only one with a stress test score < 0.75. The negative predictive value of the test, defined as the absence of pregnancy with scores < 0.75, was 98% and the positive predictive value, defined as the occurrence of pregnancy with scores > or = 0.75, was 36%. Logistic regression analysis indicated that the stress test score alone was correlated significantly with pregnancy after ART. CONCLUSION: These results indicate that stress test scores < 0.75 are predictive of poor pregnancy outcome in ART.

Gonadotropin-releasing hormone antagonist versus agonist administration in women undergoing controlled ovarian hyperstimulation: cycle performance and in vitro steroidogenesis of granulosa-lutein cells.

OBJECTIVES: We sought to determine the effectiveness of a gonadotropin-releasing hormone antagonist compared with an agonist in suppressing a spontaneous luteinizing hormone surge in women undergoing controlled ovarian hyperstimulation for in vitro fertilization and gamete intrafallopian transfer and to examine whether in vivo administration of these analogs effects granulosa-lutein cells steroidogenesis in vitro. STUDY DESIGN: This prospective case-control study included 30 healthy women undergoing ovarian hyperstimulation with human menopausal gonadotropins. Fifteen women received the Nal-Glu antagonist, 5 mg intramuscularly daily, when the lead follicle was > or = 15 mm or serum estradiol level was > or = 500 pg/ml. The control group included 15 women who underwent oocyte retrieval on the same day as the study subjects and were given the agonist leuprolide acetate, 250 micrograms subcutaneously daily, starting on cycle day 1. Granulosa-lutein cells were purified from follicular aspirates from six subjects and six controls and cultured in parallel, evaluating basal progesterone production, progesterone response to follicle-stimulating hormone or luteinizing hormone and aromatase activity. RESULTS: No difference was demonstrated in the total amount of gonadotropins received by the two groups. Overall, the gonadotropin-releasing hormone antagonist was given for only 2.5 +/- 0.2 (mean +/- SEM) days before human chorionic gonadotropin administration. The antagonist group showed significantly lower levels of serum luteinizing hormone than did the agonist group, 1.0 +/- 0.2 versus 4.2 +/- 0.5 mIU/ml (p = 0.0001) on the day of human chorionic gonadotropin administration. Serum estradiol levels were significantly lower in the antagonist than the agonist group, 820 +/- 120 versus 1361 +/- 110 pg/ml (p = 0.003) on the day of human chorionic gonadotropin administration. There was no difference in the number of retrieved oocytes, but the antagonist group had a higher proportion of mature oocytes, 82% +/- 4% versus 62.4% (p = 0.02), and a higher proportion of embryos of good quality, 69.8% +/- 9.8% versus 44.3% +/- 7.2% (p = 0.03) in the agonist group. Granulosa-lutein cells from antagonist-treated women showed significantly lower aromatase activity the first 6 hours after retrieval, 17.6 +/- 1.6 versus 31.3 +/- 7.4 ng/ml per 6 hours estradiol (p = 0.03), whereas basal and gonadotropin-stimulated with progesterone responses were similar. CONCLUSION: Gonadotropin-releasing hormone antagonist administration during the late follicular phase resulted in lower serum luteinizing hormone and estradiol levels and more mature oocytes and embryos of better quality compared with gonadotropin-releasing hormone agonist administration. These results suggest that gonadotropin-releasing hormone antagonist administration in ovarian hyperstimulation has practical advantages over the agonist regimen. Gonadotropin-releasing hormone analogs may have direct action on ovarian function with differential effects on granulosa-lutein cell aromatase activity. This could explain the lower serum estradiol levels routinely observed in women given gonadotropin-releasing hormone antagonist.

Gonadotropin-releasing hormone receptor gene expression in human ovary and granulosa-lutein cells.

GnRH regulates gonadotropin biosynthesis and release in the anterior pituitary via specific receptors. Although extrapituitary expression and action of GnRH have been shown in some species, in the human it is not clear whether GnRH has a peripheral action. In this study we sought to determine whether the human ovary expresses GnRH receptor (GnRHR) messenger ribonucleic acid (mRNA). Ovarian tissues from 11 women (32-61 yr old) and granulosa-lutein (GL) cells purified from follicular aspirates of 51 women undergoing oocyte retrieval for in vitro fertilization were analyzed by ribonuclease protection assay and reverse transcriptase-polymerase chain reaction (RT-PCR). Human pituitaries, lymphocytes, and placenta were also studied. Measurable levels of GnRHR mRNA were found by ribonuclease protection assay in 2 of 10 ovaries, in 2 of 4 GL cells preparations from women whose ovarian hyperstimulation involved a GnRH agonist, in GL cells from 3 women whose ovarian hyperstimulation involved a GnRH antagonist, and in human pituitaries. Relative to the total amount of RNA analyzed, the level of GnRHR mRNA was about 200-fold lower in the ovary than in the pituitary. A sequence of 314 basepairs of GnRHR mRNA was amplified by RT-PCR in the pituitary, in 9 of 10 ovaries, and in 4 of 5 GL cell preparations. No message could be amplified in human lymphocytes, and placental specimens showed a weak signal. The relative GnRHR mRNA levels in GL cells from 13 women analyzed by quantitative RT-PCR showed a wide range of individual differences. These results suggest that GnRHR mRNA is expressed in GL cells and the human ovary across different functional stages, implying that multiple ovarian compartments may express GnRH receptors. The administration of GnRH analogs may have a further direct action on the human ovary.

Preterm delivery and low birthweight among refugees in Greece.

Recently Greece received a large number of refugees mainly from Eastern European countries, Middle East, Africa and the Pontus region. Refugee status, implying psychosocial adversities and financial problems, has traditionally been associated with unfavourable pregnancy outcome. This study aimed to compare the incidence of preterm delivery and low birthweight among 638 refugees and 1231 indigenous women giving birth at the same hospital in Athens. Conditional logistic regression was used in the analysis to account for parity and delivery date (matching variables) as well as controlling explicitly for maternal age and gender of the neonate. It was demonstrated that refugee status did not overall influence the occurrence of preterm delivery or low birthweight, thus implying that these two variables are not sensitive or early indicators of the adverse effects of psychosocial stress suffered by refugees.

Ovarian tumors: prediction of the probability of malignancy by using patient's age and tumor morphologic features with a logistic model.

An attempt was made to predict the probability of malignancy of a given ovarian tumor in a certain patient by using the age and simple morphologic features of the tumor. A cohort of 959 patients with ovarian tumors was analysed retrospectively according to the patient's age and tumor characteristics such as greatest diameter, consistency, bilaterality and diagnosis as malignant (271 patients) or benign (688 patients). All variables were entered unconditionally in a logistic regression. The presence of solid/multilocular elements has a 9.6-fold increased risk of malignancy, where a bilateral tumor has a 2.8-fold increase. Significant increase in risk of malignancy was observed in ages under 20 and over 40 years, as well as in tumors with a diameter larger than 9 cm. All variables were highly significant associated with the discrimination between benign and malignant. A formula including all variables has been developed so that the probability of malignancy can be estimated by a scientific calculator. In conclusion, simple, easily determined by ultrasound and reproducible criteria such as patient's age, tumor size, consistency and bilaterality were assembled in a logistic model in order to predict the probability of malignancy for a given ovarian tumor, in an individual patient.

Arm morbidity following treatment of breast cancer with total axillary dissection: a multivariated approach.

In order to clarify the factors that mainly influence arm morbidity following treatment of breast cancer with the full axillary dissection protocol, we evaluated, in a model of multiple regression analysis, parameters such as the type of breast surgery, adjuvant radiotherapy, time of irradiation, age, number of dissected nodes and axillary nodal status. A total of 104 women were studied. Late arm edema was observed in 17% of the patients and was more frequent when (1) irradiation was given immediately after the operation than if it was given 6 months later (p = 0.009) and (2) the number of removed nodes exceeded 40 (p = 0.037). Upper limb pain was reported by 16% of the patients and was reported more frequently from patients over 60 years of age (p = 0.036), as well as from patients who underwent modified radical mastectomy (p = 0.044) and those in whom 30-40 nodes were dissected (p = 0.025). Shoulder joint mobility was impaired in 17% of the patients, and it was not affected by any of the examined factors. It seems that conservative breast surgery or adjuvant breast radiotherapy 6 months after the operation might reduce independently the likelihood of arm morbidity by 25%.

Intracervical prostaglandin E2 gel for cervical ripening and labor induction: what is the appropriate dose?

In order to evaluate a dose-related response of cervical ripening and labor induction to a prostaglandin E2 (PGE2) gel, 110 women with uncomplicated postdate pregnancies and unripe cervices received intracervically 0.5 mg PGE2 (n = 40), 1.5 mg PGE2 (n = 35) or 2.5 mg PGE2 (n = 35). The failure rate in terms of cervical ripening was similar in all groups. Labor characteristics such as the duration of the latent phase as well as the total length of labor, the cesarean-section rate, instrumental deliveries and neonatal outcome were similar in all groups. The number of women who required oxytocin for labor augmentation was negatively correlated to the dose of PGE2 (p < 0.05). In addition, 3 out of 35 women in the 2.5-mg group presented hypertonic uterine activity. The increase in the dose of PGE2 gel did not increase the possibility for a vaginal delivery, but reduced the requirement for oxytocin while increasing hypertonic uterine action.

Serum levels of creatine kinase and its isoenzymes during the 1st postpartum day in healthy newborns delivered vaginally or by cesarean section.

The purpose of this study is to investigate the relationship of creatine kinase (CK) and its isoenzyme levels in the newborn to the mode of delivery, time interval from birth (divided in four 6-hour time periods), parity and sex of the neonates. During the 1st postpartum day, serum levels of CK and its isoenzymes (CK-MM, CK-MB, CK-BB) were determined from 115 healthy full-term neonates born consecutively either by spontaneous vaginal delivery (VD, n = 85) or by elective cesarean section (CS, n = 30). The multiple regression analysis was applied. Total CK levels were positively correlated with VD (p < 0.0003). This was mainly attributed to a rise in the CK-MM activity which presented a similar pattern to CK. CK-MB activity was also positively correlated with VD. In contrast, CK-BB was negatively correlated to the postpartum time period. Neonatal sex and parity did not influence CK and its isoenzyme levels significantly. In conclusion, VD contributes significantly to an increase in CK levels during the 1st day of extrauterine life.

Pelvic surgery, reproductive factors and risk of ectopic pregnancy: a case controlled study.

A case controlled study among 361 women with surgically treated ectopic pregnancy and 420 women delivered at term was designed, aiming at characterization of the association among previous pelvic operations, selected reproductive factors and ectopic pregnancy. All types of previous pelvic operations increase the risk of ectopic pregnancy from a 2-fold increase for appendectomy to a 9-fold increase for ectopic pregnancy, if maternal age, parity, history of spontaneous and induced abortions and history of infertility is controlled. This study suggests that a previous pelvic operation may increase the risk of ectopic pregnancy.

Labor characteristics of uncomplicated prolonged pregnancies after induction with intracervical prostaglandin E2 gel versus intravenous oxytocin.

Labor characteristics after intracervical application of 0.5 mg prostaglandin (PG) E2 gel (n = 83) versus intravenous administration of oxytocin (n = 82) for labor induction were investigated in uncomplicated prolonged pregnancies with unripe cervix. The induction to delivery time as well as the total oxytocin dose were significantly reduced in the PGE2 group (p < 0.001). Cesarean sections, instrumental deliveries and fetal distress had the same frequency, but the failures of trial were significantly higher in the oxytocin group than in the PGE2 group (20.7 vs. 6%, p < 0.01). Twenty-four percent of women needed a second PGE2 dose, and almost half of the women in the PGE2 group experienced 'spontaneous' labor. More neonates in the oxytocin group had 5-min Apgar scores < 7 (p < 0.05). Intracervical PGE2 gel application is superior to intravenous oxytocin in terms of shortening the induction-delivery interval and increasing the frequency of successful vaginal delivery. In addition, it is safe for mother and fetus.

PIP: Labor characteristics after intracervical application of 0.5 mg prostaglandin E2 (PGE2) gel (n=83) vs iv administration of oxytocin (n=82) for labor induction were investigated in uncomplicated prolonged pregnancies with unripe cervix. The induction-to-delivery time as well as the total oxytocin dose were significantly reduced in the PGE2 group (p0.001). Cesarean sections, instrumental deliveries, and fetal distress occurred with the same frequency, but the failures of trail were significantly higher in the oxytocin group than in the PGE2 group (20.7 vs 6%, p0.01). 24% of the women required a 2nd dose of PGE2, and almost 1/2 of the women in the PGE2 group experiences spontaneous labor. More neonates in the oxytocin group had 5-minute Apgar scores 7 (p0.05). Intracervical PGE2 gel application is superior to iv oxytocin in terms of shortening the induction-to-delivery interval and increasing the frequency of successful vaginal delivery. In addition, it is safe for both mother and fetus.

Expression of carcinoembryonic antigen and ferritin in normal, hyperplastic, and neoplastic endometrium.

The distribution of carcinoembryonic antigen (CEA) and ferritin was demonstrated by immunohistochemical method in 95 patients with normal, hyperplastic, and neoplastic endometrium in order to distinguish among these conditions. Fifteen patients with normal endometrium (NE), 28 with hyperplasia (AH), 12 with atypical hyperplasia (AAH), and 40 with endometrial carcinoma (CA) were studied. Paraffin section tissues were subjected to immunostaining according to the avidin-biotin complex method. CEA was found in 33% of NE cases, 46% of AH, 75% of AAH, and 83% of CA (P less than 0.01). Ferritin was not detected in any case of NE; however, it was detected in one case (4%) of AH, in one case (8%) of AAH, and in 88% of CAs (P less than 0.001). Both tumor markers exhibited a heterogeneous staining pattern, and for a given histologic hyperplastic or malignant lesion, corresponded to several phenotypes. There was no significant correlation between clinical stage or tumor grade and CEA or ferritin expression. In conclusion, ferritin seems to be a better biological marker than CEA in distinguishing between hyperplastic and neoplastic endometrial lesions and it is also more reliable than CEA for endometrial malignancy since it was absent in normal and hyperplastic endometria.

Late midtrimester medical pregnancy terminations: three different procedures with prostaglandin F2 alpha and laminaria tents.

One hundred twenty eight women underwent midtrimester induced abortion with: 1) combined regimen of intramniotic prostaglandin (PG) F2a injection and intracervical laminaria tents (group A, 50 women), 2) intramniotic PGF2a injection only (group B, 51 women) and 3) laminaria tents followed by intracervical PGF2a tablets insertion (group C, 27 women). The mean induction-abortion time (+/- SE) was 24.9 +/- 1.7 hours for group A, 28.2 +/- 2.2 hours for group B (p greater than 0.05) and 42.1 +/- 3.4 hours for group C, significantly longer than goup A and B (p less than 0.001 and p less than 0.01 respectively). In 48 hours 98% of the patients of group A, 90% of group B (p less than 0.05) and 59% of group C (p less than 0.001) completed the abortion procedure. Parous women of group A and B presented similar induction - abortion time, while in nulliparous the use of laminaria shortened the abortion procedure significantly (p less than 0.05). The complications rate was low. In conclusion, the intracervical PGF2a insertion is a simple but very slow abortion procedure with high failure rates. The intramniotic PGF2a injection is a successful method for late midtrimester medical pregnancy termination and the concurrent use of laminaria tents shortens the abortion procedure, particularly in nulliparous, reduces the number of prostaglandins' reinjections and increases the incidence of successful abortion within 48 hours.

PIP: 128 women underwent midtrimester induced abortion with the following: 1) a combined regimen of intraamniotic prostaglandin F2alpha (PGF2alpha) injection and intracervical laminaria tents (group A, 50 women); 2) intraamniotic PGF2alpha injection only (group B, 51 women); and 3) laminaria tents followed by intracervical PGF2alpha tablets insertion (group C, 27 women). The mean induction-abortion time (+or -SE) was 23.9 +or-1.7 hours for group A, 28.2 +or-2.2 hours for group B (p0.05), and 42.1 +or-3.4 hours for group C, which was significantly longer than groups A or B (p0.001 and p0.01). In 48 hours, 98% of the patients in group A, 90% of group (p0.05), and 59% of group C (p0.001) completed the abortion procedure. Parous women in groups A and B presented similar induction-abortion time, while among nulliparous women, the use of laminaria shortened the abortion procedure significantly (p0.05). The complications rate was low. In conclusion, the intracervical PGF2alpha insertion is a simple but very slow abortion procedure with high failure rates. The intraamniotic PGF2alpha injection is a successful method for late midtrimester medical pregnancy termination and the concurrent use of laminaria tents shortens the abortion procedure, particularly in nulliparous women, reduces the number of PG reinjections, and increases the incidence of successful abortion within 48 hours.

Clinical evaluation of a sensitive urine pregnancy test in the gynecological emergencies.

A rapid sensitive urine pregnancy test (SPT) using monoclonal antibody against human chorionic gonadotropin and a conventional urine pregnancy test (GPT) were performed in 364 women attending 'Gynecological Emergencies' for lower abdominal pain and/or vaginal bleeding, aiming at early detection of ectopic and intra-uterine pregnancy-related disorders. The overall incidence of a positive test was 24%. In 42 patients, with histopathological evidence of ectopic pregnancy, SPT was positive in 41 (98%), while GPT only in 19 (45%). In 47 patients with evidence of intra-uterine pregnancy-related disorders, SPT was positive in 45 (96%), while GPT in 33 (70%). The sensitive urine pregnancy test can improve significantly the efficiency of the early diagnosis of ectopic and intra-uterine pregnancy-related disorders, and can be used as a screening method for patients having even in the slightest way suspect of having an ectopic pregnancy.

Value of immunohistochemical demonstration of several epithelial markers in hyperplastic and neoplastic endometrium.

The distribution of prekeratin, vimentin, epithelial membrane antigen (EMA), and secretory component (SC) was demonstrated immunohistochemically in 31 patients with adenomatous hyperplasia (AH), 12 patients with atypical adenomatous hyperplasia (AAH), and 39 patients with endometrial carcinoma. Prekeratin was presented in 94% of AHs, 92% of AAHs, and 87% of adenocarcinomas. Vimentin was detected in 68% of AHs, 50% of AAHs, and 37% of adenocarcinomas, showing decreased expression as the lesion progressed to malignancy (P less than 0.05). EMA was detected in 26% of AHs, 67% of AAHs, and 95% of adenocarcinomas (P less than 0.001). SC demonstrated focal and weak expression in 29% of AHs, but showed increased staining intensity in 67% of adenocarcinomas (P less than 0.01). Well-differentiated tumors expressed SC better than poorly differentiated tumors (P less than 0.01). All markers showed a heterogeneous staining pattern and, for a given histologic hyperplastic or neoplastic state, corresponded to several phenotypes. In conclusion, prekeratin seems to be a good marker for epithelial differentiation in hyperplastic endometrium, and EMA is a good marker in neoplastic endometrium. In hyperplastic lesions, the loss of vimentin expression in the absence of secretory changes gives rise to suspicions regarding their benign process. Also, EMA can help in distinguishing between hyperplastic and neoplastic states, while detection of SC may be of help in more precise grading of endometrial carcinoma.