Luteal phase empirical low molecular weight heparin administration in patients with failed ICSI embryo transfer cycles: a randomized open-labeled pilot trial.

BACKGROUND: The pathology underlying recurrent implantation failures (RIF) is not clear and treatment options proposed are generally not evidence based. Although the effect of heparin on trophoblast biology has not been studied extensively, given the available data suggesting a possible beneficial effect of heparin on embryo implantation, we decided to undertake this pilot study. METHODS: One hundred and fifty women with > or =2 failed assisted reproduction treatment cycles were included in this randomized open-label pilot trial. Participants underwent controlled ovarian stimulation with the long protocol and were randomly allocated to receive 1 mg/kg/day low molecular weight heparin (LMWH) or no treatment in addition to routine luteal phase support (LPS) on the day after oocyte retrieval. LPS and LMWH was continued up to the 12th gestational week in pregnant participants. RESULTS: There were 26 (34.7%) live births in the LMWH group, and 20 (26.7%) in the control group (absolute difference 8.0%, 95% CI -4.2 to 24.9%, P = 0.29). There were 34 (45.3%) and 29 (38.7%) clinical pregnancies in the LMWH and control groups, respectively (absolute difference 6.6%, 95% CI -9.0 to 21.8%, P = 0.41). Implantation rates were 24.5 and 19.8% in the LMWH and control groups, respectively (absolute difference 4.7%, 95% CI -4.7 to 14.1%, P = 0.33). CONCLUSION: Despite lack of statistical significance, observed relative increase by 30% in live birth rates with LMWH may be regarded as a clinically significant trend necessitating further research on the use of empirical LMWH in women with RIF and possibly in all women undergoing assisted reproduction treatment. Failure to demonstrate statistical significance of the observed treatment difference may be due to limited sample size of this pilot study.

Severe cytoplasmic abnormalities of the oocyte decrease cryosurvival and subsequent embryonic development of cryopreserved embryos.

BACKGROUND: Abnormalities of oocyte morphology affect embryo quality and viability. Whether morphological abnormalities of the oocyte influence cryosurvival and further development of derived embryos is not known. The aim of this study was to compare cryosurvival and progression to the blastocyst stage of frozen-thawed embryos derived from normal and abnormal oocytes. METHODS: A total of 5292 Grade 1 and 2 embryos from 964 women were frozen, thawed and subsequently cultured up to the blastocyst stage. The study was performed on excess embryos from patients who did not opt for cryopreservation. Cryosurvival, progression to the blastocyst stage and hatching were correlated with morphological characteristics of the oocytes that embryos were derived from. RESULTS: Presence of a cytoplasmic abnormality of the oocyte significantly decreased cryosurvival. This detrimental effect was more pronounced in embryos derived from oocytes with vacuolar cytoplasm or with central granulation. Furthermore, these embryos did not have the potential to develop into good quality blastocysts or reach the hatching stage. On the other hand, presence of a single extracytoplasmic abnormality of the oocyte did not affect cryosurvival and the potential to develop into good quality blastocysts. Grade 2 embryos derived from oocytes with irregular shape or a large perivitelline space had decreased cryosurvival. However when these embryos survived cryopreservation, their potential to develop good quality blastocysts or to reach hatching stage was unaffected. CONCLUSIONS: Embryos derived from oocytes with vacuolar cytoplasm or central granulation do not seem to bear the potential to develop good quality blastocysts or to reach hatching stage after cryopreservation. The presence of extracytoplasmic abnormalities alone does not affect blastocyst development despite decreasing cryosurvival.

GnRH agonist protocol administration in the luteal phase in ICSI-ET cycles stimulated with the long GnRH agonist protocol: a randomized, controlled double blind study.

BACKGROUND: GnRH agonist administration in the luteal phase was reported to beneficially affect the clinical outcome of intracytoplasmic sperm injection (ICSI) and embryo transfer (ET) cycles. This double blind, randomized, placebo controlled trial evaluates whether a single dose GnRH agonist administered 6 days after ICSI increases ongoing pregnancy rates following ET in cycles stimulated with the long GnRH agonist protocol. METHODS: Five hundred and seventy women undergoing ET following controlled ovarian stimulation with a long GnRH agonist protocol were included. In addition to routine luteal phase support with progesterone, women were randomized to receive a single 0.1 mg dose of triptorelin or placebo 6 days after ICSI. Randomization was done on the day of ET according to a computer generated randomization table. Ongoing pregnancy rate beyond 20th week of gestation was the primary outcome measure. The trial was powered to detect a 12% absolute increase from an assumed 38% ongoing pregnancy rate in the placebo group, with an alpha error level of 0.05 and a beta error level of 0.2. RESULTS: There were 89 (31.2%) ongoing pregnancies in the GnRH agonist group, and 84 (29.5%) in the control group (absolute difference +1.7%, 95% confidence interval -5.8% to +9.2%). Implantation, clinical pregnancy and multiple pregnancy rates were likewise similar in the GnRH agonist and placebo groups. CONCLUSIONS: Single 0.1 mg triptorelin administration 6 days after ICSI following ovarian stimulation with the long GnRH agonist protocol does not seem to result in an increase >or=12% in ongoing pregnancy rates.

A comparative study of three techniques for the analysis of sperm recovery: touch-print cytology, wet preparation, and testicular histopathology.

PURPOSE: The aim of this study is to evaluate the efficacy of simultaneous testicular touch-print cytology, testicular histopathology, and wet preparation in nonobstructive azoospermic (NOA) males. METHODS: Three hundred and sixty-three males with NOA underwent a multiple testicular sampling prior to ICSI for histopathologic evaluation, diagnostic testicular sperm extraction, and simultaneous touch-print cytology to evaluate sperm presence or absence. A total of 979 testicular samples were taken. RESULTS: Sperm recovery was achieved in 106 cases (29.2%). Patients with hypospermatogenesis and focal spermatogenesis needed 2.8 and 5.9 biopsies, respectively, to retrieve spermatozoa, while in patients with germ cell aplasia and maturation arrest, even after eight to nine samples no spermatozoa were recovered. Neither the FSH levels nor the testicular volume was found to be significant in the prediction of sperm recovery. If only a single testis was to be biopsied, 25% of the cases with sperm recovery would have been missed. The combination of touch-print cytology with histopathology and wet preparation increased the accuracy of spermatozoa identification. CONCLUSION: Touch-print cytology was found to be more predictive than wet preparation in the diagnosis of spermatogenesis; moreover, it was found to be a quick and easy technique providing an accurate diagnosis in prediction of sperm recovery.

Three blastocyst stage embryo transfer resulting in a quintuplet pregnancy.

High-order pregnancies are associated with high morbidity and mortality and the incidence is increased as a drastic complication of assisted reproductive technology. This case presents a high-order pregnancy achieved by transfer of three blastocyst stage embryos resulting in a quintuplet pregnancy including a monochorionic triplet. Following the selective termination of the monochorionic triplet, two healthy children were born. The mechanism of monochorionic development and its association with assisted reproductive technology are discussed.

Relationship between granular cytoplasm of oocytes and pregnancy outcome following intracytoplasmic sperm injection.

Couples undergoing intracytoplasmic sperm injection (ICSI) for male infertility using oocytes with centrally located granular cytoplasm (CLCG) were evaluated for fertilization, embryo development, implantation and pregnancy rate. CLCG is a rare morphological feature of the oocyte, that is diagnosed as a larger, dark, spongy granular area in the cytoplasm. Severity is based on both the diameter of granular area and the depth of the lesion. Twenty-seven couples with 39 cycles presenting CLCG in >50% of retrieved oocytes were evaluated. A total of 489 oocytes was retrieved, out of which 392 were at MII. CLCG was observed in 258 of the MII oocytes (65. 8%); 66.7% of these oocytes had slight and 33.3% had severe CLCG. The overall fertilization rate was 72.2% and no statistical significant difference was found between normal and CLCG oocytes and between the oocytes representing slight and severe CLCG. The development and quality of embryos was the same in normal and CLCG oocytes. In nine cycles, preimplantation genetic diagnosis was executed to evaluate a possible accompanying chromosomal abnormality. Out of 44 blastomeres biopsied, 23 had chromosomal abnormality (52. 3%). Eleven pregnancies were achieved in 39 cycles (28.2%), six pregnancies resulted in abortion (54.5%). The implantation rate was found to be 4.2%. Only five ongoing pregnancies were achieved in 39 cycles (12.8%). Couples with CLCG oocytes should be informed about poor on-going pregnancy rates even if fertilization, embryo quality and total pregnancy rates are normal. Furthermore, a high aneuploidy rate may be linked to a high abortion rate.

Reduction of adhesion formation with cross-linked hyaluronic acid after peritoneal surgery in rats.

OBJECTIVE: To examine the effectiveness of a cross-linked hyaluronan solution (auto-cross-linked polysaccharide [ACP] gel) for the prevention of postsurgical adhesions. DESIGN: A randomized blinded study using a rat model of laparotomy. SETTING: Surgical Research Laboratory in a university medical school. ANIMAL(S): Sixty-seven sexually mature rats. INTERVENTION(S): Standardized surgical trauma was induced in the rat uterine horn to induce adhesion formation. After trauma, group-1 animals (n = 23) received no treatment, group 2 (n = 21) received noncross-linked hyaluronic acid (HA), and group 3 (n = 23) received cross-linked HA applied on the lesion. MAIN OUTCOME MEASURE(S): Six weeks after laparotomy, repeat laparotomy was performed and the adhesions were scored according to Blauer's scoring system. RESULT(S): Overall, 84% of the untreated animals and 65% of the animals treated with noncross-linked HA presented with severe adhesions. The mean (+/-SEM) increase in the adhesion score was 2.46+/-0.23 in the untreated group, 2.23+/-0.29 in the group receiving noncross-linked HA, and 1.27+/-0.12 in the ACP gel group. CONCLUSION(S): ACP gel holds promise as a novel resorbable biomaterial for the reduction of postoperative adhesions after laparotomy.

Evaluation of intrauterine abnormalities in infertile patients by sonohysterography.

The purpose of this study was to assess the usefulness of sonohysterography in the detection of abnormalities of the uterine cavity in infertile patients, compared with other diagnostic methods. Transvaginal ultrasonography, sonohysterography, hysterosalpingography and finally hysteroscopy were performed in 37 patients with primary and 25 patients with secondary infertility. Suspected uterine anomalies were also confirmed by laparoscopy. Transvaginal ultrasonography and hysterosalpingography were able to detect 36.3 and 72.7% of uterine pathologies respectively. Sonohysterography was able to detect all the anomalies except for a single endometrial polyp (90.3%). However, there was no significant difference between the diagnostic capabilities of these methods. We recommend the use of sonohysterography as an easy, cheap and noninvasive method for the diagnosis of intrauterine pathologies in infertile patients.

The effect of uterine volume on uterine artery Doppler velocimetry in the myomatous state.

This study aimed at testing the hypothesis that lower uterine arterial (UA) Doppler indices are caused by increased uterine volume rather than the presence of myoma. Uterine volumes were calculated and uterine and/or myomal arterial pulsatility index (PI) and resistance index (RI) were obtained by transvaginal color Doppler ultrasonography. The mean uterine volume in the myomatous group (276.2 cm3; range 65-928 cm3, n = 100) was significantly greater than that of the control group (101.4 cm3; range 36-171 cm3; n = 60; p = 0.00). The mean UA PI and RI values in the study group were significantly lower than their corresponding values in the control group (0.77 +/- 0.08 and 1.69 +/- 0.47 vs. 0.82 +/- 0.06 and 1.97 +/- 0.49, respectively, p = 0.01). When the myomatous uterine volumes of the study group were categorized into two subgroups (< 200 and > or = 200 cm2) the UA PI and RI values were lower in the latter group (p = 0.006 and p = 0.015, respectively). However, after analysis of receiver-operator-characteristic curves, none of the UA Doppler indices could differentiate the myomatous uterus from the normal uterus.

Hemodynamic assessment in pelvic inflammatory disease by transvaginal color Doppler ultrasonography.

One of the major signs of inflammation is a change in vascular flow and caliber. It is possible to detect these changes with the help of transvaginal color Doppler velocitometry. The purpose of this study was to evaluate the changes in pelvic circulation in cases with pelvic infection and to correlate these findings with other infectious parameters. The study group consisted of 20 cases who had the diagnosis of pelvic inflammatory disease (PID). Resistance index (RI) and pulsatility index (PI) were measured with transvaginal color Doppler ultrasonography in the uterine and ovarian arteries as well as at the tubouterine junction three times in a one-month period. At the same time the body temperature, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and leukocyte counts were recorded. Infectious parameters declined to normal values, following a pattern parallel to clinical improvement from the first until day 30. Infectious parameters revealed significant differences between days 1-7, 1-30 and 7-30. On the other hand, low resistance in all three measurement points exhibited a rapid increase on the day 7 day and plateaued until the day 30 day. Color Doppler velocitometry measurements revealed significant differences between days 1-7 and 1-30 but not between days 7-30. These findings demonstrate that as the infection subsides, the changes in vascular flow return to normal before infectious parameters do. In conclusion, it is possible to detect decreased vascular resistance in acute infection with the help of transvaginal color Doppler ultrasonography. Furthermore, color Doppler ultrasonography can accurately detect regression of the infectious process before body temperature and acute phase reactants do.

Prediction of perinatal outcome by middle cerebral artery Doppler velocimetry.

The relationship between pulsatility index (PI) in the middle cerebral artery (MCA) and adverse perinatal outcome was studied in 162 normal and 75 high-risk pregnancies. The intrapartum cardiotocographic (CTG) findings, the mode of delivery, 1 and 5-minute Apgar scores, the pH level of the umbilical artery, admission to the neonatal intensive care unit (NICU) and the incidence of intrauterine fetal growth retardation were recorded. In the low risk group, the PI values in the MCA were only affected in growth retarded fetuses (P = 0.0084). In the high-risk group, there was an association between the MCA PI values and 5-minute Apgar scores (P = 0.0397), umbilical artery pH values (P = 0.0068) and development of IUGR (P = 0.0376). In both groups, an abnormal intrapartum CTG, the 1-minute Apgar score, cesarean section for fetal distress and admission to the NICU were not related to PI values in the MCA. Our present study suggests that Doppler flow measurement of MCA provides useful information about perinatal outcome, especially in the high-risk pregnancies.