Rescue hCG to treat empty follicle syndrome after the use of a GnRH agonist as oocyte maturation trigger: First report on fresh embryo transfer and clinical pregnancy.

We present a case series and literature review on the use of rescue human chorionic gonadotropin (hCG) in cases of empty follicle syndrome (EFS) after a gonadotropin-releasing hormone agonist (GnRHa) trigger. EFS was diagnosed after failure to collect any oocytes from one ovary. In such cases, a single dose of hCG was administered and the oocyte retrieval was repeated 36 h later. The main outcome measures were the number of mature oocytes (M2) and embryos (2PN), incidence of hospitalisation for severe ovarian hyperstimulation syndrome (OHSS) and clinical pregnancy when fresh embryo transfers occurred. Our population consisted of 322 patients, who had a GnRH agonist as oocyte maturation trigger (2-mg subcutaneous buserelin). Six patients (1.8%) developed EFS after the use of a GnRHa trigger. Mature oocytes were retrieved in 5 patients after the use of rescue hCG. One patient developed severe OHSS. Two patients had a fresh embryo transfer and one clinical pregnancy was reported. This is the first case series to report fresh embryo transfers and a clinical pregnancy with the use of rescue hCG after failure of the GnRHa trigger.

Age-specific serum FSH concentrations and their correlation with the outcome of ovarian stimulation for IVF.

The aim of this study was to investigate whether age-specific FSH concentration can be a predictor of the outcome of ovarian stimulation in women undergoing IVF, with various basal FSH (bFSH) concentrations but within the normal range, i.e. < or = 9.5 lU/l. A total of 1373 women undergoing their first NF cycle over a 5-year period were included in this retrospective cohort study. Patients were grouped according to age, and within each age range, patients were grouped into bFSH quartiles. The primary outcome measure was oocyte yield, and secondary outcome measures included number of normally fertilized oocytes (2PN), number of embryos transferred and frozen, as well as implantation, biochemical, and clinical pregnancy rates. In all study groups (25-29; 30-34 and 35-39 years), women with low bFSH concentrations had significantly more oocytes retrieved (P = 0.003; P < 0.0001 and P = 0.0001 respectively), and more normally fertilized 2PN embryos (P = 0.03; P < 0.0001 and P = 0.001 respectively) than those of the same age with 'high' normal bFSH concentrations. Although there was no significant difference in the secondary outcome measures, these were generally more favourable in patients with 'low' age-specific bFSH concentrations. The findings of this study suggest that age-specific FSH testing can serve as a good predictor of the oocyte yield in women with normal bFSH concentrations undergoing IVF.

A prospective randomized controlled trial of Wallace and Rocket embryo transfer catheters.

The aim of this study was to compare the efficacy of two embryo transfer catheters: Wallace and Rocket Embryon in an IVF programme of a tertiary referral university centre. A total of 308 patients undergoing embryo transfer were prospectively randomized to either a transfer with the Wallace catheter or a transfer with the Rocket catheter. The main outcome measure in this study was the clinical pregnancy rate, and secondary outcome measures included implantation rate, visibility of the catheter under ultrasound, number of retained embryos post transfer, and whether change of catheter was required. In addition, patient discomfort during the procedure was recorded. Pregnancy and implantation rates were similar when Wallace or Rocket catheters were used. However, for the Rocket catheter, the tip was more often clearly seen on ultrasound and it had a lower rate of retained embryos in the catheter after transfer (P < 0.05). Experience with different transfer catheters is recommended for difficult cases.

Live birth following preimplantation genetic screening for trisomy 21. Should aneuploidy screening be offered to all older patients undergoing IVF?

A 42-year-old female patient with history of secondary infertility was referred to our assisted conception unit for in vitro fertilization (IVF). Before her referral, she had two cycles of IVF at another centre; the first was unsuccessful and, after conceiving at the second attempt, the pregnancy was terminated at 14 weeks' gestation following a positive nuchal translucency scan and a diagnosis of trisomy 21 (Down syndrome) by a chorionic villous biopsy performed in the first trimester. The screening tests for trisomy 21 were offered to the patient in view of her advanced age. Subsequent karyotyping revealed that both partners had a normal chromosomal complement. Following genetic counselling, the couple were offered IVF treatment along with preimplantation genetic screening for trisomy 21. Four of the five embryos were suitable for biopsy, and one blastomere from each embryo was analyzed using fluorescent in situ hybridization for chromosome 21. The analysis revealed that two embryos had trisomy 21, one had monosomy 21, and only one embryo was diploid for chromosome 21. The single diploid embryo was transferred to the uterus on day 3, and resulted in an uneventful pregnancy and delivery of a healthy live-born male.

The J-Tip Needle-Free Injection System in controlled ovarian hyperstimulation in in vitro fertilization: a pilot study.

OBJECTIVE: To evaluate the use of a novel needle-free system (J-Tip) in the administration of gonadotropins for controlled ovarian hyperstimulation (COH) in IVF. DESIGN: An open-label, single-center, pilot study. SETTING: Assisted conception unit of a university hospital. PATIENT(S): Twenty patients undergoing COH over a 3-month period. INTERVENTION(S): COH was carried out using a fixed dose of rFSH administered via the J-Tip System in a GnRH antagonist cycle. MAIN OUTCOME MEASURE(S): The primary endpoint was the mean number of oocytes collected per patient, and secondary endpoints were incidence of technically correct injections, clinical pregnancy, and cancellation rates. Patient diaries were kept throughout the study. RESULT(S): Sixteen patients completed the trial, four of whom became pregnant, with a high overall satisfaction rate. CONCLUSION(S): This is the first report of the use of the novel J-Tip Needle-Free Injection System for administration of gonadotropins in IVF with successful ovarian stimulation and achievement of pregnancies. This report indicates that this technique is associated with minimal pain and high patient acceptability. Large-scale multicenter studies are required to examine the reproducibility of these results and the J-Tip's cost-effectiveness as well as to compare the J-tip System with conventional needle-wise administration for COH before its introduction into routine IVF practice.

Laparoscopic subtotal hysterectomy using the plasma kinetic and lap loop systems: an alternative approach in the surgical management of women with uterine fibroids.

OBJECTIVE: To evaluate the safety and applicability of laparoscopic subtotal hysterectomy (LSH) using the plasma kinetic (PK) and lap loop systems as an alternative surgical approach in the management of uterine fibroids in women who have completed their families. STUDY DESIGN: Sixty-two consecutive LSH were performed during this prospective study from March 2003 to March 2005 at Princess Royal University Hospital, Kent, UK. RESULTS: All study patients had menorrhagia resistant to at least one form of therapy, with a mean duration of symptoms of 3.5 years. In addition, four patients had previous myomectomy. The mean number of fibroids removed was 2.7. The mean weight of the uterus was 141.9 g. The mean operative time was 46.8 min, and the mean blood loss was 126.6 mL. The overall perioperative complication rate was 4.8% with no visceral injury, or return to theatre. At follow-up, all patients were satisfied with surgery. CONCLUSION: The study describes the first application of the PK and Lap Loop systems in LSH for the surgical management of uterine fibroids in women in whom fertility is not an issue, and its findings suggest that this minimally invasive technique is a safe, and valid alternative. Larger adequately-powered studies are however still required.

A dedicated ectopic pregnancy team leads to an improvement in patients' management.

INTRODUCTION: The aim of the study is to determine whether a dedicated ectopic pregnancy team improves the management of haemodynamically stable patients with suspected ectopic pregnancy who do not require immediate life-saving surgery. METHODS: A non-randomized population based study involving 210 patients admitted with a suspected ectopic pregnancy over a 2-year period in a university teaching hospital in the UK, was carried out to compare the management of those women before and after the introduction of the ectopic pregnancy team. RESULTS: Following the introduction of an ectopic pregnancy team, there were fewer laparotomies performed, fewer negative diagnostic laparoscopies, a reduced overall surgical intervention rate, and a reduced duration of hospital stay. Although, it was difficult to quantify the extent of improvement of training, yet there were fewer operations performed out-of-hours, more continuity of care, more learning opportunities and acquisition of laparoscopic skills of junior staff. CONCLUSIONS: The introduction of an ectopic pregnancy team led to an improvement in the management of patients with suspected ectopic pregnancies. Efforts aiming at setting up such a specialized team and its implementation in day-to-day clinical practice should be considered in hospitals where the mainstay of treatment remains laparotomy.

Maternal C-reactive protein levels in patients undergoing frozen embryo replacement cycles: a prospective study.

This prospective study shows that the early pregnancy inflammatory response following frozen embryo replacement (FER) cycles may be absent or suppressed, in contrast to that following IVF. To our knowledge, this is the first study to evaluate the maternal inflammatory response following FER cycles, but larger studies are still required to explore this novel finding, and investigate whether this may explain the lower ongoing pregnancy rates generally achieved following FER cycles.

Thrombocythemia and hemoperitoneum after transvaginal oocyte retrieval for in vitro fertilization.

OBJECTIVE: To present the first report of massive hemoperitoneum in a case of essential thrombocythemia after transvaginal oocyte retrieval for IVF and review the relevant literature related to the management of patients with this condition. DESIGN: Case report. SETTING: Assisted conception unit of a tertiary care university hospital in the United Kingdom. PATIENT(S): A 37-year-old woman with essential thrombocythemia who developed massive intra-abdominal bleeding after transvaginal oocyte retrieval for IVF. INTERVENTION(S): Emergency laparotomy and right salpingoophorectomy. RESULT(S): Resuscitation of the patient. MAIN OUTCOME MEASURE(S): Overall management of the patient is discussed. CONCLUSION(S): The management of patients with essential thrombocythemia at the childbearing period poses a difficult problem. Fertility may be reduced, and an adverse outcome of pregnancy due to thrombotic or bleeding complications is a matter of concern. A multidisciplinary approach with close and early cooperation with the hematologists before initiation of IVF therapy for patients with essential thrombocythemia is essential. Efforts should be made to reduce the platelet count and assess the platelet function before embarking on IVF, keeping in mind the double jeopardy from bleeding and thrombosis in these cases.

A review of complications following transvaginal oocyte retrieval for in-vitro fertilization.

Transvaginal ultrasound guided oocyte retrieval (TVOR) during in vitro fertilization (IVF) treatment was first described in 1985. By virtue of its simplicity and effectiveness, it has gained widespread popularity and has now become the gold standard for IVF therapy. Nevertheless, despite the advantages, the aspiration needle may injure the adjacent pelvic organs and structures leading to serious complications. The most common complications are haemorrhage, trauma and injury of pelvic structures, and pelvic infection. Other complications described include adnexal torsion, rupture of endometriotic cysts, anaesthetic, and even vertebral osteomyelitis. In the last two decades, several reports have described the complications associated with this technique, and tried to address the risk factors and safety issues. However there is wide variation in the way this common procedure is performed, with room for improvement through published guidelines. This article reviews the most common complications reported in literature, summarizes the recommendations made to minimize their occurrence, and raises some of the controversial issues related to the procedure especially that of pelvic infection.