Lower chance of pregnancy with repeated cycles with in vitro fertilization.

OBJECTIVE: To evaluate pregnancy outcomes in initial and replicate IVF cycles. STUDY DESIGN: A retrospective analysis of 2,167 fresh, nondonor IVF cycles performed in a large private practice from January 1, 2005, to March 1, 2006. Standard controlled ovarian hyperstimulation and laboratory protocols were followed. RESULTS: Patients undergoing multiple treatment cycles were significantly older. There was no difference in body mass index or percentage of cancelled cycles with increasing number of IVF attempts. The number of retrieved, mature and fertilized oocytes progressively declined as the number of treatment cycles increased. The number of embryos transferred increased with increasing number of treatment cycles. Implantation, pregnancy and clinical pregnancy rates decreased significantly with the second treatment cycle and more markedly with 3-5 treatment cycles. CONCLUSION: The likelihood of a successful outcome declined with each additional treatment cycle. The most notable decrease in clinical pregnancy rates occurred after the third cycle. Patients who fail to conceive after 3 cycles of IVF should be counseled to begin considering other options.

Therapeutic amenorrhea in patients at risk for thrombocytopenia.

To examine the need for and evaluate the method of menses suppression in women at risk for thrombocytopenia. A systematic review of the published literature in MEDLINE using the search terms thrombocytopenia, menorrhagia, therapeutic amenorrhea, progestin intrauterine device, combination oral contraceptive--extended and cyclic, gonadotropin releasing hormone agonist, danazol, and progestins. There are an increased number of reproductive age women at risk for thrombocytopenia who would benefit from menses suppression. A number of effective medical regimens are available. In patients who fail medical therapy, endometrial ablation appears to be effective in women with thrombocytopenia. As a result of the increased number of women at risk for thrombocytopenia, there is a need for therapeutic amenorrhea. The type of regimen selected depends upon the patients need for contraception and the ability to tolerate estrogen-containing medications. For women who fail medical therapy, there are surgical options, which are associated with less morbidity than hysterectomy.

Adding human menopausal gonadotrophin to antagonist protocols - is there a benefit?

The objective of this retrospective analysis was to compare the clinical outcomes of recombinant FSH (r-FSH) with combination r-FSH plus human menopausal gonadotrophin (HMG) protocols in a large private practice using a single IVF laboratory, from 2001 to 2003. Patients underwent ovarian stimulation by standard gonadotrophin-releasing hormone (GnRH) antagonist protocol using r-FSH or combination r-FSH plus HMG. When two or more follicles had attained a minimum mean diameter of 20 mm, follicular triggering was achieved with either recombinant HCG (r-HCG; Ovidrel, 250 microg s.c.) or urinary HCG (u-HCG; 10,000 IU i.m.). The main outcome measures were number of oocytes retrieved and clinical pregnancy rate. There was a lower percentage of cancelled cycles and an increased number of oocytes retrieved, mature oocytes, oocytes that fertilized, embryo that cleaved and a tendency towards higher clinical pregnancy rates in patients treated with r-FSH alone compared with those treated with r-FSH plus HMG. Patients treated with r-FSH plus HMG had lower miscarriage rates and the live birth rate was similar in both treatment groups. In conclusion, irrespective of age, using a treatment regimen consisting of a combination of HMG plus r-FSH was not beneficial compared with r-FSH alone in patients using a GnRH antagonist protocol.