Ovarian morphology and serum hormone markers as predictors of ovarian follicle recruitment by gonadotropins for in vitro fertilization.

Twenty-five normal ovulatory women underwent three-dimensional transvaginal ultrasonography and blood sampling before and after oral glucose tolerance testing to compare ovarian morphology and circulating hormone levels in the early follicular phase as predictors of the number of oocytes retrieved after gonadotropin stimulation for in vitro fertilization. Serum levels of gonadotropins, inhibins, testosterone, dehydroepiandrosterone sulfate, and estradiol as well as summed ovarian volume were unrelated to oocyte number. Antral follicle number and serum androstenedione level, however, positively correlated, whereas postoral glucose tolerance test (post-OGTT) insulin release negatively correlated, with total and mature oocyte numbers. Adjusting for age and body mass index by regression analysis, the serum androstenedione level significantly predicted mature, but not total, oocyte number. The relationships of antral follicle number and post-OGTT insulin release to total oocyte number were additive; each was significant after controlling for the other. In contrast, antral follicle number significantly correlated with mature oocyte number after controlling for post-OGTT insulin release, whereas post-OGTT insulin release was unrelated to mature oocyte number after controlling for antral follicle number. Therefore, early follicular phase antral follicle number positively correlates with total and mature oocyte numbers after gonadotropin stimulation for in vitro fertilization and is linked to androgen and insulin actions in predicting ovarian follicle recruitment by gonadotropins.

Interstitial heterotopic pregnancy in a woman conceiving by in vitro fertilization after bilateral salpingectomy.

Heterotopic pregnancy, defined as the coexistence of an intrauterine pregnancy and an ectopic pregnancy, occurs in approximately 1 in 100 pregnancies conceived by in vitro fertilization (IVF), particularly when multiple embryos are transferred into the uterus. The ectopic gestation of the combined pregnancy usually occurs within the ampulla of the fallopian tube. If it implants within the interstitial portion of the fallopian tube, however, the resulting interstitial pregnancy eventually can rupture through the uterus, leading to sudden, severe hemorrhage and maternal death. This article describes the rupture of an interstitial heterotopic pregnancy in a 37-year-old woman conceiving by IVF after bilateral salpingectomy. The interstitial pregnancy was removed by laparotomy to protect the intrauterine pregnancy from damage. Physicians should consider interstitial ectopic pregnancy as a cause of abdominal pain, even when a viable pregnancy occurs by IVF after salpingectomy.

Synergistic effects of insulin-like growth factor-I and human chorionic gonadotropin in the rat ovary.

Insulin and low doses of lutenizing hormone (LH) activity (human chorionic gonadotropin [hCG]) act synergistically in the rat to produce anovulation, large ovarian cysts, and elevated plasma androstenedione levels. Further, both insulin and insulin-like growth factor-I (IGF-I) affect the ability of gonadotropins to enhance both ovarian theca and granulosa cell function in vitro. The present series of experiments were performed to determine if recombinant human IGF-I (rhIGF-I) can act in a manner similar to insulin when combined with subovulatory doses of hCG in adult normally cycling rats. Fifty-four female Sprague-Dawley rats were randomly assigned to the following treatment groups at the age of 64 days: (A) vehicle alone (controls, phosphate-buffered saline containing 0.09% pig gelatin), (B) twice-daily subcutaneous injections of 0.5 to 3.0 U insulin, (C) twice-daily subcutaneous injections of 1.5 U hCG, (D) both insulin and hCG, (E) twice-daily subcutaneous injections of rhIGF-I (2.5 mg/kg/d), and (F) both hCG and rhIGF-I. After 22 days of treatment, the animals were killed on day 23, trunk blood was collected, and the ovaries were excised for histological study. Eight of 9 control rats and 5 or 6 of 9 rats treated with insulin, hCG, or rhIGF-I alone displayed normal estrus cycles throughout the in vivo treatment period as assessed by daily vaginal smears. In marked contrast, only 1 animal treated with hCG + insulin and 2 animals treated with hCG + rhIGF-I continued to display vaginal smears indicative of normal cycling. Multiple large ovarian follicular cysts were found only in these latter 2 groups (3 of 9 animals in each group). Mean serum testosterone levels were significantly elevated in animals receiving insulin + hCG (0.72 +/- 0.28 v 0.17 +/- 0.03 ng/mL in controls, P = .05). Mean serum androstenedione levels were significantly elevated in animals receiving hCG and animals receiving rhIGF-I + hCG (5.57 +/- 0.99 and 2.39 +/- 0.68 ng/mL, respectively, v0.14 +/- 0.14 ng/mL in controls, P< .01 and P< .05, respectively). We conclude that rhIGF-I and insulin act synergistically with subovulatory doses of hCG to disrupt normal reproductive cycling, elevate serum androgen concentrations, and induce large ovarian cysts in intact adult rats.

Delay of gonadotropin stimulation in patients receiving gonadotropin-releasing hormone agonist (GnRH-a) therapy permits increased clinic efficiency and may enhance in vitro fertilization (IVF) pregnancy rates.

OBJECTIVE: To promote an even temporal distribution of patients starting IVF cycles at our center, patients undergoing GnRH agonist (GnRH-a) suppression frequently delay the start of gonadotropin stimulation. Our objective was to analyze the effect that the delay of initiation of gonadotropin stimulation has on outcome parameters in this population. DESIGN: Retrospective analysis. SETTING: A tertiary referral reproductive medicine unit. PATIENT(S): Patients undergoing IVF cycles on long GnRH-a protocols. INTERVENTION(S): Patients were treated with either a "standard-dose" or "low-dose" leuprolide acetate protocol initiated in the mid-luteal phase. MAIN OUTCOME MEASURE(S): Delay time, clinical pregnancy rate, ongoing pregnancy rate, cancellation rate. RESULT(S): Analysis of the overall group revealed associations between stimulation delay and decreases in stimulation duration and the number of gonadotropin ampules administered. Weighted linear regression analyzes revealed statistically positive relationships between delay time and both clinical pregnancy rates and ongoing pregnancy rates, despite a positive relationship between delay time and cancellation rates. Analysis of the standard-dose and low-dose subgroups revealed that the enhancement of pregnancy rates was attributable primarily to patients in the standard-dose protocol. CONCLUSION(S): Delay of gonadotropin stimulation while patients are receiving GnRH-a therapy allows for increased clinic efficiency. There appears to be an enhancement of clinical and ongoing pregnancy rates for the standard-dose leuprolide acetate protocol that is associated with stimulation delay.

Embryo cryopreservation at the pronuclear stage and efficient embryo use optimizes the chance for a liveborn infant from a single oocyte retrieval.

OBJECTIVE: To estimate the potential for a liveborn in our program achieved through either fresh or frozen embryos derived from a single oocyte retrieval. DESIGN: Retrospective analysis. SETTING: A tertiary referral reproductive medicine unit. PATIENT(S): All consecutive patients undergoing oocyte retrieval from January 1, 1996, to June 30, 1997. INTERVENTION(S): All couples undergoing IVF-ET at our center are counseled about a specific embryo transfer number after oocyte retrieval based on demographic and historical factors. Only this specified number of embryos is retained in culture. All normally fertilized (2PN) oocytes exceeding this number are immediately cryopreserved at the pronuclear stage. For couples who do not conceive after fresh embryo transfers, frozen embryo transfers are subsequently performed by usually thawing only the number of embryos intended for transfer, thereby conserving remaining embryos for further potential frozen embryo cycles. MAIN OUTCOME MEASURE(S): Liveborn delivery per oocyte retrieval.39.0 years were 61.2%, 59.7%, and 18.5%, respectively. CONCLUSION(S): For women <39 years of age, the efficient use of embryo cryopreservation at the pronuclear stage and economical embryo utilization policies results in cumulative chances for a liveborn exceeding 60%.

Crinone 8% vaginal progesterone gel results in lower embryonic implantation efficiency after in vitro fertilization-embryo transfer.

OBJECTIVE: To evaluate the outcome of IVF-ET after the use of Crinone 8% (Wyeth-Ayerst Laboratories, Inc., Philadelphia, PA) vaginal progesterone gel and to compare these results with those seen in our program with the use of IM progesterone-in-oil. DESIGN: Retrospective cohort study. SETTING: A tertiary referral reproductive medicine unit. PATIENT(S): Patients <40 years of age undergoing IVF-ET cycles. INTERVENTION(S): Patients were treated with either Crinone 8% vaginal progesterone gel (90 mg) administered daily or IM progesterone-in-oil (50 mg) administered daily. MAIN OUTCOME MEASURE(S): Biochemical pregnancy rate, implantation rate, and clinical and ongoing pregnancy rates. RESULT(S): The use of Crinone 8% vaginal progesterone gel was associated with a lower implantation rate (16.6% versus 26.2%; odds ratio [OR] = 0.56; 95% confidence interval [CI], 0.35-0.89) compared with the use of IM progesterone-in-oil. Biochemical pregnancies were more common after the use of Crinone 8% vaginal progesterone gel as defined by either biochemical pregnancies per transfer (15.9% versus 5.7%; OR = 3.11; 95% CI, 1.17-8.32) or biochemical pregnancies as a proportion of positive serum hCG titers (29.2% versus 9.8%; OR = 3.80; 95% CI, 1.33-10.86). Clinical pregnancy rates also were lower with the use of Crinone 8% vaginal progesterone gel (36.4% versus 52.9%; OR = 0.51; 95% CI, 0.26-0.99). CONCLUSION(S): Implantation efficiency is reduced, as demonstrated by lower embryonic implantation rates and higher biochemical pregnancy rates, when Crinone 8% vaginal progesterone gel rather than IM progesterone-in-oil is used for luteal phase support after IVF-ET.

Pronuclear stage cryopreservation after intracytoplasmic sperm injection and conventional IVF: implications for timing of the freeze.

OBJECTIVE: To compare clinical outcomes of frozen embryo transfers using cryopreserved pronuclear stage oocytes that had undergone either intracytoplasmic sperm injection (ICSI) or conventional IVF. DESIGN: Observational. SETTING: A tertiary referral reproductive medicine unit. PATIENT(S): Couples undergoing either ICSI or conventional IVF from January 1, 1995 to December 31, 1997. INTERVENTION(S): Patients underwent a standard controlled ovarian hyperstimulation protocol and transvaginal ultrasound-guided oocyte retrieval. All normally fertilized (2PN) oocytes exceeding a specified embryo number designated for fresh transfer were immediately cryopreserved at the pronuclear stage. Our cryopreservation method included timing of the freeze according to pronuclear morphology. Subsequent frozen embryo thaw-transfer cycles were usually performed by thawing only the intended number of embryos for transfer. MAIN OUTCOME MEASURE(S): Thaw survival rate, implantation rate, clinical pregnancy rate, delivery rate. RESULT(S): Ninety-six thaw-transfer cycles (n = 72) and 93 thaw-transfer cycles (n = 67) were undertaken in patients who had previously undergone conventional IVF or ICSI, respectively. Embryo thaw survival rates (IVF, 90.4%; ICSI, 91.1%) were similar. Clinical pregnancy (IVF, 40.6%; ICSI, 44.1%) and delivery (IVF, 36.4%; ICSI, 39.8%) rates per transfer, as well as implantation (IVF, 19.1%; ICSI, 19.9%) rates, were also similar. There were only four clinical pregnancy losses in both groups. CONCLUSION(S): Embryo thaw survival is similar for cryopreserved pronuclear stage oocytes derived from ICSI and conventional IVF. Clinical pregnancy, implantation and delivery rates were also similar for the two groups. In addition, there was no increase in the rate of pregnancy loss in ICSI patients after frozen embryo transfers.

Blood on the embryo transfer catheter is associated with decreased rates of embryo implantation and clinical pregnancy with the use of in vitro fertilization-embryo transfer.

OBJECTIVE: To examine the relation between blood found on the transfer catheter after ET and the rates of embryo implantation and clinical pregnancy with the use of IVF-ET. DESIGN: Retrospective cohort study. SETTING: A tertiary care center for assisted reproductive technology. PATIENT(S): Three hundred seven couples who underwent 354 ETs between January 1, 1994, and June 30, 1996. INTERVENTION(S): A semiquantitative system for recording the amount of blood found inside and outside the transfer catheter after ET. MAIN OUTCOME MEASURE(S): Embryo implantation rate and clinical pregnancy rate (PR). RESULT(S): Blood found outside the transfer catheter after ET was associated with decreased rates of embryo implantation and clinical pregnancy. In contrast, blood located inside the transfer catheter after ET, the type of catheter used for ET, the number of transfer attempts, and the time required for ET did not significantly affect either the embryo implantation rate or the clinical PR. CONCLUSION(S): Blood found outside, but not inside, the transfer catheter after ET is associated with lower rates of embryo implantation and clinical pregnancy with the use of IVF-ET. An emphasis on atraumatic transfer techniques, with prevention of bleeding at the time of ET, should contribute to improved pregnancy outcome with the use of IVF-ET.

Human preembryo development on autologous endometrial coculture versus conventional medium.

OBJECTIVE: To evaluate the effect of autologous endometrial coculture versus conventional medium on preembryo development. DESIGN: Controlled systematic clinical study. SETTING: University-based IVF center. PATIENT(S): Women with a history of failed IVF-ET with poor preembryo quality. INTERVENTION(S): Patients underwent a luteal phase endometrial biopsy. The tissue then was digested enzymatically, and the stromal and glandular cells were separated by differential sedimentation rates. These cells were cultured to confluence, released, and then cryopreserved until the patient's IVF-ET cycle. All normally fertilized oocytes then were allocated systematically to growth on autologous endometrial coculture or conventional medium until transfer on day 3. MAIN OUTCOME MEASURE(S): Preembryo blastomere numbers and cytoplasmic fragmentation rates were measured. RESULT(S): Forty-two women underwent 44 cycles of IVF-ET. In the morning on day 3, the mean (+/-SD) number of blastomeres and cytoplasmic fragments per preembryo on coculture compared with conventional medium was 5.9+/-1.5 versus 5.5+/-1.4 and 21%+/-13% versus 24%+/-11. At transfer the mean (+/-SD) number of blastomeres per preembryo on coculture was 7.4+/-1.3 versus 6.7+/-1.9 on conventional medium. CONCLUSION(S): There was a significant improvement in the mean (+/-SD) number of blastomeres per preembryo and decrease in the fragmentation rate for preembryos on autologous endometrial coculture compared with noncocultured preembryos from the same patient.

Anonymous oocyte donation performed exclusively with embryos cryopreserved at the pronuclear stage.

OBJECTIVE: To evaluate the clinical outcomes of patients who participated in an anonymous oocyte donation program that used embryos cryopreserved at the pronuclear stage. DESIGN: Observational study. SETTING: A tertiary care reproductive medicine unit. PATIENT(S): Anonymous oocyte donors and their respective recipients. INTERVENTION(S): Oocyte donors underwent a standard controlled ovarian hyperstimulation protocol and transvaginal ultrasound-guided oocyte retrieval. Oocyte recipients underwent at least one programmed hormone replacement cycle with transcervical ET. MAIN OUTCOME MEASURE(S): Thaw survival, implantation, clinical and ongoing pregnancy rates. RESULT(S): Thirty-six oocyte retrievals resulted in one ET to date. The mean numbers of oocytes that were retrieved and normally fertilized were 18.2 and 11.6, respectively. Fifty-one embryo thaw-transfer cycles were performed, with an embryo thaw survival rate of 93.5%. The clinical and ongoing pregnancy rates per ET were 52.9% and 51%, respectively. The overall implantation rate was 28.7%. The percentage of oocyte retrievals that resulted in at least one ongoing pregnancy to date was 69.4%. CONCLUSION(S): Anonymous oocyte donation can be conducted efficiently with the exclusive use of embryos cryopreserved at the pronuclear stage. This approach facilitates synchronization of the donor-recipient pair, eliminates the risk that recipients will begin hormonal therapy without embryo availability, and produces an acceptable ongoing pregnancy rate per oocyte donation.

Pain recurrence: a quality of life issue in endometriosis.

Studies reveal endometriosis to be present in 38-51% of women undergoing laparoscopy for chronic pelvic pain. Symptoms attributable to endometriosis include dysmenorrhea, dyspareunia, generalized pelvic pain, dyschezia, and radiation of pain to the back or leg. Psychological factors may also contribute to a more intense pain experience. Medical therapy provides symptom relief in 72-93% of patients, although recurrence is common following treatment discontinuation. Surgical therapy has had varying results for long-term pain relief; adequacy of the initial surgical treatment appears to be a critical factor. Important adjunctive measures include presacral neurectomy and excisional techniques to remove deep, fibrotic, retroperitoneal lesions. The quality of life of women with endometriosis will improve with greater focus on achieving the long-term relief of pelvic pain. Limitation of pain recurrence would benefit the patient greatly, by providing symptom relief and preventing the cycle of its probably adverse effects on physical activity, work productivity, sexual fulfilment, and mood.

New considerations for the classification of endometriosis.

The historical background to the classification of endometriosis is presented and modern classification systems are reviewed. The effectiveness of the currently used revised American Fertility Society classification system is limited and improved systems are required. Factors that should be incorporated into such systems include the documentation of endometriotic implants, classification of disease, prediction of pregnancy rates and prediction of prognosis for relief of pain.

Reconstruction of the external genitalia in females with bladder exstrophy.

OBJECTIVES: A very characteristic genital anomaly accompanies bladder exstrophy in females. This includes anterior displacement and narrowing of the vagina and separation of the clitoris into two distinct bodies. The authors have had a relatively large experience with correction of this rare genital anomaly. From this experience, it began to appear that certain procedural details were associated with improved outcomes. The objective of this article was to review this experience and detail the reconstruction of the external genitalia in these patients. METHODS: All cases of bladder exstrophy in females presenting from January 1, 1970 to December 31, 1992 were reviewed. A total of eight patients who underwent surgical correction of the external genitalia were included. Data was obtained regarding urologic treatment, associated anomalies, corrective gynecologic procedures, complications and subsequent course. RESULTS: Corrective gynecologic surgery included enlargement of the vaginal orifice in all eight patients. Five patients had reapproximation of the bifid clitoris. Three patients performed postoperative dilatation therapy. Postoperatively, one patient experienced dyspareunia requiring a repeat procedure to enlarge the vaginal orifice. No patient had complications related to pelvic organ prolapse. CONCLUSIONS: Care should be taken not to extend the perineal incision too far posteriorly in reconstruction of the external genitalia in females with bladder exstrophy. Failure to do so may further predispose the patient to uterine prolapse. Post-operative dilator therapy may be an important adjunctive technique.

Recent advances in infertility treatment.

Infertility is defined as the inability to conceive after one year of regular coitus without contraception. Approximately 10% to 20% of childbearing-age couples are infertile in the United States. The demand for infertility investigations has increased dramatically in recent decades. The number of women using infertility services rose from 600,000 in 1968 to 1.35 million in 1988, an increase due, in part, to improved technology and increased publicity that began in the early 1980s. By 1995, the numbers were about 2.7 million. Recent advances in assisted reproductive technologies (ART) have provided greater possibilities for successful infertility treatment. Examples of new technologies include intracytoplasmic sperm injection, oocyte donation, and embryo cryopreservation.

Classification of endometriosis.

Classification systems for endometriosis continue to evolve. Past systems have been modeled primarily after those in use for grading malignant disease. Unfortunately, classification methods that attempted to quantitate the severity of disease have suffered from only modest predictability in determining outcome. The 1985 revised American Fertility Society classification system is limited by scoring arbitrariness, potential for observational error, limited reproductivity, failure to consider lesion morphologic type and a particularly poor correlation with pelvic pain. These shortcomings are being presently addressed.

Bilateral femoral neuropathy complicating a combined laparoscopic-vaginal procedure.

Excision of a longitudinal vaginal septum combined with operative laparoscopy for treatment of pelvic adhesions was complicated postoperatively by a profound bilateral femoral neuropathy. Prolonged operating time and excessive abduction and lateral rotation of the hip joints may have been contributory factors.

The role of maternal age in assisted reproduction.

There is a significant decline in human fecundity with advancing age. A significant decrement in success rates is also seen in older women undergoing assisted reproduction, including in-vitro fertilization. We have observed a drop in the ongoing pregnancy rate per embryo transfer, from 48.8% in women aged < 30 years to 13.6% in women aged > or = 42 years. Embryo implantation rates also decline in a linear fashion, from 29% in women < 34 years to approximately 5% at age 42. We observed that the impaired implantation efficiency seen in older women is apparently independent of the magnitude of their stimulation response. Oocyte factors are felt to be primarily responsible; however, some available data suggest that uterine factors, e.g. diminished endometrial receptivity, may also play a role. There are presently no treatment strategies apart from oocyte donation, which have been shown to significantly improve implantation efficiency in older women. However, recent efforts have focused on the continued development of improved stimulation protocols, facilitation of embryo implantation by zona pellucida micromanipulation, and the possibility of screening preimplantation embryos for aneuploidy.

Dual suppression with oral contraceptives and gonadotrophin releasing-hormone agonists improves in-vitro fertilization outcome in high responder patients.

Certain patients have a tendency for high response to gonadotrophin therapy which is often not ameliorated with prior gonadotrophin-releasing hormone agonist (GnRHa) suppression. As a result, these patients are frequently cancelled and often experience ovarian hyperstimulation syndrome (OHSS) episodes during in-vitro fertilization (IVF)-embryo transfer cycles. Patients with polycystic ovarian syndrome (PCOS) have been noted to be particularly sensitive to exogenous gonadotrophin therapy. We have developed a protocol which is effective in improving IVF outcome in high responder patients, including those with PCOS. Oral contraceptive pills (OCP) are taken for 25 days followed by s.c. leuprolide acetate, 1 mg/day, which is overlapped with the final 5 days of oral contraceptive administration. Low-dose gonadotrophin stimulation is then initiated on the third day of withdrawal bleeding in the form of either human menopausal gonadotrophins or purified urinary follicle-stimulating hormone at a dosage of 150 IU/day. Over a 5 year period, we reviewed our experience utilizing this dual method of suppression in 99 cycles obtained in 73 high responder patients. There were only 13 cancellations prior to embryo transfer (13.1%). The clinical and ongoing pregnancy rates per initiated cycle were 46.5 and 40.4% respectively. Only eight patients experienced mild-moderate OHSS following treatment. For those patients who had undergone previous IVF-embryo transfer cycles at our centre, significant improvements were noted in oocyte fertilization rates, embryo implantation rates and clinical/ongoing pregnancy rates with this protocol. Hormonal analyses revealed that the chief mechanism may be through an improved luteinizing hormone/follicle-stimulating hormone ratio following dual suppression. An additional feature of this dual method of suppression is significantly lower serum androgen concentrations, particularly dehydroepiandrosterone sulphate.

PIP: Presented is a protocol that is effective in improving in vitro fertilization (IVF) outcome in women with a tendency for a high response to gonadotrophin therapy. High responders to exogenous gonadotrophin therapy show recruitment of large numbers of follicles, rapid estradiol responses, and a significant cycle cancellation rate due to the potential risk of hyperstimulation during IVF-embryo transfer attempts. Women with polycystic ovarian syndrome are especially sensitive to exogenous gonadotrophin therapy. The protocol entails 25 days of oral contraceptive (OC) use, followed by 1 mg/day of subcutaneous leuprolide acetate overlapped with the final 5 days of OC therapy. On the third day of withdrawal bleeding, gonadotrophin stimulation is initiated through either human menopausal gonadotrophins or purified urinary follicle-stimulating hormone (150 IU/day). This approach permits normalization of the luteinizing hormone/follicle-stimulating hormone ratio and reduces ovarian androgen concentrations, while circumventing the initial gonadotrophin flare response. This protocol was tested in a retrospective review (1990-94) of 99 cycles from 73 high-responder women treated at a US infertility center. There were only 13 cancellations (13.1%) prior to embryo transfer. The clinical and ongoing pregnancy rates per initiated cycle were 46.5% and 40.4%, respectively. Only 8 women experienced ovarian hyperstimulation syndrome after treatment. Among women who had undergone previous IVF embryo transfer cycles at the center, the present regimen was associated with significant improvements in oocyte fertilization rates, embryo implantation rates, and pregnancy rates.