Intracytoplasmic sperm injection with motile and immotile frozen-thawed testicular spermatozoa (the Hungarian experience).

The authors summarize their experience in 75 in vitro fertilization cycles, where frozen-thawed testicular spermatozoa were used for intracytoplasmic sperm injection. In 32 cases, motile spermatozoa could be observed in the frozen-thawed sample. In 34 cases, motility could be induced by pentoxifylline and in nine cases immotile spermatozoa, selected with hypoosmotic swelling test, were used for fertilization. The fertilization rates obtained with motile and immotile spermatozoa (66.1% versus 52.3%) were not significantly different. Our data demonstrate that freezing of testicular spermatozoa opened new possibilities for the treatment of azoospermic men. The clinical pregnancy rate per embryo transfer (ET) (21.87%) was comparable with previous results use of fresh testicular spermatozoa (27.7%). The quality and number of transferred embryos had the most significant impact on the pregnancy rate. The fertilization rate and frequency distribution of good-quality embryos were lower in the case of immotile spermatozoa, and pregnancies were only achieved when motile spermatozoa had been used.

Birth weight discordance in spontaneous versus induced twins: impact on perinatal outcome.

PURPOSE: To compare the rate of birth weight discordance and perinatal outcome of twin pregnancies after assisted reproduction with that of spontaneous twins. METHOD: A total of 12,920 deliveries were analyzed retrospectively. Seventy-five twin pregnancies after ART were compared to the 94 spontaneous counterparts. Birth weight discordance was defined as a difference of 20% or more. RESULTS: Discordance rate was elevated (25.3% vs. 17.0%) among ART twins. SGA was increased and NICU admission was more frequent in discordant group. Unlike-sexed twins were more prevalent (73.7% vs. 37.5%) among discordants after ART. CONCLUSIONS: ART can increase discordance rate which can elevate perinatal risk.

The effect of endometrial thickness on IVF/ICSI outcome.

BACKGROUND: During the menstrual cycle the endometrium undergoes cyclic proliferative and secretory changes in preparation for implantation. If this preparation is not sufficient, then implantation will fail. The impact of endometrial thickness on the day of embryo transfer on IVF outcome was investigated in the present study. METHODS: A retrospective analysis was conducted of 1228 IVF/ICSI cycles. Stimulation was with clomiphene citrate (CC) + hMG in one-third of the cycles, and ultrashort GnRH agonist stimulation in two-thirds. Cycle parameters were compared between pregnant and non-pregnant patients. A similar comparison was made between ongoing pregnancies and those that resulted in a loss. RESULTS: There were more follicles, oocytes and embryos, the endometrium was thicker and the embryo quality was higher among women who became pregnant when compared with non-pregnant women after assisted reproduction. The pregnancy rate improved as endometrial thickness increased. No difference in cycle parameters and endometrial thickness was found between ongoing pregnancies and pregnancies that resulted in a first-trimester loss. CC had no measurable adverse endometrial effect, but the pregnancy rate was lower in CC+hMG cycles. CONCLUSIONS: Increased endometrial thickness is associated with higher pregnancy rates. However, neither attainment of pregnancy nor pregnancy outcome was predicted by endometrial thickness alone.

The incidence of major birth defects following in vitro fertilization.

PURPOSE: To evaluate the risk of congenital malformations in newborns delivered after IVF-ET in comparison with matched controls from spontaneous pregnancies. METHODS: A total of 12,920 deliveries were subjected to retrospective analysis. A total of 301 neonates were evaluated. The incidence of major birth defects was compared with controls matched with regard to age, gravidity, parity, and previous obstetric outcome after spontaneous pregnancies. RESULTS: The incidence of major congenital abnormalities was not significantly higher (p > 0.05) among the cases (1.90%) than among the controls (1.15%). CONCLUSION: The risk of major birth defects following IVF-ET is comparable with that of spontaneously conceived, matched pregnancies.

Isolation of ejaculated spermatozoa six hours after unsuccessful testicular biopsy in nonobstructive azoospermia.

Azoospermia, the absence of sperm in ejaculated semen, is the most severe form of male factor infertility and is present in approximately 5% of all investigated infertile couples. The condition is currently classified as obstructive and nonobstructive subgroups. In nonobstructive azoospermia, testicular sperm extraction (TESE) is usually necessary for sperm recovery. This is a case report of pregnancy and subsequent birth of healthy babies following intracytoplasmic sperm injection (ICSI) of ejaculated motile spermatozoa presented 6 h after unsuccessful testicular biopsies in four subsequent in vitro fertilization (IVF) cycles with infertility due to nonobstructive azoospermia.

Five years experiences with microinjection of testicular spermatozoa into oocytes in Hungary.

The aim of the study was to summarize our five years experience (1996-2000) of testicular spermatozoa for intracytoplasmic sperm injection in Hungary. The influence of sperm count, maternal age, number of transferred embryos, and application of assisted hatching on outcome was investigated. Testicular spermatozoa were retrieved by microsurgical testicular sperm extraction. Samples were classified depending on the number of spermatozoa. Indication for testicular sperm extraction in conjunction with intracytoplasmic sperm injection was severe azoospermia or azoospermia combined with tubal origin infertility. Ovarian stimulation was carried out using an ultrashort protocol with GnRH agonist and gonadotrophin. Intracytoplasmic sperm injection was performed without PVP. Embryos were cultured for 48 or 72 h before embryo transfer. Indications for assisted hatching included elevated maternal age, increased zona thickness or at least two previous unsuccessful IVF cycles. Testicular spermatozoa were successfully retrieved in 218 out of 273 cases. Extreme low sperm count was found more frequently in cases of nonobstructive azoospermia. No significant differences were observed in fertilization rate (61.1% vs. 51.7%) or clinical pregnancy rate (29.0% vs. 26.7%) between patients with obstructive or nonobstructive azoospermia. Maternal age, number of transferred embryos and application of assisted hatching had a significant effect on outcome. A total of 55 clinical pregnancies were achieved, including 14 sets of twins, three sets of triplets and two sets of quadruplets. It is concluded that testicular sperm extraction is an efficient way of obtaining testicular spermatozoa, allowing not only successful fertilization by ICSI, but also freezing of testicular spermatozoa for use in subsequent cycles.

Seasonal influences on in vitro fertilization and embryo transfer.

PURPOSE: The study was aimed to investigate the influence of time factors (day, week, month) on pregnancy rates and in vitro fertilization (IVF) and embryo transfer (ET) parameters. METHODS: 8,184 IVF-ET cycles, taking place in two IVF centers from 1992 to 1999, were analyzed. Multiple logistic and linear regression methods were performed as statistical analyses. RESULTS: Oocyte pickup on Tuesdays achieved a significantly higher mean number of oocytes (median: 7) and the highest pregnancy rate (PR) (33.4%) per ET There was a significant variation over the year, with the lowest PR/ET in July (25.71%) and the highest in December (35.5%). Concerning outcomes, the age factor and the number of embryos transferred had the highest significant (p < 0.0001) influence. CONCLUSIONS: The observed weekly rhythm for oocyte pick-ups is certainly due to preprogrammed ovarian stimulation used in our IVF programs. Age as well as the number of embryos transferred are the main influencing factors on a positive outcome and more predictive than seasonal aspects.

Establishment of primary port without insertion of a sharp trocar.

A new method allows a primary laparoscopic port to be established without inserting a Veress needle or sharp cannula. In this prospective case series of 348 consecutive healthy women undergoing elective laparoscopic sterilization, the laparoscope was complemented with an access cannula that enabled the surgeon to guide it directly into the abdominal cavity.

Modified open laparoscopy through placement of an optical surgical obturator.

OBJECTIVE: To describe a new technique for open laparoscopy. DESIGN: Prospective case series. SETTING: Ambulatory surgical unit. PATIENT(S): Fifty-six women undergoing laparoscopic sterilization. INTERVENTION(S): Intra-abdominal placement of an optical surgical obturator. MAIN OUTCOME MEASURE(S): Evaluation of surgical technique. RESULT(S): The technique was completed successfully in all cases. CONCLUSION(S): This new surgical approach may assist surgeons in avoiding inadvertent injuries.

Biocompatible electric current attenuates HIV infectivity.

The number of individuals infected by the human immunodeficiency virus type-l (HIV) continues to increase on a worldwide basis.' A significant percentage, ifnot all, of these individuals will eventually develop the acquired immunodeficiency syndrome (AIDS).2 While horizontal transmission in the homosexual population may be contained or decreasing,' heterosexual transmission and infection through contaminated blood supplies continues to increase: Additionally, vertical transmission from infected females to their fetuses is also on the rise with a resultant increase in the number of children with AIDS.S New strategies, therefore, must be devised in order to limit more effectively the spread of this virus.

Visually guided trocar entry: experience with the optical trocar.

Blind insertion of the Veressneedle and the conventional primary trocar have remained troublesome steps during laparoscopic surgical procedures. The standard primary trocar can be inserted directly without preexisting pneumoperitoneum, thus avoiding use of the Veressneedle. This approach still requires blind insertion, and inadvertent traumatic injuries have been reported.' Complications from such trocar insertions can be severe and at times lethal. Although the rate of such complications is acknowledged to be small, the ab- solute number becomes a relevant public health issue in light ofthe high frequency of both operative and di- agnostic laparoscopic procedures worldwide. Traumatic injuries to vessels, bowel, and other abdominal or- gans continue to occur despite proper surgical training, operator experience, and use of up-to-date equipment.

The effect of various ovulation induction protocols on pregnancy rates following intracytoplasmic sperm injection.

In the last two years intracytoplasmic sperm injection (ICSI) has become frequently employed as an assisted reproductive technique primarily to treat male factor infertility.' In order to achieve high pregnancy rates, all assisted reproductive technologies including ICSI require sufficient number and quality oocytes. In our practice we use three different ovulation induction regimens (CC/hMG, GnRH-a/hMG, and GnRH-a/FSH) to maximize the number of oocytes available for fertilization. In this present report, we retrospectively com- pared pregnancy rates with ICSI following the use of these protocols.

Abdominal wall stability: a comparison of the optical trocar with a reusable laparoscopic trocar.

The principal reason for employing an optical trocar has been described by Kaali.' The potential clinical benefits of a visually directed trocar entry system have been identified in a follow-up clinical series. 2 Current experience with the commercially developed Endopath Opt.iview" trocar has suggested an ad- ditional surgical advantage through an enhanced abdominal wall stability of the trocar sheath. The purpose of the current investigation was to determine whether or not this clinical observation could be mechanically quantified.

Comparison of visual and tactile localization of the trocar tip during abdominal entry.

We attempted to determine whether video-aided visual imaging during laparoscopic insertion of the trocar would improve the surgeon's ability to localize the sharp penetrating tip of the instrument. A newly described, visually directed laparoscopic trocar was inserted in 184 subjects to correlate visual localization of the tip with the accuracy of the conventional tactile sensory approach. In 164 of the 184 cases the fascia was recognized visually at the same time that the surgeon acknowledged tactile resistance. However, partial intraabdominal penetration was noted in 102 of these cases just before the anticipated loss of resistance could be felt manually. More important, in 20 women there was no subjective manual confirmation of the tip location by the time intraabdominal placement of the trocar was confirmed visually. In this limited series there were no multiple insertions or complications under visually directed trocar entry. Video-aided direct visualization improves the surgeon's ability to localize the tip of the trocar throughout the insertion. It may help the surgeon to recognize and possibly avoid some inadvertent distant intraabdominal organ injuries.

Introduction of the Opti-trocar.

To deal with the problems associated with blind trocar insertion for conventional laparoscopy, an image-receivable and light-transmissible, optically clear trocar tip was conceived. Consultation with persons with optical engineering expertise resulted in the design of a prototype instrument for clinical testing. Results of a feasibility study conducted in 150 subjects indicate that a significant advance in the performance of laparoscopic surgery is possible with wide-scale implementation of this innovation. Video-aided continuous visual imaging during trocar insertion provides identification of distinct layers of the abdominal wall and helps ensure proper intraabdominal placement without the need for minilaparotomy or open laparoscopy.

Incidence of bowel injury due to dense adhesions at the sight of direct trocar insertion.

A retrospective review of 4,532 outpatient laparoscopic procedures was conducted to determine the frequency of dense bowel adhesions at the level of the umbilicus. The umbilicus is the classical site of entry for the laparoscopic trocar. Using direct trocar insertion in all cases we encountered four bowel injuries. Bowel adhesion to the insertion site was noted in one case.