Evaluation of the clinical efficacy of embryo cryopreservation.

To fully evaluate the advantages of a cryopreservation program a method needs to be established to express the additional patients pregnant from cryopreservation. The patient specific method considers cryopreservation as augmentation only among patients without a pregnancy from the fresh transfer, or from previously transferred frozen material from the same harvest. In an analysis of the pregnancy rate at the Jones Institute between January 1996 and December 1998 we found a fresh pregnancy rate of 40.8% in the good responders and 28.8% in poor responders. The patient specific pregnancy rate in the same cycles was 53.4% in good responders and 32.3% in poor responders. Good responders less than 35 years of age with ten or more mature eggs at retrieval had a fresh pregnancy rate of 40.2% and a patient specific pregnancy rate of 57.9%. It is exceedingly important for the physician and patient to understand and comprehend the potential in cryopreserved material.

Endometrial receptivities after leuprolide suppression and gonadotropin stimulation: histology, steroid receptor concentrations, and implantation rates.

The effect of markedly supraphysiologic levels of E2 and P4 on the endometrium was assessed by examining endometrial histology, E2 and P4 receptor concentrations, and embryo implantation rates in IVF cycles with and without leuprolide use. Results suggest that 1) the high ovarian response common in leuprolide pretreated cycles can advance endometrial histology, but only up to a certain limit, 2) P4 greater than 25ng/ml or E2 greater than 200pg/ml on the day of transfer was associated with non-lagging endometria, 3) implantation rate in high response cycles is not impaired and may be increased, 4) earlier P4 supplementation in low response cycles may be beneficial, 5) extraordinarily high response (E2 greater than 5000pg/ml) may be detrimental to implantation, and 6) the optimal histology for implantation appears to be at least day 16.

Use of gonadotrophin-releasing hormone agonists in controlled ovarian hyperstimulation for in vitro fertilization.

The aim of ovarian hyperstimulation for in vitro fertilization (IVF) is the recruitment of multiple fertilizable healthy oocytes. Transfer of multiple embryos yields a better success rate than single-embryo transfers. Moreover, cryopreservation of excess pre-embryos allows patients an added opportunity to achieve a pregnancy without undergoing a repeat stimulated cycle. In the last 4 years, gonadotrophin-releasing hormone (Gn-RH) agonists have been used widely as adjuncts to gonadotrophins for ovarian hyperstimulation. Advantages of Gn-RH agonist use include prevention of a premature luteinising hormone (LH) surge, suppression of endogenous basal LH levels and recruitment of a larger cohort of follicles. Gn-RH agonists can be used in a long (suppression) or a short (stimulatory, flare-up) protocol. In our clinic, the use of Gn-RH agonist suppression (starting in the mid-luteal phase) prior to ovarian hyperstimulation was demonstrated to be extremely beneficial in intermediate and high responder patients but not in low responders (defined endocrinologically as patients with a basal follicle-stimulating hormone [FSH]: LH ratio of 1:1 and a basal LH:FSH ratio of greater than or equal to 1.5, respectively). We have not been able to demonstrate any beneficial effects from the use of Gn-RH agonist suppression in low responder patients (defined endocrinologically as patients with a basal FSH greater than or equal to 15 mIU/ml). In such low responder patients, the use of a 'flare-up' Gn-RH agonist protocol (Gn-RH agonist starting on day 2 of the cycle, followed by gonadotrophins on day 4 of the cycle), taking advantage of the initial agonistic stimulatory effect of Gn-RH agonists on endogenous FSH and LH secretion, has provided significant improvements in stimulation characteristics and better pregnancy results. It should be emphasised that comparisons of results cannot be attempted due to the selective use of each protocol in different patient populations.

The significance of hydrosalpinx in in vitro fertilization.

OBJECTIVE: To review the effects of hydrosalpinx on IVF/ET and the role of salpingectomy. DESIGN: The literature on hydrosalpinx, IVF/ET, embryotoxicity, and salpingectomy for hydrosalpinx was identified through MEDLINE searches and reviewed. RESULT(S): Hydrosalpinx has been associated with poor fertility prognosis. IVF/ET is a better alternative to tubal surgery for those patients with severe distal tubal disease, and it is also more cost effective. However, the presence of hydrosalpinx has a negative effect on IVF/ET by decreasing the pregnancy rates and implantation rates compared with patients undergoing IVF/ET for tubal disease but without hydrosalpinx. The hydrosalpingeal fluid has been demonstrated to be embryotoxic to developing embryos, thus leading to increased early pregnancy losses. Poor endometrial receptivity has also been demonstrated in the presence of hydrosalpinges. Removal of the hydrosalpinges leads to improved IVF/ET rates comparable to those patients without hydrosalpinx. Therefore, salpingectomy has been recommended for patients with hydrosalpinx who will be undergoing IVF/ET. CONCLUSION(S): The presence of hydrosalpinx has a negative effect on IVF/ET because of the suspected embryotoxicity of the hydrosalpingeal fluid. Surgical removal of the hydrosalpinx has been shown to improve IVF/ET rates.

The combination of follicle-stimulating hormone and human menopausal gonadotropin for the induction of multiple follicular maturation for in vitro fertilization.

One hundred fifty-one cycles in 134 consecutive patients were stimulated with 150 IU of human urinary follicle-stimulating hormone (FSH) and 150 IU of human menopausal gonadotropin (hMG) on cycle days 3 and 4 and then with 150 IU of hMG daily for the purpose of multiple follicular development for in vitro fertilization (IVF). Seventy-three patients did not have a prior IVF attempt, and 61 patients in 78 cycles had prior IVF attempts at least once with their previous cycles stimulated with the same method and/or hMG and/or FSH. There was an average of three preovulatory oocytes retrieved per laparoscopy and a pregnancy rate of 27% per transfer cycle. The results were equally favorable in "new" and "old" patient cycles. The pregnancy rate increased with the transfer of two or more conceptuses of preovulatory origin. The multiple pregnancy rate, but not the abortion rate, increased with increased numbers of conceptuses transferred.

Basal follicle-stimulating hormone level and age affect the chance for and outcome of pre-embryo cryopreservation.

All IVF cycles in which subsequent transfers of thawed pre-embryos occurred were studied. Both age and basal (cycle day 3) FSH level are important determinants of the chance for cryopreservation and the performance of cryopreserved pre-embryos. Although there was no age or FSH level above which pregnancy with frozen pre-embryos was not possible, the chances clearly decline. Thus, consideration to transferring larger numbers of pre-embryos fresh should be given to women in the fifth decade and those with basal FSH > 15 IU/L.

The incidence of multiple gestations after in vitro fertilization is dependent on the number of embryos transferred and maternal age.

OBJECTIVE: To determine if the incidence of multiple gestations after IVF differs significantly depending on the number of embryos transferred and maternal age. DESIGN: Retrospective analysis of IVF database. SETTING: Tertiary care academic center. PATIENTS: One thousand eight hundred sixty-seven patients undergoing IVF with up to four embryos transferred during 1986 through 1993. MAIN OUTCOME MEASURES: The rate of singleton and multiple gestations > 20 weeks estimated gestational age (EGA). RESULTS: The incidence of triplet gestations > 20 weeks EGA among patients < or = 34 years of age with three versus four embryos transferred was 0.3% (1/335) versus 2.4% (15/662), respectively. The incidence of twin gestations > 20 weeks EGA among patients < or = 34 years of age with two versus four embryos transferred was 1.3% (3/234) versus 7.4% (46/622), respectively. Also among patients < or = 34 years of age, the incidence of singleton gestations > 20 weeks EGA with two versus three embryos transferred was 12.8% (30/234) versus 15.8% (53/335); with two versus four embryos was 12.8% (30/234) versus 17.2% (107/622); and with three versus four embryos was 15.8% (53/335) versus 17.2% (107/622), respectively. CONCLUSIONS: In women < or = 34 years of age undergoing IVF-ET, the transfer of four versus three and four versus two embryos significantly increased the incidence of triplet and twin gestations, respectively, without significantly improving the chance of singleton conception. This implies that a policy of transferring only three embryos should be considered in this age group (realizing that such a policy may merit modulation if pretransfer embryo selection is used.).

Progesterone levels on the day of human chorionic gonadotropin do not predict pregnancy outcome from the transfer of fresh or cryopreserved embryos from the same cohort.

OBJECTIVE: To analyze the differences in pregnancy rates (PRs) from the transfer of fresh and cryopreserved embryos from the same cohort of oocytes based on serum P levels on the day of hCG administration and the day after. DESIGN: Retrospective analysis. SETTING: Infertility patients stimulated for IVF-ET in an academic center. PATIENT(S): Three hundred thirty-three patients with fresh transfer and at least one transfer of cryopreserved embryos from the same cohort of recruited oocytes. All stimulations were down-regulated with a GnRH agonist in a long protocol before gonadotropin stimulation. MAIN OUTCOME MEASURE(S): Clinical PR. RESULT(S): The clinical PR in fresh cycles was 24% for the P < or = 0.9 ng/mL group (group A; conversion factor to SI unit, 3.18) and 34% for the P > 0.9 ng/mL group (group B). Group B patients were younger, received fewer ampules of gonadotropins, had higher peak E2 levels, and had more mature oocytes. There were no significant differences in the P levels on the day of hCG between patients who conceived in both fresh and cryopreserved cycles and any other combination of pregnancy outcome sequence. CONCLUSION(S): These findings suggest that serum P level cutoffs, on the day of hCG and the day after, as a means of making clinical decisions with respect to cancelling the fresh transfer and cryopreservation of all embryos for future transfer should be questioned.

Intercycle variability of day 3 follicle-stimulating hormone levels and its effect on stimulation quality in in vitro fertilization.

Prior studies have demonstrated that gonadotropin stimulation quality and pregnancy rates are better in in vitro fertilization (IVF) patients with low basal cycle day 3 follicle-stimulating hormone (FSH) levels. The records of 81 patients who had undergone three or more IVF attempts during a 2-year period were studied to determine the degree and potential impact of intercycle variability in basal FSH concentrations. The mean of the individual standard deviations for all 81 patients was 4.2 +/- 0.4 mIU/mL. However, the patients with a mean basal FSH of less than 15 mIU/mL had a mean deviation of only 2.6 +/- 0.2 mIU/mL, whereas those with a mean basal FSH of greater than or equal to 15 mIU/mL had a mean deviation of 7.3 +/- 0.7 mIU/mL. Intercycle variability in basal FSH values did not predict changes in ovarian response to gonadotropin stimulation and thus may not be used to select an optimal cycle in which to stimulate an individual patient. Furthermore, patients with large intercycle variation responded poorly to gonadotropin stimulation independent of their basal FSH concentration. This information allows more precise counseling of patients regarding their appropriateness for assisted reproduction.

Outcome of twin, triplet, and quadruplet in vitro fertilization pregnancies: the Norfolk experience.

OBJECTIVE: To review the maternal morbidity and neonatal morbidity and mortality associated with in vitro fertilization (IVF) multiple pregnancies. DESIGN: Retrospective analysis of data collected from office and hospital records and from questionnaires sent to patients, their obstetricians, and pediatricians. SETTING: Patients (all with private insurance carriers) enrolled in an academic IVF program (The Jones Institute for Reproductive Medicine). PATIENTS, PARTICIPANTS: All IVF pregnancies resulting in one or more gestational sacs on the initial ultrasound at 6 to 7 weeks were reviewed. MAIN OUTCOME MEASURES: The frequency and severity of obstetrical and neonatal complications and the perinatal mortality of IVF twins, triplets, and quadruplets were compared. These were also compared with non-IVF multiple pregnancies. RESULTS: From 1982 to 1990, 629 IVF pregnancies progressed beyond 20 weeks; 115 twins (18.3%), 15 triplets (2.4%), and 4 quadruplets (0.6%). There was a high incidence of antenatal complications such as abortions (30.3%, 42%, and 20%), premature labor (41.5%, 92.3%, and 75%), pregnancy-induced hypertension (17.0%, 38.6%, and 50%), and gestational diabetes mellitus (3.1%, 38.5%, and 25%) for twins, triplets, and quadruplets, respectively. The mean gestational age at delivery was 35.5 +/- 3.7, 31.8 +/- 2.7, and 31.0 +/- 1.7 weeks, respectively. There was also a proportionate progressive increase in neonatal complications. The mean weights were 2,473 +/- 745, 1,666 +/- 441 and 1,414 +/- 368 g, respectively. Twins (22.7%), 64.1% of triplets, and 75% of quadruplets needed admission to the neonatal intensive care unit and remained for an average of 12.0 +/- 2.3, 17.4 +/- 14.0, and 57.8 +/- 17.9 days, respectively. There was no difference in the mean Apgar scores or the incidence of congenital malformations in the three groups. The corrected perinatal mortality rates were 38.5, 0.0, and 0.0 per thousand live births, respectively. CONCLUSION: Triplet and quadruplet IVF pregnancies have increased obstetrical and neonatal complications compared with IVF twins. The perinatal mortality and the incidence of congenital malformations are, however, comparable in all three groups.

Significance of basal follicle-stimulating hormone levels in women with one ovary in a program of in vitro fertilization.

OBJECTIVE: To understand the impact of having a single ovary on basal follicle-stimulating hormone (FSH) level and its diagnostic and prognostic usefulness in in vitro fertilization (IVF). DESIGN: All IVF cases from July 1987 to June 1990 with known basal FSH (n = 1,272) were divided into those with one and those with two ovaries to compare outcomes based on basal FSH levels. SETTING: Tertiary care academic center with a large IVF practice. MAIN OUTCOME MEASURES: Basal FSH, age, and IVF outcomes including peak estradiol, numbers of follicles aspirated, oocytes retrieved, fertilized, and transferred, and pregnancies (clinical and ongoing). RESULTS: In women with only one ovary, basal FSH was increased, and IVF outcomes were poorer. The rise in FSH was able, in large part, to account for the diminished performance in the single ovary cases. CONCLUSIONS: Women with only one ovary have higher basal FSH levels than those with two ovaries, and this rise can be used to predict their IVF performance.

Experience with diethylstilbestrol-exposed infertile women in a program of in vitro fertilization.

Twenty infertile women with a history of diethylstilbestrol exposure in utero were seen in Norfolk for the purpose of in vitro fertilization. Seventeen patients had undergone 25 stimulated cycles with harvest of oocytes by laparoscopy. The serum estradiol response to stimulation in these patients and the number and quality of oocytes retrieved did not differ significantly from those of patients with infertility due to blocked fallopian tubes. There were four pregnancies in 17 patients after 21 cycles of embryo transfers, for a pregnancy rate of 23.5% per patient, or 19% per embryo transfer. Two of the pregnant patients have had a term delivery, one has had a preclinical abortion, and one has a single intrauterine gestation in progress.

Basal follicle-stimulating hormone level is a better predictor of in vitro fertilization performance than age.

A study of 1,478 consecutive in vitro fertilization (IVF) cycles was made to determine if basal follicle-stimulating hormone (FSH) levels and age were independent predictors of IVF performance. Regression analyses indicated independent contributions of both basal FSH and age in predicting cancellation rate, peak estradiol, number of oocytes retrieved, fertilized, and transferred, and total and ongoing pregnancy rates. Miscarriage rate was unrelated to both age and basal FSH. Follicle-stimulating hormone level was a better predictor than age for all outcome variables examined and remained a significant predictor after accounting for age, etiology of infertility, and semen quality. The combined use of age and basal FSH in counseling patients improves the accuracy of prognosis, and may provide an index of functional ovarian reserve ("ovarian age").

Alterations in luteal phase progesterone and estradiol production after leuprolide acetate therapy before ovarian stimulation for in vitro fertilization.

The impact of pituitary suppression with a gonadotropin-releasing hormone agonist (GnRH-a) on the luteal phase of in vitro fertilization (IVF) cycles was examined in 21 women who underwent identical stimulation regimens with and without leuprolide acetate pretreatment. The areas under the serum progesterone curves, measured over the 1st 10 days of the luteal phase, were significantly greater in the GnRH-a cycles compared with the non-GnRHa cycles, but when calculated per oocyte retrieved were similar in GnRH-a and non-GnRH-a cycles. In contrast, the areas under the luteal phase serum estradiol curves were significantly less in the GnRH-a cycles. These data suggest that GnRH-a treatment is accompanied by potentially beneficial alterations in the systemic steroidal milieu of the luteal phase of IVF cycles.

Predictive value of pregnancy during original in vitro fertilization cycle on implantation and pregnancy in subsequent cryothaw cycles.

OBJECTIVE: To understand the homogeneity of oocyte quality within a cohort. DESIGN: All women (n = 367) that had cryopreserved pre-embryos subsequently thawed were studied. Pregnancy and implantation rates in the in vitro fertilization (IVF) and cryothaw transfers were examined. SETTING: Tertiary care academic center. RESULTS: Pregnancy in original IVF cycle predicted higher implantation rates at subsequent cryothaw transfers. Similarly, pregnancy in cryothaw cycles was associated with higher implantation and ongoing pregnancy rates at the initial IVF cycle. CONCLUSIONS: Within a cohort of oocytes, pregnancy with some of the pre-embryos in a cohort predicts pregnancy with the remaining oocytes in the cohort. Thus, oocytes within a cohort have similar pregnancy potential.

Embryo quality and pregnancy rates in patients attempting pregnancy through in vitro fertilization.

Patients at low risk for producing abnormal gametes produce a wide range of embryo qualities that correlate well with PRs. These data may be useful in counseling patients and in reviewing treatment and laboratory protocols.

Transfer of cryopreserved-thawed pre-embryos in a natural cycle or a programmed cycle with exogenous hormonal replacement yields similar pregnancy results.

OBJECTIVE: To examine the results of 7 years of thawed ET during natural or controlled cycles using exogenous steroids. DESIGN: Retrospective evaluation to compare implantation and pregnancy rates with two protocols for transfer of cryopreserved-thawed pre-embryos. SETTING: Tertiary care academic center. PATIENTS: From January 1987 to December 1993, 521 patients who were < 40 years of age underwent 628 thawed embryo transfers. MAIN OUTCOME MEASURE: Pregnancy and implantation rates per thawed embryo transfer cycle. RESULTS: A total 1,987 pre-embryos survived the thawing process and were used in 628 thaw-transfer cycles. Transfer was performed in a natural cycle 2 days after the LH peak or on day 17 of a programmed cycle using a GnRH-agonist and hormone replacement therapy protocol; 182 pregnancies were established (182/628; 29%). Similar pregnancy rates were seen in the natural cycle (112/398; 28%) and the programmed cycle (70/230; 30%). The implantation rates were similar in the two methods of transfer cycles (11.9% versus 10.3%, natural versus programmed cycle). There were no significant differences in clinical or ongoing pregnancy rates in a natural or programmed cycle, correcting for the number of cryopreserved-thawed pre-embryos transferred. Patient's age at the time of freezing and the number of cryopreserved-thawed pre-embryos transferred are more important determinants of pregnancy than the type of cycle in which transfer occurs. CONCLUSION: Transferring cryopreserved-thawed pre-embryos in a natural or programmed cycle yields similar pregnancy results.

The perimenopausal patient in in vitro fertilization: the use of gonadotropin-releasing hormone.

The perimenopause, incipient ovarian failure, is a major problem in stimulation failures during an in vitro fertilization program. This must be recognized as not necessarily related to age but also associated with adnexal inflammatory and operative processes. Although ovulation occurs uninterruptedly, the follicle-stimulating hormone in the early follicular phase is elevated and the luteinizing hormone is normal. Characteristically, there is no estradiol response to human menopausal gonadotropin therapy or a rapid response with a premature luteinizing hormone surge. These problems sometimes may be overcome with pulsatile intravenous gonadotropin-releasing hormone therapy, 5 or 10 micrograms/90 or 120 minutes. The major therapeutic problem is in the identification of a luteinizing hormone surge in these patients. Of eight women who were treated, two failed to respond with follicular maturation, three either had no oocytes aspirated from apparently postmature follicles or had postmature oocytes; and one had treatment cancelled due to ovulation. The four latter patients may have failed because of unrecognized ovulation. In the remaining two patients, one oocyte was fertilized and transferred, and one pregnancy occurred.

Low-dose glucocorticoids after in vitro fertilization and embryo transfer have no significant effect on pregnancy rate.

OBJECTIVE: To determine the effect on pregnancy rate (PR) of low-dose glucocorticoid treatment in cycles without micromanipulation. DESIGN: Randomized, prospective, double-blinded, placebo-controlled trial. SETTING: One university-based tertiary infertility center and two private infertility centers. PATIENTS: All patients receiving standard stimulation IVF-ET or transfer of cryopreserved embryos at the participating facilities from January to September 1993 were asked to participate in this study. Patients having micromanipulation were excluded from this study. INTERVENTIONS: Participating patients were randomized to either 16 mg oral 6-alpha-methylprednisolone for four evenings starting the evening of retrieval or the evening before thawing cryopreserved embryos or to placebo administered in an identical fashion. Both groups were treated with 250 mg oral tetracycline four times per day starting with initiation of the study medication and continuing for 4 days. Cryopreservation and stimulation cycles were managed according to pre-established protocols for all patients. A clinical pregnancy was confirmed by an appropriately rising hCG titer and a gestational sac on ultrasound. RESULTS: A total of 206 stimulation patients and 61 cryopreservation patients were randomized and had an ET. Patient characteristics were similar between groups. The clinical pregnancy and implantation rates between placebo and glucocorticoid groups were 35.9% versus 40.8% and 12.8% versus 11.7% for stimulation cycles and 30.3% versus 25% and 9.9% versus 7.4% for cryopreservation cycles, respectively. None of these differences were statistically significant. CONCLUSIONS: Glucocorticoid plus antibiotic treatment at these doses for transfers of nonmicromanipulated embryos does not appear to have a significant effect on pregnancy or implantation rates.

Delaying the initiation of progesterone supplementation results in decreased pregnancy rates after in vitro fertilization: a randomized, prospective study.

OBJECTIVE: To compare IVF outcome between two protocols for luteal phase supplementation, one beginning on day 3 after oocyte retrieval and the other beginning on day 6 after retrieval. DESIGN: Prospective, randomized study. SETTING: University-based assisted reproductive technology center. PATIENT(S): One hundred twenty-six consecutive patients undergoing IVF between January and July 2000. INTERVENTION(S): Patients were randomized to begin luteal phase support using vaginal progesterone beginning either on day 3 after oocyte retrieval or on day 6 after oocyte retrieval. MAIN OUTCOME MEASURE(S): Clinical pregnancy rates and implantation rates. RESULT(S): All patients randomized underwent transfer. There were no differences in age, oocytes retrieved, or embryos transferred between the two groups. Those patients receiving luteal phase support with progesterone beginning on day 6 after retrieval had a significantly lower clinical pregnancy rate per transfer compared with those beginning support on day 3 after retrieval (44.8% vs. 61.0%, respectively). This difference in pregnancy rates was greater in those patients undergoing a luteal gonadotropin releasing hormone (GnRH) agonist down-regulation protocol (47.5% vs. 71.4%, day 6 vs. day 3, respectively). Beginning support on day 6 also significantly decreased implantation rates in the GnRH agonist group (21.0% vs. 34.0%, day 6 vs. day 3, respectively). CONCLUSION(S): Pregnancy rates are significantly decreased by initiating luteal-phase progesterone supplementation on day 6 after oocyte retrieval during in vitro fertilization cycles.