ICSI outcome in patients with transient azoospermia with initially motile or immotile sperm in the ejaculate.

BACKGROUND: In patients with transient azoospermia, few sperm may be found in the ejaculate. We investigated the outcome of ICSI in patients with transient azoospermia. METHODS: Records of patients with transient azoospermia referred during a 42 month period were reviewed. If only immotile sperm were found, the sample was incubated with 30% human serum albumin (HSA) before motility re-assessment. If still immotile, mechanical assessment of sperm viability was utilized. Study groups were: (A) motile sperm; (B) motility achieved by HSA; (C) no motility, but viability assessed by a mechanical technique; and (D) control group with sperm counts from 1 to 5 x 10(6)/ml. There were 57 couples (cycles) in the study group and 43 couples (cycles) in the control group. RESULTS: Age, days of stimulation and endometrial thickness were comparable among groups. In 29.8% of the cycles, only immotile sperm were found. Fertilization and cleavage rates were higher in groups A and D than in groups B and C. Clinical pregnancy rate/cycle and live birth rate/cycle were not different among groups. No congenital malformations were found in newborns. CONCLUSION: Fertilization and cleavage rates were lower in patients with initially immotile sperm compared with those with initially motile sperm and oligoasthenoteratozoospermia patients. Clinical pregnancy and viable pregnancy rates were not statistically different among groups, although when only immotile sperm were present both clinical pregnancy and live birth rate were lower in comparison with cycles with motile sperm.

Ovarian origin of plasma and peritoneal fluid prorenin in early pregnancy and in patients with ovarian hyperstimulation syndrome.

Prorenin is the major product of renin gene expression in the ovary. Plasma levels of prorenin are elevated in ovarian-stimulated patients and during early pregnancy. To further elucidate the source of the elevated plasma levels of prorenin, we measured prorenin, renin activity, angiotensinogen, and steroid hormone levels in the plasma, luteal fluids (luteal cysts), ascitic fluid, and in ovarian venous samples collected from a patient with severe ovarian hyperstimulation syndrome (OHSS) and ectopic pregnancy. Prorenin/renin was also measured in plasma and in peritoneal fluid obtained during, therapeutic paracentesis from four patients with OHSS. Several corpora luteal fluids were obtained that were rich in estradiol (E2) and progesterone (P). Ovarian venous E2 and P were 20-fold higher than in arterial blood and as high or higher than the levels detected in the luteal fluids. The ratios of the hormonal levels in ascitic fluid and plasma were 1.9 for P and 1.4 for E2. A wide range of prorenin concentrations [1279 +/- 918 SD ng/mL/hr, n = 6] were found in corpora luteal fluids, but in each the prorenin concentration was higher than in plasma (494 ng/mL/hr). Prorenin but not renin was higher (+23%) in ovarian venous than arterial blood. Prorenin in the 7 liters of ascitic fluid aspirated (2686 ng/mL/hr) was 5-fold higher than in plasma and similar to the levels measured in the corpora lutea with the highest prorenin concentrations. Renin in luteal cysts and ascitic fluid constituted 3% and 6% of the total renin (renin+prorenin), respectively. Total renin was also higher in peritoneal fluid (1538 +/- 925 ng/mL/hr) than in plasma (375 +/- 237 ng/mL/hr) of the 4 additional patients with severe OHSS. These findings indicate that the ovary secretes prorenin during early pregnancy and that its secretion is directed preferentially from the luteal cysts into the peritoneal cavity. In light of recent evidence of an effect of prorenin on the vascular system, the presence of a huge reservoir of prorenin in the peritoneal cavity of patients with OHSS suggests a potential role for prorenin in the pathogenesis of this syndrome.

Undocumented embryos: do not trash them, FISH them.

Pronuclei formation is routinely assessed 16-20 h after oocyte insemination in in-vitro fertilization (IVF). Occasionally, the pronuclei disappear before this time, rendering them as 'undocumented'. Since the number of pronuclei detected is used to distinguish normal from abnormal embryos in the context of ploidy, the diploidy of undocumented embryos is questionable, and therefore they are routinely discarded. The introduction of fluorescent in-situ hybridization (FISH) technology allows the assessment of ploidy status in undocumented embryos that continue to cleave to form blostomeres. In this study, we used FISH to analyse the chromosomal status of 23 undocumented embryos obtained from 10 patients. Biopsied blastomeres were fixed and probed for five chromosomes (X, Y, 13, 18, 21). Diploidy was confirmed in 13 (57%) embryos while the remaining 10 embryos displayed various chromosomal anomalies. Six of the diploid embryos were transferred subsequently to the patients. One ongoing pregnancy was achieved following transfer of an undocumented, analysed embryo, which was already cleaved when assessed 20 h after insemination. We suggest that accelerated dismantling of the pronuclear membrane and subsequent cleavage do not necessarily indicate abnormal chromosomal content and may result in normal pregnancy. In a patient with a small number of embryos, FISH may be used to ascertain diploidy of undocumented embryos, thereby increasing the number of available embryos for transfer.

does intravenous administration of human albumin prevent severe ovarian hyperstimulation syndrome?

OBJECTIVE: To report our experience with i.v. albumin as a means to prevent ovarian hyperstimulation syndrome (OHSS) in high-risk patients. DESIGN: Retrospective case-series. SETTING: University hospital-based IVF program. PATIENTS: Five women undergoing controlled ovarian stimulation for IVF-Based on previous history and/or E2 measurements and number of ovarian follicles, these patients were considered to be at high risk for developing OHSS. INTERVENTIONS: Intravenous albumin was given at the time of oocyte retrieval. Additional doses were given 12 and 24 hours later. MAIN OUTCOME MEASURE: Development of OHSS. RESULTS: Four patients developed OHSS; two of them had the severe form of the syndrome. CONCLUSIONS: Severe OHSS may develop in high-risk patients despite the prophylactic administration of i.v. albumin.

Comparison of gonadotrophin-releasing hormone analogues and human chorionic gonadotrophin for the induction of ovulation and prevention of ovarian hyperstimulation syndrome: a case-control study.

Gonadotrophin-releasing hormone analogue (GnRHa) has been suggested as an alternative to human chorionic gonadotrophin (HCG) for triggering ovulation, while preventing ovarian hyperstimulation syndrome (OHSS). Since a prospective, controlled study would be unethical at this point, we used a retrospective, case-self control approach to compare GnRHa with HCG in that context. A group of 16 in-vitro fertilization (IVF) patients who had severe OHSS in previous cycles, in which HCG was given to trigger ovulation, were studied in subsequent cycles in which GnRHa was used. Each GnRHa cycle (case) was compared to a previous HCG cycle that resulted in OHSS (self control). None of these subsequent cycles resulted in severe OHSS. The use of GnRHa did not affect the number of oocytes retrieved or their quality. Serum oestradiol concentrations on the day of ovulation triggering were significantly (P < 0.01) higher in the GnRHa cycles compared to HCG cycles. Exogenous progesterone and oestradiol were effective in maintaining relatively constant serum oestradiol and progesterone serum concentrations during the luteal phase. Pregnancy rate per cycle was similar in the two groups. In conclusion, the use of GnRHa to induce ovulation in IVF patients, who are at high risk for developing OHSS, effectively eliminates this risk without affecting other parameters of the stimulation cycle.

Prenatal diagnosis of congenital diaphragmatic hernia: timing of visceral herniation and outcome.

Ultrasonographic prenatal diagnosis of congenital diaphragmatic hernia is well established, but the correlation of prenatal detection with clinical outcome remains unclear. We report our experience with 15 cases of prenatally diagnosed congenital diaphragmatic hernia. Seven fetuses were detected at 14-16 weeks' gestation; two with a normal sonographic study at 15 and 16 weeks' gestation showed visceral herniation at 21 and 23 weeks, respectively. In the remaining six cases, a diaphragmatic hernia was found at ultrasonography after 24 weeks' gestation, while previous sonographic studies had been normal. All seven fetuses in whom a diaphragmatic hernia was diagnosed before 16 weeks' gestation were aborted; four of them had severe malformations or karyotype abnormalities. The two neonates who were diagnosed at 21 and 23 weeks' gestation died after surgical repair. In contrast, all six infants whose visceral herniation was diagnosed after 24 weeks of gestation, and whose sonographic studies at 15-23 weeks had been normal, are alive and well after corrective surgery. The results of this series suggest that the timing of visceral herniation into the thoracic cavity is a major indicator of the prognosis of these fetuses and that herniation that occurs after 25 weeks of gestation carries a favourable clinical outcome. Normal sonographic studies during the first half of pregnancy do not exclude the subsequent development of congenital diaphragmatic hernia, raising questions about the advisability of repeat examinations at later stages of gestation.

The natural history of multiple pregnancies after assisted reproduction: is spontaneous fetal demise a clinically significant phenomenon?

OBJECTIVE: To determine the rate of spontaneous fetal demise after heartbeats are demonstrated in multiple pregnancies conceived after IVF-ET. DESIGN: Retrospective case series. SETTING: University-based IVF-ET program. PATIENTS: Eighty-one patients in whom initial transvaginal ultrasound (US) study, performed at 5 to 6 weeks of gestation, identified more than one gestational sac. Total number of sacs was 191. INTERVENTION: Patients were followed by serial US examinations. MAIN OUTCOME MEASURE: Outcome of pregnancies. RESULTS: Twenty-four empty gestational sacs were identified in 21 patients, of whom 15 delivered, 2 miscarried, and 4 are currently ongoing beyond first trimester. Of the 167 initially viable embryos, 9 (5%) underwent spontaneous fetal demise. In 5 of these 9 pregnancies, initial US identified significant interfetal size variation. CONCLUSIONS: The rate of spontaneous fetal demise for a specific embryo in multiple gestation, after fetal heartbeats have been identified in early pregnancy, is 5%. This rate is similar to that seen in spontaneous conceptions. The chance of future fetal demise increases if first trimester interfetal size variation is significant.

Assessment of ovarian and uterine blood flow by transvaginal color Doppler in ovarian-stimulated women: correlation with the number of follicles and steroid hormone levels.

OBJECTIVE: To study the changes that occur in vascular resistance to flow in the utero-ovarian circulation and their correlation with the number of follicles and steroid hormone levels in patients undergoing ovarian stimulation with gonadotropin. DESIGN: In a prospective study, the impedance to flow in the intraovarian and uterine vessels was measured by means of transvaginal color flow Doppler imaging throughout the cycle. SETTING: University-based IVF program. PATIENTS: Eleven infertile patients undergoing ovarian stimulation with gonadotropin in preparation for IVF and ET. MAIN OUTCOME MEASURES: Intraovarian, uterine, and arcuate artery blood flow velocity waveforms, follicular growth, and serum E2 and P concentrations throughout the cycle. RESULTS: Pulsatility index (PI) of the intraovarian blood vessels and uterine artery decreased gradually during the follicular and luteal phase. The PI of the arcuate artery did not change significantly. The PI of the intraovarian blood vessels correlated with the number of follicles (> 15 mm; day of hCG). Serum E2 concentrations but not P demonstrated negative linear correlation with the PI of the intraovarian vessels and uterine artery. CONCLUSIONS: Induced cycles are associated with decreased impedance to blood flow in the utero-ovarian circulation. Intraovarian PI correlates negatively at each stage of the cycle with the eventual number of preovulatory follicles. Little or no changes are observed when the response to ovarian stimulation is poor.

No beneficial effects of human growth hormone therapy in normal ovulatory patients with a poor ovarian response to gonadotropins.

We studied the effects of human growth hormone (hGH) in 7 in vitro fertilization (IVF) patients with normal ovulatory menstrual cycles who showed a low response to ovarian stimulation with follicle-stimulating hormone (FSH) and human menopausal gonadotropin (hMG). Human growth hormone therapy had no significant effect on the number of days of gonadotropic stimulation, on the total amount of hMG administered, on the serum estradiol level on the day of human chorionic gonadotropin injection, or on the IVF outcome. Our preliminary results do not encourage the routine use of hGH to improve IVF outcome in normogonadotropic ovulatory patients who respond poorly to the standard FSH/hMG protocol.

The uterus: a new look with transvaginal sonography.

Targeted scanning of the uterus and its adjacent structures is made possible by high-resolution transvaginal sonography. A systematic approach is applied so that the normal anatomy and abnormal processes in the various uterine components can be visualized. By adopting this method we detected various pathologies in the cervix, endometrium, myometrium, and in the uterine vessels and ligaments. Cervical pathology included inflammatory processes, cysts, malignant lesions, and incompetence during pregnancy. By scanning the endometrium, a reflection of the hormonal status of the patient under both normal (e.g., the menstrual cycle) and abnormal conditions may be obtained. More sinister lesions, such as endometrial hyperplasia and carcinoma, can be suspected based on the sonographic appearance of the endometrium. In hydatiform mole, a typical sonographic picture directs the sonographer to the diagnosis. Uterine fibroids are the most common lesion of the corpus uteri, and are readily detected by transvaginal sonography, including any degenerative changes that may complicate this condition. Changes in uterine size, particularly when accompanied by profuse intracavitary fluid, should raise the suspicion of a malignant process. Intracavitary fluid may also be associated with inflammatory lesions (e.g., tuberculosis). Congenital uterine anomalies may be diagnosed and defined by this method. Uterine ligaments are best visualized in the presence of fluid in the pelvis. Intraligamentary masses can be also be detected and defined. Finally, the main vessels supplying the uterus can be visualized, both in pregnant and nonpregnant patients. Using a transvaginal image-directed Doppler system, flow velocity profiles can be obtained from these vessels and form the basis for defining abnormalities in uterine perfusion.

Early treatment by plasmapheresis in a woman with multiple abortions and the rare blood group p.

Women with the rare blood group p are known to have an increased rate of abortions. The case of a 36-year-old woman is presented who had had 7 spontaneous abortions in the first trimester and no live child. When treated by plasma exchange begun early in pregnancy and continued until the 29th week, she delivered a normal child. Time to begin, amount and length of time necessary to continue plasma exchange in these patients are considered. In addition, the question of which fraction of the anti-PP1Pk could be responsible for abortion is discussed. To our knowledge, this is the first case of a woman of p phenotype with no live children but with multiple abortions treated by this method, which should be seriously considered in similar cases.