Sex ratio and birth weights of infants born as a result of blastocyst transfers compared with early cleavage stage embryo transfers.

OBJECTIVE: To analyze the birth weights and sex ratio of infants born as a result of blastocyst transfer and compare them with data resulting from the transfer of early-cleavage stage embryos. DESIGN: Retrospective analysis. SETTING: Monash IVF (private in vitro fertilization clinic). PATIENTS(S): One hundred twenty-five infertile patients who became pregnant after IVF procedures involving blastocyst transfer. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Sex ratio and birth weights of infants born after blastocyst transfer. RESULT(S): The sex ratio of 129.6 for infants born after blastocyst transfer was not significantly different from the sex ratio calculated from data compiled by NPSU for births resulting from early cleavage stage embryo transfers at Monash IVF (100.6) and all other assisted conception units in Australia and New Zealand (97.9). No differences were observed in the combined mean birth weight of male and female infants born as a result of blastocyst transfers and early-cleavage stage embryo transfers. CONCLUSION(S): There is no evidence of abnormal fetal growth or a shift in the sex ratio for infants born as a result of blastocyst transfer when compared with the case of births resulting from early cleavage stage embryo transfers within our unit or all other assisted conception units in Australia and New Zealand.

Cumulative pregnancy and live birth rates in women with antiphospholipid antibodies undergoing assisted reproduction.

The aims of this study were to investigate the influence of antiphospholipid antibodies (APA) on cumulative pregnancy and live-birth rates in patients undergoing assisted reproductive treatment. Serum samples from 173 patients were collected prior to initiation treatment cycle and tested by enzyme-linked immunosorbent assay (ELISA) for the presence of immunoglobulin (Ig)G, IgM and IgA against cardiolipin, phosphoserine, phosphoethanolamine, phosphoinositol, phosphatidic acid, and phosphoglycerol. Fifty-six samples from patients who had at least two failed cycles by assisted reproductive treatment were also tested by a bioassay for the presence of lupus anticoagulants. Both cumulative pregnancy and live birth rates were not affected by the presence of any specific or any number of seropositive APA. There was no association between multiple assisted reproductive treatment failures and APA seropositivity. Neither the serum concentration of any of the 18 APA, nor the number of positive APA was correlated with the number of assisted reproductive treatment failed cycles or affected the probability of pregnancy. No patient was found to be positive for lupus anticoagulants. Using life table analyses, which has been recognized as the most appropriate method available to analyse assisted reproductive treatment results, we conclude that there is no relationship between circulating APA and assisted reproductive treatment outcome. APA do not affect the early process of implantation or maintenance of pregnancy among assisted reproductive treatment patients.

The mechanism of action of epidermal growth factor and transforming growth factor alpha on aromatase activity in granulosa cells from polycystic ovaries.

We investigated aromatization and the mechanism of action of epidermal growth factor (EGF) and transforming growth factor alpha (TGFalpha) on oestradiol biosynthesis in freshly prepared granulosa cells from polycystic ovaries. Freshly prepared granulosa cells from polycystic ovaries incubated for only 3 h under basal conditions secreted significantly (P< 0.001) greater amounts of oestradiol-17beta than that of granulosa cells from normal ovaries. 8-Bromo-cyclic adenosine monophosphate (8-Br-cAMP), but not follicle stimulating hormone (FSH) or luteinizing hormone (LH), further enhanced this activity. Both EGF and TGFalpha inhibited gonadotrophinor 8-Br-cAMP-stimulated, but not basal, oestradiol production. LH receptor (LHR) binding, estimated by immunolabelling the bound LH, was significantly (P< 0.001) reduced in granulosa cells from polycystic ovaries when compared with cells from normal ovaries. EGF or TGFalpha significantly reduced the binding in cultured cells from all patient groups (P< 0.05). More interestingly, a further increase of the inhibitory effect was seen in granulosa cells from polycystic ovaries (P < 0.001). In conclusion, granulosa cells from polycystic ovaries contain high levels of basal aromatase activity in vitro, which is probably inherited from the in-vivo condition. EGF and TGFalpha suppress oestradiol synthesis at a step beyond the production of cAMP and also LHR binding with more effect in granulosa cells from polycystic ovaries.

Factors affecting the success of human blastocyst development and pregnancy following in vitro fertilization and embryo transfer.

OBJECTIVE: To determine the factors affecting blastocyst development and pregnancy after IVF and ET. DESIGN: Retrospective analysis of data arising from a clinical trial. SETTING: Private in vitro fertilization clinic. PATIENT(S): Fifty-six patients aged < or = 40 years, undergoing IVF procedures for infertility, recruited specifically for blastocyst transfer. INTERVENTION(S): All zygotes were cultured to days 5 or 6 after insemination, and one to four of the most advanced blastocysts were transferred to the patient's uterus. MAIN OUTCOME MEASURE(S): Development of zygotes to blastocysts in vitro and pregnancy and implantation rates after ET. RESULT(S): Fifty-one percent of all zygotes developed to blastocysts. Significant positive correlation between the number of blastocysts formed was observed with the number of oocytes, pronuclear zygotes, and eight-cell embryos formed. There was a negative correlation with male factor infertility. By day 5 or 6, 93% of the patients had at least one blastocysts, and the clinical pregnancy rate per transfer was 43% and the implantation per embryo transferred was 25%. No other clinical factor significantly affected the number of blastocysts formed, pregnancy rate, or implantation rate. CONCLUSION(S): The numbers of oocytes, zygotes, and normally developing embryos in culture significantly affects the production of blastocysts in vitro. Male infertility significantly reduces blastocyst production. The number and the quality of the blastocysts transferred significantly influences clinical pregnancy rate.

Oocyte maturation.

Primary oocytes recovered from small and growing follicles of > or = 3 mm in the ovaries of untreated women, can be matured in vitro, will fertilize and develop in vitro, and when transferred to the patient, develop to term. However, the implantation rate of cleaved embryos has been disappointingly low and when embryos are allowed to develop beyond the 4-cell in vitro, retardation of development and blockage is frequently observed, with relatively few embryos developing to blastocysts. We have devised new culture systems for human embryos to enable high rates of development of in-vivo matured oocytes to blastocysts within 5-6 days of culture, and high implantation rates of these blastocysts when they are transferred to the patients' uterus. These culture systems are now being used for in-vitro matured oocytes. In order to determine whether embryo developmental competence could be improved, a number of factors were examined. Treatment of patients with pure follicle stimulating hormone (FSH) early in the follicular phase, or treatment with oestrogen prior to oocyte recovery, had no apparent effect on any parameters of oocyte developmental competence. There was no indication that a medium made specifically for human oocyte maturation improved oocyte developmental competence. Nuclear and cytoplasmic changes in oocytes matured in vitro appear to be similar to that in vivo, although some lack of synchronization in completing maturation is evident. It is possible that follicles of < 10 mm diameter in the human contain developmentally-incompetent oocytes. However, the development to term and birth of normal babies from germinal vesicle stage oocytes recovered from small follicles and matured in vitro, suggests that further research will identify the factors necessary to improve embryo developmental competence. The application of immature oocyte collection (IOC) and in vitro maturation (IVM) as an alternative to ovulation stimulation with high doses of gonadotrophins for in-vitro fertilization (IVF), remains a priority for research in human medicine.

Hyperexpression of epidermal growth factor receptors in granulosa cells from women with polycystic ovary syndrome.

OBJECTIVE: To compare the localization and quantitation of epidermal growth factor (EGF) receptor in granulosa cells from women with normal and polycystic ovaries. DESIGN: Controlled, comparative study. SETTING: Academic research laboratory. PATIENT(S): Forty-two women with normal or polycystic ovaries who attended our facility for the recovery of their immature or mature oocytes or for therapeutic purposes. INTERVENTION(S): Patients underwent intravaginal ultrasound-guided oocyte retrieval or laparoscopic follicular aspiration with or without prior stimulation. MAIN OUTCOME MEASURE(S): Quantitation of EGF receptor in granulosa cells. RESULT(S): Granulosa cells from polycystic ovaries expressed significantly higher levels of EGF receptor than granulosa cells from normal ovaries. In contrast with patients who were treated with clomiphene citrate, those who were treated with gonadotropins showed low levels of the receptor. However, the levels of the receptor in granulosa cells were not correlated with circulating levels of LH, FSH, progesterone, or E2. Immunolabeling of EGF receptor was confined to the cell membrane of granulosa cells. This receptor was fully functional, mediating the ligand-induced inhibition of E2 production in culture. CONCLUSION(S): These results provide further evidence supporting a possible role of EGF/transforming growth factor-alpha in the aberration of ovarian function in polycystic ovary syndrome.

Evolution of a culture protocol for successful blastocyst development and pregnancy.

A cell-free culture system was designed for human embryo development to the blastocyst stage by testing a range of culture conditions in a series of protocols. The culture system that was evolved has a brief 1 h exposure to spermatozoa and then culture of the pronucleate zygote for 2 days in IVF-50 medium. Two or three embryos were cultured together in 20 microl microdrops of medium under oil. Embryos were then regrouped and two or three at a similar stage were cultured together in 50 microl microdrops of Gardner's G2 medium under oil from days 3 to 5. Embryos were transferred to fresh G2 medium on day 5 and cultured for a further 1 or 2 days (day 6 or 7). No serum was used in any of the cultures. The embryo transfer medium and G2 medium were supplemented with human serum albumin. The zonae of all blastocysts to be transferred to patients were completely removed enzymatically. Using this protocol, 52% of zygotes developed to blastocysts and 34 out of 35 patients treated received 82 blastocysts and 11 morulae on day 5 or 6. Twenty-one fetal sacs with positive heartbeats (23% implantation rate) were detected in 13 ongoing pregnancies (38% pregnancy rate/transfer or 37%/patient treated). We anticipate that further improvements in embryo development and the selection of viable embryos can be achieved using this simple and effective culture system.

Laparoscopic and abdominal hysterectomy: a cost comparison.

OBJECTIVE: To compare the cost of laparoscopically assisted vaginal hysterectomy (LAVH) with that of total abdominal hysterectomy (TAH) under casemix. DESIGN: Retrospective comparison of the costs, operating time and length of hospital stay. PATIENTS: The 16 women undergoing consecutive LAVH and 16 age-matched women undergoing TAH between 1 February 1994 and 31 July 1995; all women were public patients undergoing hysterectomy for benign disease. SETTING: Monash Medical Centre, a large tertiary teaching hospital in Melbourne, Australia, where casemix is used to determine funding and budget allocation. RESULTS: The difference between the costs of the two procedures was not statistically significant (P = 0.5), despite the cost of laparoscopic hysterectomy including that of disposables. The mean operating time for TAH was 86 minutes (95% CI, 65.5-106.5), compared with 120 minutes (95% CI, 100.8-140.5) for LAVH (P < 0.01). The mean length of stay in the TAH group was 5.75 days, compared with 3.25 days in the LAVH group (P < 0.001). CONCLUSION: In hysterectomy for benign gynaecological disease, the laparoscopic procedure costs the same as the total abdominal procedure. Audit such as this is important in patient management and in guiding hospitals in funding and bed allocation.

Laparovaginal hysterectomy.

The technique and complications of 141 patients having laparovaginal hysterectomy in private practice are reported. Abdominal hysterectomy was avoided in the 110 patients having preliminary laparoscopic surgery for pelvic disease, ovarian removal, or a uterus larger than 12cm. Postoperative morbidity included pulmonary embolus (3), vesicovaginal fistula (2) and pelvic haematoma (4). The frequency of complications was less than that reported after abdominal or vaginal hysterectomy. The surgical technique changed during the series; the operative care of the bladder and ureter requires particular attention. A larger number of patients in a variety of centres require study before the laparoscopic procedure can be determined to be as safe as abdominal or vaginal hysterectomy. The laparoscopic procedure has the potential to replace the majority of abdominal hysterectomies.

Complications of laparoscopic hysterectomy.

Although laparoscopic hysterectomy is now being performed worldwide, few reported data are available on the associated morbidity and mortality. Between December 1990 and September 1993, 220 women underwent laparoscopic hysterectomy at the Melbourne Gynoscopy Centre. Complications occurred in 35 (15.9%). Among these were anterior abdominal wall vessel injury in 5 patients, bladder injury in 5, febrile illness in 13, secondary hemorrhage in 4, temporary ureteral obstruction in 4, and Richter hernia in 1.

Laparoscopic adnexectomy--indications, technique and results.

Laparoscopic adnexectomy was performed successfully in 38 patients in whom the procedure was attempted. Failure may result from inexperience of the surgeon or when preliminary dissection near bowel suggests trauma is likely. The duration of the operation was between 15 and 105 minutes, blood loss was minimal and all but 2 patients were discharged within 24 hours of surgery. Pain was relieved in 33 of 35 patients in whom this was the dominant symptom. In 1 patient a small ovarian remnant implanted on the bladder was removed at subsequent laparoscopy. Preliminary experience of this procedure suggest it may be preferable to laparotomy because of the reduced risk of wound complications, pain, time in hospital and duration of convalescence.

Laparoscopically assisted hysterectomy.

OBJECTIVE: To determine the feasibility and effectiveness of laparoscopically assisted hysterectomy. DESIGN: A prospective study of the planned surgical procedure was carried out by two teams, each with two gynaecologists, who were experienced in operative laparoscopy. SETTING: The operations were carried out in a private hospital, where advanced operative laparoscopy equipment was available. PATIENTS: Seventeen patients were selected for the procedure, all of whom required hysterectomy for symptoms of pain or menorrhagia in association with uterine or other pelvic disease. Patients with carcinoma or uterine enlargement beyond 12 cm were excluded. PROCEDURE: Laparoscopically assisted hysterectomy was carried out by means of a video monitor, uterine manipulation by vaginal instrumentation, three or four abdominal punctures of less than 1 cm, and bipolar diathermy to secure vascular pedicles. The uterus was removed from the vagina by cutting vaginal skin and the cardinal ligaments. RESULTS: The operating time was 90-220 min, the blood loss was 30-200 mL, and the hospital stay lasted two to five days and convalescence two to four weeks. No serious complications occurred. CONCLUSIONS: Laparoscopically assisted hysterectomy may be valuable when adnexal or uterine abnormalities are present and vaginal hysterectomy is either contraindicated or more difficult. The procedure requires special equipment and may only be carried out by experienced gynaecological operative laparoscopists. Its acceptance will depend upon reducing the operating time to less than 90 min. It has the advantage of reducing the duration of hospital stay and the duration of convalescence when compared with abdominal hysterectomy.

Second-trimester termination with 16,16 dimethyl-PGE1-methyl ester (gemeprost), compared with a regimen that included intra-amniotic PGF2 alpha and hypertonic saline.

The use of gemeprost (16,16 dimethyl-PGE1-methyl ester) pessaries was compared in an open, randomized single-centre trial with the intra-amniotic injection of PGF2 alpha combined with hypertonic saline, intravenous oxytocin and a hygroscopic cervical dilator (Dilapan) for the termination of pregnancy between 14 and 20 weeks. There was no significant difference in the induction-delivery interval for the two groups. With the exception of an increased incidence of diarrhoea in the gemeprost group, there was no significant difference in other side effects, analgesic requirements or retained placentae. Gemeprost pessaries are an effective alternative to the more invasive methods previously used for the induction of second-trimester termination.

PIP: Gemeprost vaginal suppositories (16,16-dimethyl-PGE1 methyl ester) were compared with intraamniotic Pgf2alpha in 20% saline after Dilapan tents for termination of 14-16 week pregnancies in 58 women. After randomization there were 44% multigravidae in the Gemeprost group and 58% in the Pgf2alpha-saline-Dilapan group; the Gemeprost group averaged 23.4 years, the Pgf2alpha group 26.2%. Gemeprost 1 mg vaginal pessaries were inserted at 3 hr intervals for a maximum of 5 doses. Pgf2alpha 20 mg in 40 ml 20% NaCl was injected intraamniotically under ultrasonic control immediately after Dilapan was inserted in the cervix. If abortion had not occurred within 24 hours, management by iv oxytocin, iv Pgf2alpha, intraamniotic Pgf2alpha or saline or both was at the physician's discretion, as was post-abortion treatment with oxytocin, ergometric or surgical evacuation of the placenta if not delivered within 2 hours. Successful abortion, defined as induction abortion intervals of 24 hours, occurred in 58% of the Gemeprost group and 90% of the PG-saline group, for mean induction-abortion intervals of 12.6 and 11.7 hours. 6 more Gemeprost patients aborted within 27.8 hours without additional treatment, while the last 2 patients to deliver took 42 and 50 hours, compared to a 32-hour maximum interval for PG-saline patients. Much of the difference in intervals was accounted for by primigravidas, who took 15.84 hours on average with Gemeprost, compared to 13.7 hours with PG-saline. Gastrointestinal side effects were more common in the Gemeprost group: diarrhea in 58% and vomiting in 62%, compared to 7% with diarrhea and 34% with vomiting in the PG-saline group. Retained placenta, hemorrhage 300 ml and pain requiring narcotics were similar in both series. The outcomes in terms of induction-abortion intervals were not significantly different. Gemeprost was considered the agent of choice, since it is not invasive, and avoids the risk of sudden collapse or death, intrauterine infection, saline intoxication or clotting disorders, which occur on rare occasions in Pgf2alpha- or saline-induced midtrimester abortions.