Management of patients with endometriosis and infertility: laparoscopic treatment and spontaneous pregnancy rate.

OBJECTIVE: To evaluate factors involved in spontaneous pregnancy rate after surgery for endometriosis in patients with endometriosis and infertility. METHODS: This retrospective study spanned from 2014 to 2020 and included a follow-up period of two years of patients with endometriosis-related infertility who underwent laparoscopic surgery. Women aged 25 to 43 years with patent tubes, no/mild male factor and no other infertility factors were selected and grouped according to fertility management as follows: patients immediately prescribed ART (16.5%, ART-p); patients who chose not to undergo ART (83.5%) and achieved spontaneous pregnancy (71.8% SP-p); and patients who first chose not to undergo ART but had it subsequently (28.2%, NSP-p). RESULTS: A total of 200 patients were analyzed. Of the 167 patients who waited for spontaneous pregnancy, 71.8% achieved it. We observed a tendency of higher endometriosis ASRM scores in the ART-p group compared with patients who waited for spontaneous pregnancy, and lower scores in individuals that achieved spontaneous pregnancy. When we looked at how long it took to achieve pregnancy, we found that individuals in the SP-p group achieved pregnancy in 5.7 months, while subjects in the NSP-p group took 1.8 times longer than their peers in the SP-p group (p<0.001). However, once prescribed ART, the individuals in the NSP-p group achieved pregnancy within a similar time when compared with subjects in the SP-p group. In order to identify individuals that might benefit from ART early on, we performed a multivariable analysis and developed a decision tree (81.3% accuracy and 53.3% sensitivity). CONCLUSIONS: The present results indicated that, after surgery, the majority of patients achieved spontaneous pregnancy. The decision tree proposed in this study allows the early identification of patients who might require ART, thus decreasing the time between surgery and pregnancy and improving overall outcomes.

Sperm DNA fragmentation and male age: results of in vitro fertilization treatments.

OBJECTIVE: This study aimed to assess the effects of sperm DNA fragmentation in parents belonging to different age groups. The couples included in the study comprised normozoospermic men and infertile women undergoing conventional IVF. METHODS: The results obtained from 163 conventional IVF cycles were analyzed retrospectively. The couples enrolled in the study included women aged between 30 and 37 years. Sperm DNA fragmentation was studied using the TUNEL assay. The patients were split into four groups based on male age and sperm DNA fragmentation, as follows: Group 1: ≤39 years and TUNEL assay ≤20%; Group 2: ≤39 years and TUNEL assay >20%; Group 3: ≥40 years and TUNEL assay ≤20%; and Group 4: ≥40 years and TUNEL assay >20%. RESULTS: No significant differences were found in semen parameters or fertilization rates between groups. Groups with <20% sperm DNA fragmentation showed significant differences in other parameters, including higher blastocyst formation rate (Group 1: 63% and Group 3: 60% vs. Group 2: 43% and Group 4: 41%, p<0.05) and higher expanded blastocyst formation rate (Group 1: 42% and Group 3: 40% vs. Group 2: 21% and Group 4: 18%, p<0.05). Miscarriage rate was significantly higher in Group 4 (42% and 46% vs. 5%, 25% and 5% in Groups 1, 2 and 3, respectively, p<0.05). CONCLUSIONS: Our results showed lower blastocyst formation rates from IVF when males had high levels of sperm DNA fragmentation. Higher miscarriage rates were also observed in couples with males aged 40+ years. These results reinforce the need to inform couples with male partners aged 40+ years about the potential risks inherent to fertility treatment.

Optimizing the number of embryos to transfer on day 5: two should be the limit.

OBJECTIVE: To define the appropriate number of embryos to be transferred at day 5. METHODS: Retrospective analysis of 784 consecutive fresh day-5 embryo transfers performed between 2007 and 2015, divided in three groups: Group A (N = 219): received the only 2 embryos that reached a transferable stage; Group B (N = 357): received 2 selected embryos among several that reached a transferable stage; Group C (N = 208): received the only 3 developing embryos. Clinical pregnancy, implantation, multiple pregnancy and delivery rates were registered. Kruskal-Wallis and Fisher Exact tests were applied as appropriate. RESULTS: Age and previous attempts were comparable in the 3 groups. Compared with Group A, Groups B and C had a higher oocyte recovery (10.7 ± 5.6 vs. 14.7 ± 8.0 vs. 13.8 ± 6.6), fertilization rate (75.97% vs. 81.60% vs. 83.29%) and percentage of embryos reaching a transferable stage on day 5 (39.98% vs. 63.99% vs. 60.97%), as well as a significantly higher clinical pregnancy (42.92% vs. 61.06% vs. 58.17%) and implantation rates (21.09% vs. 40.98% vs. 36.97%). The multiple pregnancy rate was higher in Groups B and C than in Group A (11.70% vs. 31.19% vs. 37.19%). The high order multiple pregnancy rate (> 2) was significantly increased in group C (1.06% vs. 0.92% vs. 14.05%). CONCLUSIONS: In patients with 3 or more day 5 developing embryos, delivery rates are similar if 2 or 3 embryos are transferred. The transfer of 3 embryos carries an unacceptable increase in the risk of high order multiple pregnancy, with its known consequences. According to our data, we should not exceed the number of 2 day-5 fresh embryos transferred.

Embryo Transfer Catheters: Softer is Easier.

OBJECTIVE: This study aimed to compare the use of semi-rigid and flexible catheters in terms of pregnancy rate and level of difficulty of the embryo transfer (ET) procedure. METHODS: Seven hundred and thirty-nine consecutive follicular aspirations for IVF or ICSI performed in our private fertility clinic within a 30-month period were randomly divided into two groups. Patients were allocated to either of the groups at the time of follicular retrieval with the aid of a random number generator according to the catheter used in ET: Group 1 (n = 370) - Frydman Classic Catheter 4.5 catheters; and Group 2 (n = 369) - Frydman Ultrasoft 4.5 catheters. Only patients offered ET in the randomized cycle were included (Group 1 = 363 and Group 2 = 340). Patients did not change groups after catheter allocation. Statistical analysis was carried out using an unpaired t-test or a chi square test as appropriate. Differences with P<0.05 were considered. RESULTS: A statistically significant difference in favor of the use of the Ultrasoft catheter was evident for parameters use of a tenaculum (19.8% vs. 5.9%) or a hysterometer (5.0% vs. 1.2%), presence of blood during post-ET inspection of the catheter (9.9% vs. 3.8%), and implantation rate (13.0% vs. 16.4%). Clinical pregnancy and delivery rates were comparable in both groups. CONCLUSION: Our results suggest that a softer catheter may help with difficult ETs. Softer catheters, as also reported by other authors, resulted in better implantation rates.