Treatment-related and treatment-independent deliveries among infertile couples, a long-term follow-up.

BACKGROUND: The aim of this hospital based long-term follow-up study was to further elucidate resolved and unresolved infertility in relation to risk factors and perinatal outcome considering treatment-related and treatment independent pregnancies. METHODS: The study included all couples attending the out-patient clinic of the Department of Gynecology in Umeå due to failure to initiate a pregnancy after at least 12 months during the period 1.1.1980-31.12.1989. Data from the Swedish Medical Birth Registry consisting of all registered births during 1.1.1980-31.12.1992 was linked to establish the number of children born. RESULTS: Six hundred and ninety-one couples were analyzed, out of which 42% had a delivery outcome. Of these women, 53% conceived in relation to given treatment whereas 47% conceived treatment-independently. Women with ovulatory disorder had a cumulative delivery rate of 82%, whereas those with unexplained infertility and tubo-peritoneal pathology displayed delivery rates of 57% and 31% respectively. Duration of infertility > 3 years was the major negative prognostic factor among patients with unexplained infertility. The frequency of premature deliveries, low birth weight and perinatal mortality was increased among patients with treatment related pregnancies. CONCLUSION: For ovulatory disorders the prognosis for a resolved infertility is good. The results among patients with tubo-peritoneal pathology emphasizes the need of in vitro fertilization in modern treatment of infertility. Unexplained infertility is accompanied with a high rate of spontaneous pregnancies but prolonged duration is a negative prognostic factor for these patients. Irrespective of diagnosis, the perinatal outcome is worse in patients with treatment-related pregnancies.

Evaluation of different ovarian stimulation protocols for in vitro fertilization.

In this study we evaluated retrospectively the efficacy of five different ovarian stimulation protocols in an in vitro fertilization program, in which 512 women were involved. Ovulation was induced by the following protocols: group I (271 cycles): buserelin short protocol (1 mg/day, intranasally) with human menopausal gonadotropin/human chorionic gonadotropin (hMG/hCG); group II (45 cycles): buserelin (short protocol) with pure follicle stimulating hormone (p-FSH)/hMG/hCG; group III (24 cycles): clomiphene citrate (100 mg/day) with hMG/hCG; group IV (122 cycles): hMG (3 ampules/day) and hCG; group V (113 cycles): hMG/hCG and prednisolone (7.5 mg/day) after cycle programming with oral contraceptives. The lowest cancellation rate (3.3%) was noted in group I, followed by group V (9.7%). The highest number of follicles was observed in groups I (8.3 +/- 0.3; mean +/- SEM) and V (7.8 +/- 0.5). Also, more oocytes were retrieved in group I (7.2 +/- 0.3, p < 0.001), which were of good quality based on oocyte maturity as well as on the fertilization rate, and more embryos (4.5 +/- 0.3, p < 0.05) were developed. The correlation between estradiol and the total follicular volume on the day of hCG administration was also examined in the five groups. The best correlation (r = 0.6502) was found in group I, followed by group V (r = 0.5810). Significant differences were observed in the five groups with regard to the number of hMG ampules administered (p < 0.0001, F = 15.393) and the stimulation days (p < 0.0001, F = 35.32). Sixty-six clinical pregnancies were achieved: 37 (17.5%) in group I, seven (25.9%) in group II, one (10%) in group III, ten (15.6%) in group IV and 11 (15.5%) in group V (differences were not statistically significant). In conclusion, all five protocols were satisfactory in ovarian stimulation for in vitro fertilization, and gonadotropin releasing hormone (GnRH) analogs seemed to be more advantageous by reducing the cancellation rate, enhancing the number of oocytes retrieved and embryos developed and by improving the pregnancy rates.

A short course of menotropin after clomiphene failure in infertile women with luteal phase defects.

Twenty-four women with luteal phase defects who were ovulatory on clomiphene therapy with or without human chorionic gonadotropin (hCG) at midcycle for three to eight cycles yet failed to produce a live birth were treated with a short course of menotropin (hMG-S), one to two ampules for five days in the early follicular phase followed or not followed by hCG at midcycle for three to eight cycles. The luteal phase defect was diagnosed with repeat endometrial biopsies with a lag time of three or more days prior to clomiphene therapy. A complete infertility workup revealed only eight patients (33%) with a purely endocrine factor (luteal phase defect). The rest (16 patients, or 67%) had one or two additional infertility factors. Two abortions occurred in this group during clomiphene therapy, while five pregnancies (four live births and one spontaneous abortion) occurred during hMG-S therapy. The ovulation rates were similar for hMG-S (89%) and clomiphene (91%) therapy, but the frequency of a normal ovulatory cycle was significantly greater (P = .026) for hMG-S therapy (71%) than for clomiphene therapy (57%). The midluteal mean serum progesterone level was lower and the mean luteal length shorter in the cycles with less than 130 ng/mL/d of total integrated luteal progesterone. The postcoital test results showed better cervical mucus, with increased mucus volume and better fluidity and spinnbarkeit, in hMG-S cycles than in clomiphene cycles. It appears that hMG-S treatment can improve ovarian function and achieve successful pregnancy in patients with luteal phase defects who fail to produce a live birth during clomiphene treatment.