Pregnancies in humans by fertilization in vitro and embryo transfer in the controlled ovulatory cycle.

Normal pregnancies have been established in four women with tubal infertility by fertilization in vitro, embryo culture, and embryo transfer after stimulation of follicular growth with clomiphene citrate. In three of these women the time of oocyte maturation was controlled by human chorionic gonadotropin. This procedure for the control of ovulatory response has many advantages when compared with the previously successful method of using the natural ovulatory cycle.

Effect on plasma gonadotropins of cyclic steroid replacement in women with premature ovarian failure.

A sequential regimen of steroid replacement of oral estradiol valerate and progesterone (P) by intravaginal suppository was developed for women with premature ovarian failure or ovarian agenesis. The regimen, based on a 28-day cycle, resulted in peripheral plasma concentrations of estradiol and P within the normal range of the menstrual cycle and endometrial differentiation consistent with the normal secretory phase. Pregnancy has now been successfully established in four patients following this regimen of steroid treatment and transfer of donated embryos. Plasma concentrations of LH were within the normal range by the end of the first cycle of treatment with exogenous steroids. However, plasma FSH remained above the normal range, even during the third treatment cycle, consistent with the necessity of a gonadal feedback factor (inhibin?) other than estradiol and P for maintaining FSH in the normal range. Although 7/8 patients had a surge of LH at midcycle, only 3/8 patients had concomitant FSH surges, supporting a role for progesterone in facilitating the midcycle FSH surge.

An analysis of plasma estradiol concentrations during clomiphene citrate-human menopausal gonadotropin stimulation in an in vitro fertilization-embryo transfer program.

We report here a range of plasma estradiol (E2) concentrations suitable for use in an in vitro fertilization (IVF) program. This range was derived from nonparametric analysis of plasma E2 levels using plasma E2 measurements beginning 10 days before the anticipated day of the midcycle LH surge (midpoint), as calculated from each patient's six previous menstrual cycles, during which time the patients all received the same ovarian stimulation regimen. The regimen consisted of 100 mg clomiphene citrate/day for 5 days, beginning 10 days before the anticipated midpoint, plus 150 IU human menopausal gonadotropin, commencing the day after clomiphene. A consecutive series of 102 IVF conception cycles induced in this standardized fashion were analyzed in this study. The 5th-95 percentile envelope of plasma E2 concentrations was derived as a valid clinical indicator of satisfactory folliculogenesis during IVF treatment. Five women had plasma E2 concentrations below the 5th percentile of the E2 range on at least 3 consecutive days of ovarian stimulation, while six women had E2 levels above the 95th percentile of this range on at least 3 consecutive days. This plasma E2 range defined objectively the diagnoses of ovarian hyperstimulation and inadequate stimulation in an IVF program. These criteria should help clinicians in managing ovarian responses during IVF superovulation stimulation treatment.

The collection of human oocytes for in vitro fertilization. I. An instrument for maximizing oocyte recovery rate.

An instrument has been devised specifically for the collection of mature oocytes of laparoscopy for the purpose of in vitro fertilization. The instrument was evaluated and the oocytes recovery rate was compared with that obtained with two other instruments, which had been in use previously, in a controlled trial over the same period of time. It was found that the newly devised instrument resulted in the recovery of all of the oocytes from 17 follicles in which aspiration was attempted. The oocytes recovery rate was significantly better with this instrument than with either of the two instrument previously used. It was also apparent that the finer-bore needle of the two instruments previously used was more effective for oocytes recovery. The new instrument is now in routine use for oocyte collection.

The relationship of tubal blockage, infertility of unknown cause, suspected male infertility, and endometriosis to success of in vitro fertilization and embryo transfer.

The success of in vitro fertilization (IVF) and embryo transfer has been examined with regard to five categories of infertility over a 2-year period. Fertilization rates in vitro were highest in women with bilateral tubal blockage and women treated for endometriosis. There was a significant reduction of approximately 13% in the fertilization rate of couples with idiopathic infertility and women who had failed to conceive after 12 cycles of artificial insemination by donor. A further substantial reduction in the fertilization rate occurred when the husband had low quality semen, particularly when no abnormality was detected in the wife. Repeated IVF in couples with idiopathic infertility eventually resulted in fertilization. It is recommended that donor spermatozoa not be used for cases of idiopathic infertility, but it may be needed in cases of poor semen quality. There were no differences in the pregnancy rates following embryo replacement in any of the groups studied, nor was there any detectable effect of age on fertilization or pregnancy rates up to the age of 44 years.

Successful use of human semen cryobanking for in vitro fertilization.

Frozen-thawed donor semen was compared with freshly ejaculated donor semen for in vitro fertilization of human oocytes in patients with infertile husbands. There was no significant difference in the fertilization rates between frozen-thawed (85%) and fresh spermatozoa (78%). Fertilization occurred with semen stored for as long as 27 months and with numbers of spermatozoa as low as 20,000/ml culture medium for insemination of oocytes. Pregnancy rates of embryos, fertilized with frozen-thawed and freshly ejaculated spermatozoa, were similar following embryo transfer.

Donor oocyte pregnancy with transfer of deep-frozen embryo.

An infertile woman suffering from premature menopause conceived on her eighth attempt of ET following the transfer of a single frozen-thawed embryo, the ovum being donated anonymously by a patient undergoing tubal sterilization.

The investigation of idiopathic infertility by in vitro fertilization.

The results of in vitro fertilization of mature oocytes obtained at diagnostic laparoscopy from patients with both known and unknown clinical causes of infertility are presented. A simple regimen involving the use of clomiphene and human chorionic gonadotropin which enabled laparoscopy to coincide with available surgical lists resulted in the recovery of mature oocytes from 15 of the 18 patients treated. Apparently normal embryos developed from five of six oocytes recovered from patients who had blocked fallopian tubes or who were being investigated after 8 to 12 months of artificial insemination by donor. No normal embryos developed from oocytes from nine patients who had sustained infertility of unknown cause for 2 years or more. When this latter group was compared with other groups a high rate of fertilization failure was noted, and severe polyspermy developed in two cases. The results are discussed in relation to the diagnosis of infertility and the management of infertile patients.

PIP: This study examines the use of in vitro fertilization as a diagnostic procedure for patients with long-term infertility of unknown cause (idiopathic infertility). 18 infertile patients participated in the study and included: 1) 5 patients with occluded fallopian tubes who served as controls; 2) 3 patients who failed to become pregnant after 8 to 12 months of AID (artificial insemination by donor); and 3) 10 patients who had not conceived in spite of 2 years of regular unprotected coitus (those with idiopathic infertility). Clomiphene citrate and human chorionic gonadotropins (hCG) were administered to control follicular development and maturation to coincide with time of laparoscopy. 25 mature oocytes were extracted from 15 out of the 18 patients at laparoscopy. In vitro fertilization was performed by adding washed spermatozoa to culture tube containing oocyte-cumulus mass and then incubating the culture. Embryo development occurred in the oocytes of 5 of 6 patients who had blocked fallopian tubes and who had AID. No normal embryos developed in the oocytes of 9 patients with idiopathic infertility. Furthermore, fertilization failures and oocyte abnormalities were higher in this group than in the other 2 groups. Clinical recommendations for managing the 3 groups of infertile patients were discussed. Further research should be done on the long-term infertility of unknown cause.

Collection of human oocytes at laparoscopy and laparotomy.

PIP: In order to determine whether ovarian follicular aspiration at laparoscopy would provide enough oocytes for adequate in vitro studies, oocytes were collected during the periovulatory stage of the normal menstrual cycle from 45 women undergoing laparoscopy and from 25 women undergoing laparotomy. A larger average number of oocytes was recovered per patient at laparotomy due to better oocyte recoveries from ovarian wedges. However, the average number of oocytes rocovered per patient was the same at both procedures, providing that a suction vacuum of 200 mm Hg was used at laparoscopy, and under these conditions a greater percentage of follicles yielded oocytes at laparoscopy. Overall, 498 follicles were aspirated and 217 oocytes collected; the average recovery was 3 per patient. Moreover, the mean follicular diameter was 9.1 mm in infertile and 8.0 mm in fertile patients (p less than .05).^ieng

Clinical features of eight pregnancies resulting from in vitro fertilization and embryo transfer.

In vitro fertilization (IVF) and embryo transfer (ET) have resulted in the birth of nine babies, including twins. One of the twins had a congenital cardiac malformation and seven of the nine babies were girls. Labor occurred preterm in two pregnancies; and in six delivery was by cesarean section. Plasma human chorionic gonadotropin (hCG), progesterone (P), and estriol (E3) measurements and ultrasonic scans showed no obvious differences from pregnancies resulting from natural conception. Cytogenetic studies from cord blood and histologic examination of the placentas were unremarkable. The theoretic risks of pregnancy following IVF and ET are discussed. Definite conclusions cannot be drawn until a large number of babies are delivered and a long-term follow-up is completed. Initial results from the current small sample are encouraging.

Vaginal progesterone as luteal phase support in an IVF/GIFT programme.

To determine whether luteal phase support with vaginal progesterone could improve pregnancy rates in our IVF/GIFT programme, we performed a prospective randomised controlled study. After stimulation with clomiphene citrate/human menopausal gonadotrophin, 123 women received no luteal support and 122 received progesterone pessaries 100 mg b.d. from 48 hours prior to embryo transfer and continued throughout the luteal phase. There was no difference in the pregnancy rate following IVF/ET (6/58 and 10/58 for the pessary and control group respectively), but a significantly higher rate was noted for GIFT (13/34 and 5/42 for the pessary and control group respectively; P less than 0.05). Of interest, only one of the 19 pregnancies using luteal support was extra-uterine, compared with 6/15 in the control group.

The regulation of assisted reproductive technology in Australia: issues and solutions.

The legislative response to assisted reproduction technology had been inappropriate and inflexible for such a rapidly developing area of medicine. A national system of regulation, consisting of a merger of components of already established committees and based on the United Kingdom system introduced in 1990, would overcome the legislative differences between States, and provide a more responsible and responsive regulatory system.

Oocyte and embryo donation in IVF programmes.

We have described a cyclic steroid replacement regimen of oestradiol and progesterone which is able to produce physiological concentrations of these steroids in plasma indicative of a normal menstrual cycle. The stimulation of a secretory endometrium at the appropriate time in this artificial menstrual cycle bears testament to the suitability of the treatment and has led to the establishment of pregnancy in three women with complete ovarian failure or ovarian agenesis when used in combination with the established techniques of in vitro fertilization and embryo transfer. The steroid replacement regimen can easily be adjusted to maintain pregnancy until the time of luteoplacental shift, based on the close monitoring of the plasma steroid and hCG levels in the pregnant individual. The implications of this form of treatment for other disease states and for our understanding of the mechanisms involved in ovarian hormone action, pregnancy maintenance and parturition are immense.

Effect of oocyte quality and sperm characteristics on the number of spermatozoa bound to the zona pellucida of human oocytes inseminated in vitro.

Sperm characteristics and oocyte quality may play a role in in vitro fertilization. The objective of this paper is to analyze the effect of the quality of oocytes, the husband's semen characteristics, and category of the couple's infertility on the number of spermatozoa bound to the zona pellucida. One hundred eighty-one oocytes which failed to fertilize or failed to cleave were fixed in 2.5% glutaraldehyde 40 to 60 hr after insemination in vitro and examined under interference microscopy and the number of sperm bound to the zone pellucida was determined. The means +/- SD of sperm bound to mature, immature, and atretic oocytes were 51.0 +/- 50.7, 7.3 +/- 12.1 10.4 +/- 17.8, respectively. Fertilized mature oocytes (81.0 +/- 53.3) had a significantly higher number of sperm bound to zonae compared to unfertilized oocytes (41.8 +/- 47.3). It is concluded that the number of sperm bound to zonae is functionally important. The sperm motility and the number of motile sperm used to inseminate oocytes were significantly correlated with the number of sperm bound to zonae, whereas sperm morphology and sperm concentration did not correlate. This study supports the notion that sperm motility is the single most important factor influencing fertilization of human oocytes in vitro.

Effect of factors related to the recipient and insemination characteristics on the success of artificial insemination with frozen semen.

It is of clinical importance to determine the factors which influence the outcome of insemination with frozen human semen. The number of inseminations per cycle and the season of the year had significant effects on the outcome of the insemination in all the recipients in the AID programme and in those who became pregnant within six cycles of treatment. The chance of pregnancy was greater with increasing number of inseminations per cycle. During winter the proportion of insemination cycles resulting in pregnancy was lower than in the other three seasons. The proportion of insemination cycles resulting in pregnancy was higher when the maximum cervical scores of the cycle were high (greater than 10 in a scale of 12) when compared with lower scores in all the recipients but not in those who became pregnant within six cycles. Duration of infertility and previous fertility of the recipients had a significant effect on the outcome of insemination in all the recipients but not in those who became pregnant within six cycles. Age of the recipient had a positive effect on the abortion rate.

Influence of semen and donor factors on the success rate of artificial insemination with frozen semen.

Influence of some semen and donor factors on the success rate of artificial insemination by frozen donor semen (AID) was examined. The percentage of insemination cycles resulting in pregnancy was significantly higher for women who became pregnant within six cycles (33%) when compared with all the women in the AID programme (14%). Therefore the influence of semen and donor characteristics on the fertilizing capacity of frozen semen was studied in women who became pregnant within the first six cycles of insemination in order to minimize any influence of non-semen effects such as recipient and insemination factors. Donors less than 20 years of age appear to have a better chance of obtaining a pregnancy. Semen stored for less than six months in liquid nitrogen had a similar proportion of insemination cycles resulting in pregnancy compared with semen stored for longer than six months. Conventional semen values were not correlated with fertility, and none of these values could be used accurately to predict the fertilizing capacity of frozen semen.