Testicular Sperm Extraction and Intracytoplasmic Sperm Injection: Outcomes in a specialist fertility centre.

Assisted reproduction with testicular sperm extraction (TESE) and intra-cytoplasmic sperm injection (ICSI) are fertility treatment options for couples with severe oligospermia or azoospermia. A retrospective review was performed of 146 TESE procedures in a specialist fertility centre in Ireland. The indication for TESE was obstructive azoospermia (OA) in 59% (n = 80) and non-obstructive azoospermia (NOA) in 41% (n = 56). Sperm retrieval rates after TESE were determined and the pregnancy rates per ICSI cycle number were evaluated. Sperm retrieval rates were 99% (n = 79/80) and 32% (n = 18/56) for OA and NOA men respectively. Fifty-eight couples proceeded to ICSI. Overall 114 ICSI cycles were performed and 33 cycles resulted in fertilisation (29%). Our sperm retrieval and pregnancy rates are consistent with international studies and support the ongoing role for TESE and ICSI as successful assisted reproductive techniques for male factor infertility in Ireland.

How do patients choose private in vitro fertilization treatment? A customer survey in a tertiary fertility center in the United Kingdom.

OBJECTIVE: To assess the relevant factors affecting patients' decision when choosing a clinic for private, self-funded IVF treatment. DESIGN: Prospective anonymous closed questionnaires. SETTING: Single tertiary-care private IVF center. PATIENT(S): New patients attending primary consultation in a period of 7 months from September 1999 to March 2000. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Primary knowledge about the clinic, source of referral, knowledge of, availability of information pack, and familiarity with the clinic's success rates and treatment's price. The last question assessed the relative importance of each factor in the decision-making process according to the SERVQUAL model, modified version. All items were measured as perceptions on a 5-point Likert scale. 1 = not important, 3 = neutral, and 5 = very important. RESULTS(S): One hundred seventy-five patients completed the questionnaire. They were well informed and investigated the market before making their final choice. Patients collect information from many sources, including new channels such as the Internet. Up to one third of patients do not consult their doctor before treatment. By far the most relevant factor in decision making is the success rate (i.e., delivery rates) of the clinic, followed by recommendation by general practitioner (GP) or consultant (respectively, Likert scale score, 4.6; 95% confidence interval [CI], 4.5-4.7; and Likert scale score, 4.0; 95% CI, 3.9-4.2; P<.01). Other factors, such as cost of the treatment, friends and relatives' opinions, and distance from home were not relevant. CONCLUSION(S): Units that wish to thrive and increase their market share should deliver high-quality service and concentrate their efforts on excelling in performance.

Primary ovarian pregnancy after in vitro fertilization and embryo transfer: report of seven cases.

We have reported seven cases of ovarian pregnancy from among 116 EPs and 2,745 clinical pregnancies achieved after IVF and ET at Bourn Hall Clinic. All were associated with lower than normal serial levels of serum hCG and P. Transvaginal US scanning correctly made the diagnosis of ectopic gestation in all cases, and in five, ovarian pregnancy was suspected on the scan findings. Three patients were asymptomatic, whereas four complained of lower abdominal pain with or without vaginal discharge or bleeding. All patients were treated conservatively; four had ovarian wedge resection and three ovarian cystectomy.

How useful is cervical dilatation in patients with cervical stenosis who are participating in an in vitro fertilization-embryo transfer program? The Bourn Hall experience.

OBJECTIVE: To evaluate the place of cervical dilatation performed at the initial visit in an IVF-ET cycle in patients with known cervical stenosis. DESIGN: Retrospective study. SETTING: A tertiary care assisted conception unit. PATIENT(S): Fifty-seven patients who failed to conceive after a previous ET attempt and in whom the ET was classified as "difficult." INTERVENTION(S): Cervical dilatation under general anesthesia after pituitary suppression and before gonadotropin stimulation. MAIN OUTCOME MEASURE(S): Ease of the ET procedure and clinical pregnancy rate. RESULT(S): Eighteen (31.6%) of 57 women who failed to conceive after a previous attempt at IVF-ET achieved a clinical pregnancy after cervical dilatation. In 40 patients (70.2%), the subsequent ET was classified as "easy," whereas in the other 17 (29.8%), it remained difficult. The pregnancy rate was significantly higher when the ET was easy than when it was difficult (40% versus 11.8%, P<.05). CONCLUSION(S): In patients with cervical stenosis and a previous difficult ET, cervical dilatation during the initial visit leads to an easier subsequent ET and improves the pregnancy rate.

Risks for transmission of hepatitis C virus during artificial insemination.

OBJECTIVE: To identify risks of hepatitis C virus transmission by semen from infected donors. DESIGN: Case report. SETTING: Assisted fertility clinic. PATIENTS: Hepatitis C virus-infected semen donor and recipients of his donations. INTERVENTION: Testing for hepatitis C virus by serology and polymerase chain reaction. MAIN OUTCOME MEASURES: Detection of hepatitis C virus antibodies and viral RNA. RESULTS: Hepatitis C virus RNA was detected in the semen donation before but not after purification; none of the recipients of the donors samples were found to have antibodies to hepatitis C virus. CONCLUSIONS: Hepatitis C virus RNA can be detected in semen donations from infected donors; purification of donations before insemination significantly reduces the amount of viral RNA in the semen pellet.

The effect of the dose of human chorionic gonadotropin and the type of gonadotropin stimulation on oocyte recovery rates in an in vitro fertilization program.

The effect of the dose of human chorionic gonadotropin (hCG) on oocyte retrieval in an in vitro fertilization (IVF) program was studied. Following ovulation induction using clomiphene citrate and either pure follicle-stimulating hormone (FSH) or human menopausal gonadotropin (hMG), hCG was administered at a dose of 2000 IU (n = 88), 5000 IU (n = 110), and 10,000 IU (n = 104). There was a significantly lower successful oocyte recovery in patients who received 2000 IU of hCG (77.3%) compared with patients who received either 5000 IU of hCG (95.5%) or 10,000 IU of hCG (98.1%; P less than 0.001). There was no significant difference between 5000 or 10,000 IU of hCG. In patients who received 2000 IU of hCG, successful oocyte recovery was significantly lower when pure FSH was used (60%) compared with those who received hMG (84.1%; P less than 0.03). Patients have different thresholds for follicular response to hCG and the recommended minimum dose of hCG should be at least 5000 IU.

A comparison of the efficacy and tolerability of two recombinant human follicle-stimulating hormone preparations in patients undergoing in vitro fertilization-embryo transfer.

OBJECTIVE: To compare the efficacy and tolerability of two recombinant human FSH (r-hFSH) preparations, follitropin-alpha (Gonal-F; Ares Serono, Geneva, Switzerland) and follitropin-beta (Puregon; Organon, Oss, the Netherlands), for superovulation in patients undergoing IVF-ET. DESIGN: Randomized, parallel-group, assessor-blind, single-center trial. SETTING: Outpatient tertiary referral center for assisted reproductive techniques. PATIENT(S): Forty-four infertile women undergoing IVF-ET. INTERVENTION(S): After down-regulation with buserelin acetate, patients were randomized to receive follitropin-alpha or follitropin-beta, 150 IU/d for 6 days; after that, dosages were adjusted according to the ovarian response. MAIN OUTCOME MEASURE(S): Cumulative dose of r-hFSH; duration of r-hFSH treatment; number of follicles of > or =11 mm and of 14 mm on day 7 of r-hFSH treatment and on the day of hCG administration; number of oocytes retrieved; number of viable embryos; and number of pregnancies (biochemical, ectopic, miscarried) and clinical pregnancies. RESULT(S): There were no statistically significant differences in any efficacy measures between the two preparations. The incidence of systemic adverse events was comparable in the two groups. Local reactions at the injection site were significantly more common and more severe with follitropin-beta than with follitropin-alpha CONCLUSION(S): Follitropin-alpha and follitropin-beta have comparable efficacy in patients undergoing IVF-ET.

The use of luteinising hormone releasing hormone agonists for ovarian stimulation in assisted reproductive technology.

Although the use of luteinising hormone releasing hormone (LHRH) agonists and human menopausal gonadotrophin (hMG) for ovarian stimulation in assisted reproductive technology has gained wide-spread popularity, a number of major issues regarding their use remain unresolved. In this paper, we examine some of these issues in the light of the results of our own studies. We have found that although the use of LHRH agonists may be advantageous for some patients, its routine use for all patients produces no significant medical advantage compared with conventional stimulation regimens. In a number of prospective randomised studies, we have found that the long protocol of LHRH agonist administration is superior to the short and ultrashort protocols and the administration of glucocorticoids to patients at high risk of developing ovarian hyperstimulation syndrome does not reduce the incidence of this complication. Finally, we have found that when the long protocol of LHRH agonist administration is used, precise timing of human chorionic gonadotrophin administration (hCG) is not important. There are no significant differences in oocyte recovery, fertilisation and cleavage rates, or in pregnancy rates when the results of standard timing of hCG administration are compared with delayed administration. It would, therefore, appear that the major advantage of the routine use of LHRH agonists is for practical, rather than medical reasons.

Alternatives to IVF: the outcome of 1071 first GIFT procedures.

Gamete intra-Fallopian transfer (GIFT) is the most important treatment method for infertile couples that has been developed since in-vitro fertilization and embryo transfer (IVF/ET) became available. Analysis of the data of 1071 first GIFT procedures is presented and the predominant factors affecting success are discussed. An overall pregnancy rate of 33.6% was achieved in this group of patients who were unselected in relation to age, number of oocytes transferred, quality of sperm and response to ovulation induction. The success of GIFT is dependent upon the number and quality of oocytes transferred and upon the quality of the sperm. Pregnancy occurred in 21.4% of patients receiving up to four oocytes compared with 40.3% in whom five or more were transferred. Multiple pregnancy rates however were 17.3% in the first group and 32.3% in the second group. Age is a major factor influencing the chances of success with patients less than 30 years of age achieving a 40.2% pregnancy rate reducing to 19.2% in the over 40 group. Conversely the spontaneous abortion rate increased from 23.4% in the under 30 group to 48.6% in those over 40 years of age. No pregnancies were achieved when sperm motility was less than 20% in the original specimen, whereas pregnancy rates of up to 20% resulted when sperm density was below 10 million. The overall results of this study show comparable success rates for different causes of infertility and that there is a definite association between the outcome of treatment and the number and quality of gametes transferred. A philosophy of flexibility in the treatment of infertile couples is advocated.

The role of ovarian volume in reproductive medicine.

The human ovary is a dynamic organ which continually changes in size and activity through life, as an integral part of the changes that the female is going through before during and after her reproductive life. Following the rapid increase in the use of transvaginal scan in recent years, the measurement of ovarian volume has become quick, accurate and cost-effective. Ovarian volume is an important tool in the screening, diagnosis and monitoring the treatment of conditions such as polycystic ovarian syndrome, ovarian cancer and adolescent abnormalities. In reproductive medicine, measurement of ovarian volume has a role in the assessment of ovarian reserve and prediction of response to superovulation.

Analysis of the incidence and risk factors associated with ectopic pregnancy following in-vitro fertilization and embryo transfer.

Ectopic pregnancy is a well known complication of in-vitro fertilization (IVF) and embryo transfer. From March 1983 to December 1993, 3000 clinical pregnancies were achieved at Bourn Hall Clinic, including 135 ectopic pregnancies (4.5%). Of these ectopics 20 were heterotopic, eight ovarian, six bilateral tubal and the remainder were singleton tubal pregnancies. The main risk factor identified in the series was a history of pelvic inflammatory disease (P < 0.001). The data also showed that ectopic pregnancy is at present more prevalent among patients in whom tubal damage is the reason for treatment. There was slight statistical evidence (P = 0.05) that patients having ectopic pregnancies received a higher volume of culture medium than those having normal deliveries. There was also an apparent trend (P = 0.07, not significant) that high progesterone/oestradiol ratio on the day of embryo transfer was associated with ectopic pregnancy. There was no statistical evidence of association between ectopic pregnancy and a history of ectopic pregnancy, abortion, still birth, termination of pregnancy, neonatal death, tubal surgery, ovarian stimulation protocol, plasma concentration of oestradiol, luteinizing hormone and progesterone, number of oocytes retrieved, number or quality of embryos transferred, administration of general anaesthesia for embryo transfer, and the number of patent Fallopian tubes. Awareness of the risk factors associated with ectopic pregnancy plays an important part in the early diagnosis of this potentially fatal condition.