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.

Nonsurgical management of unruptured tubal pregnancy with intra-amniotic methotrexate: preliminary report of two cases.

Two cases of unruptured tubal pregnancy were managed conservatively by the aspiration and injection of 50 mg methotrexate into the amniotic sac with the use of a vaginal ultrasound transducer under local anesthesia. Both women experienced no pain or side effects and went home within 12 hours. Spontaneous menstruation began in both cases within 6 weeks of the procedure.

The technique for human embryo transfer.

In a program of human in vitro fertilization (IVF), the results of 204 attempted intracervical embryo transfers (ETs), using a variety of catheters in three trials over 18 months, have been analyzed for the ease of transfer and pregnancy rate. In nulliparous patients, transfers were more difficult than in multiparous patients; and a closed-end Teflon catheter was found to be more easily passed through the smaller cervical canal than an open-end catheter. The overall pregnancy rate was 17% (March 1980 to August 1981) and was not related to catheter type, although when chemical pregnancies were excluded, it was found that transfers using open-end catheters were more successful. The transfer procedure developed finally for routine use incorporates a consideration of these results.

Ultrasound-guided fallopian tube catheterization per vaginum: a feasibility study with the use of laparoscopic control.

The fallopian tube can be cannulated per vaginum under ultrasound control. The sensation and ultrasound appearance of smooth passage without visible kinking are accurate predictors of success. The average time taken for each cannulation was 7.2 minutes. Adequate practice in non treatment cycles is essential before proceeding to cell transfer, while further modification of the catheters used may improve overall success.

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.

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.

Factors influencing pregnancy rates following in vitro fertilization and embryo transfer.

In 831 patients having 1533 in vitro fertilization treatments, pregnancy rates were examined in relation to clinical and laboratory factors. Pregnancy rates were significantly affected by the month and year of treatment, the age of the patient, the type of ovarian stimulation, the use of human chorionic gonadotropin, the number of eggs collected, the number of eggs fertilized, the number of embryos developed, and the number of embryos transferred. The most important factors determining pregnancy rates were the number of oocytes collected and the number of embryos transferred. The low pregnancy rate when only one egg was collected raises the problem of how to predict and manage such a patient in a current or future treatment cycle.

A controlled study between the use of gamete intrafallopian transfer (GIFT) and in vitro fertilization and embryo transfer in the management of idiopathic and male infertility.

A randomized controlled trial comparing the use-effectiveness between gamete intrafallopian transfer (GIFT) and in vitro fertilization (IVF) and embryo transfer (ET) procedures showed no significant difference in pregnancy rates in the management of patients presenting with idiopathic or male infertility. The cost-effectiveness of GIFT appears superior to IVF and ET with laparoscopic oocyte collection, but comparable to IVF-ET with ultrasonic oocyte collection. The lack of data on the fertilizing capacity of sperm in GIFT procedures in cases of male infertility is a real disadvantage and currently precludes the management of severe male infertility with this method.

Ultrasound-guided embryo transfer: a controlled trial.

Embryo transfer (ET) was performed in 94 patients using transvaginal ultrasound guidance. Pregnancy rates were increased over a control group of 246 patients, although statistical significance was reached only in the subgroup of single ETs. Advantages over the traditional blind technique of ET were observed. Acceptance of the procedure by both clinicians and patients was high.

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.

Environment of the preimplantation human embryo in vivo: metabolite analysis of oviduct and uterine fluids and metabolism of cumulus cells.

OBJECTIVE: To determine the levels of metabolites surrounding the human oocyte and embryo in vivo. DESIGN: Oviduct and uterine fluids were collected throughout the menstrual cycle. Cumulus cells were collected at oocyte retrieval and their production of metabolites was assessed. Samples were analyzed for pyruvate, lactate, and glucose by microfluorimetry. PATIENTS: Luminal fluids were collected from naturally cycling patients at the time of routine clinical investigation. Patient consent and hospital ethics approval were obtained for this study. RESULTS: Pyruvate in the oviduct did not vary with the day of cycle, the mean value was 0.24 mM. Lactate and glucose concentrations varied with the day of cycle; lactate increasing from 4.87 mM in the follicular phase to 10.50 mM at the time of ovulation, whereas glucose decreased from 3.11 mM in the follicular phase to 0.50 mM midcycle and subsequently increased to 2.32 mM in the luteal phase. The concentrations of pyruvate, lactate, and glucose in uterine fluid remained constant throughout the cycle (0.10, 5.87, and 3.15 mM, respectively). All metabolite concentrations in uterine fluid were significantly different from those in the oviduct midcycle. Cumulus cells readily consumed glucose in vitro, with lactate being the major metabolite produced. CONCLUSION: These data indicate that lactate and glucose concentrations in the oviduct change with day of cycle and that the human embryo is exposed to different metabolite concentrations as it passes along the tract. Furthermore, cumulus cells readily consume glucose, producing lactate. Therefore, the early human embryo is exposed to low glucose and high lactate levels in vivo.

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

A clinical assessment of nine pregnancies obtained by in vitro fertilization and embryo transfer.

An analysis of nine pregnancies resulting from in vitro fertilization and embryo transfer was made in order to identify factors common to all of the pregnancies. These factors included clomiphene stimulation; general anesthesia for laparoscopy; identification of large follicles (greater than 8 ml) and a mature oocyte; preincubation of the oocyte for 4.7 to 6.5 hours in vitro before insemination; insemination with 0.8 to 1.3 x 10(6) fresh spermatozoa from fertile samples; transfer to the uterus of two-, four-, and eight-cell embryos, 38 to 50 hours after insemination; and uncomplicated uterine transfers of embryos. It was difficult to determine whether these factors are causal or coincidental in the attainment of successful pregnancies. The detailed analysis was useful in demonstrating factors which did not prevent the establishment of pregnancy by in vitro fertilization and embryo transfer. These factors included a variety of causes of infertility, including idiopathic and male infertility; age of the infertile woman over 35 years; the presence of T-mycoplasma in the genital tract; the use of human chorionic gonadotropin; a variety of agents used for general anesthesia; the use of carbon dioxide to induce pneumoperitoneum; a delay of up to 50 minutes in the interval between the induction of general anesthesia and oocyte recovery; the use of antiprostaglandins at the time of embryo transfer; and a brown discharge from the vagina following embryo transfer.

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.

Modern aspects of infertility treatment.

New techniques give promise in the management of infertility. In the UK, a decade of experimentation with in vitro fertilization and embryo transfer has met with some success, and given encouragement to other workers. The most important change in this technique appears to have been to utilize only spontaneous ovulation and to transfer the fertilized ovum at night. Artificial donor insemination using frozen sperm is attaining a success rate of up to 66 percent after six cycles of insemination.