Comparisons of follicular levels of sex steroids, gonadotropins and insulin like growth factor-1 (IGF-1) and epidermal growth factor (EGF) in poor responder and normoresponder patients undergoing ovarian stimulation with GnRH antagonist.

OBJECTIVE: To determine the serum and intrafollicular concentrations of sex steroids, epidermal growth factor (EGF) and insulin like growth factor-1 (IGF-1) in women demonstrating poor response to ovarian stimulation with gonadotropins and GnRH antagonists, and to compare the results with age-matched women displaying normal ovarian response. STUDY DESIGN: This is a prospective cross-sectional study conducted in a private IVF center. Forty-eight age-matched women producing 5 or fewer oocytes (poor responders) or 10 or more oocytes (normoresponders) at the end of controlled ovarian stimulation for assisted conception participated in the experiment. Gonadotropins and GnRH antagonists were used for ovarian stimulation, while ICSI was employed for assisted fertilization. Serum and follicular concentrations of FSH, LH and sex steroids (estradiol, progesterone and testosterone), and follicular concentrations of EGF and IGF-1 were assayed in both groups. RESULTS: Serum and follicular levels of E(2) and progesterone were significantly lower in the poor responder group compared to the normoresponder group. Follicular level of testosterone was also lower in poor responders, but not to a level of statistical significance. The serum FSH level was higher in the poor responder group, but follicular levels of gonadotropins did not differ between the two groups. The follicular level of IGF-1 was significantly lower in poor responders. In contrast, the EGF concentration did not differ between the two groups. CONCLUSIONS: Decreased levels of sex steroids in poor responder patients undergoing COH with GnRH antagonist, suggests that reduced IGF-1 expression acts as a modulator of impaired ovarian steroidogenesis.

Use of a GnRH antagonist in controlled ovarian hyperstimulation for assisted conception in women with polycystic ovary disease: a randomized, prospective, pilot study.

OBJECTIVE: To compare the outcome of using gonadotropin-releasing hormone (GnRH) antagonists versus agonists in women with polycystic ovary disease (PCOD) who underwent controlled ovarian hyperstimulation (COH) for assisted reproductive techniques (ART). STUDY DESIGN: A total of 129 patients with PCOD were randomly allocated to undergo COH with a GnRH antagonist (59 patients) and GnRH agonist (leuprolide acetate) (70 patients) to prevent a premature luteinizing hormone (LH) surge. Assisted fertilization following oocyte retrieval and embryo transfer was performed. RESULTS: None of the cycles were cancelled due to a premature LH surge. There was no significant difference between the antagonist and agonist arms in the number of gonadotropin ampules consumed per cycle. However, in the antagonist arm a shorter duration of ovarian stimulation was recorded as compared to the agonist arm. Although similar numbers of oocytes was retrieved from both groups of patients, the quality of the oocytes, as measured by metaphase 2/total oocyte ratio, was lower in the antagonist arm as compared to the agonist arm. Pregnancy rates were 57.6% and 58.5% in the antagonist and agonist arms, respectively (p > 0.05). Implantation rates were not different (34.0% and 34.6%, respectively). The frequency of ovarian hyperstimulation syndrome also did not differ between the treatment groups (5% and 7.1%, respectively). CONCLUSION: The size of our study, on a specific subgroup of patients, does not allow a reliable conclusion regarding ART outcomefollowing the use of a GnRH antagonist versus agonist. Nevertheless, the protocol with the antagonist gave results that were as good as those of the protocol with the agonist in this PCOD patient population.

Successful resection of a heterotopic cervical pregnancy resulting from intracytoplasmic sperm injection.

OBJECTIVE: To report a case of cervical heterotopic pregnancy after IVF-ET treatment. DESIGN: Case report. SETTING: Private IVF center. PATIENT(S): A woman who had undergone controlled ovarian hyperstimulation and intracytoplasmic sperm injection-ET for primary male factor infertility. INTERVENTION(S): Resection of cervical heterotopic pregnancy by hysteroscopy. MAIN OUTCOME MEASURE(S): Successful treatment of heterotopic cervical pregnancy. RESULT(S): A successful pregnancy resulting in a term baby. CONCLUSION(S): Hysteroscopic resection can be used to treat a cervical heterotopic pregnancy.

Partners of men with Klinefelter syndrome can benefit from assisted reproductive technologies.

OBJECTIVE: To report the birth of a healthy female infant from a father with nonmosaic Klinefelter syndrome (KS) and document the experience of men with KS undergoing assisted conception. DESIGN: Retrospective. SETTING: Private IVF center. PATIENT(S): Twelve couples with male factor infertility due to Klinefelter syndrome undergoing assisted reproduction treatment. INTERVENTION(S): Controlled ovarian hyperstimulation, testicular sperm extraction, intracytoplasmic sperm injection (ICSI), round spermatid injection (ROSI), and preimplantation genetic diagnosis. MAIN OUTCOME MEASURE(S): Testicular sperm retrieval rate, fertilization rate, and pregnancy outcome. RESULT(S): There was a sufficient amount of motile sperm for injection into mature oocytes in 6 of the 11 testicular biopsies (54.5%). Fertilization rates for ICSI and ROSI cases were 54.2% and 41.6%, respectively. The pregnancy rate per ET was 27.2%. None of the ROSI cases resulted in pregnancy. Two patients had spontaneous abortions at 8 and 18 weeks of gestation, respectively. Only one patient delivered a healthy female baby after 36 weeks of an uneventful pregnancy. CONCLUSION(S): Men with KS can benefit from assisted reproductive technologies, and the testicular sperm retrieval rate among them is promising. Although sex chromosome aberrations among the embryos from men with KS are not common, couples can be offered preimplantation genetic diagnosis before ET.

Efficiency of changing the embryo transfer time from day 3 to day 2 among women with poor ovarian response: a prospective randomized trial.

OBJECTIVE: To compare the outcome of day 2 and day 3 embryo transfers in women demonstrating poor ovarian response. DESIGN: Prospective randomized clinical trial. SETTING: Private assisted reproductive technology center. PATIENT(S): Two hundred eighty-one women demonstrating poor ovarian response to controlled ovarian hyperstimulation. INTERVENTION(S): Women who were poor responders were randomly allocated to day 2 or day 3 embryo transfer following oocyte retrieval. MAIN OUTCOME MEASURE(S): Implantation rates and pregnancy rates per oocyte retrieval and embryo transfer. RESULT(S): The clinical pregnancy rates per oocyte retrieval (37.2% vs. 21.4%, respectively; P<.05) and per embryo transfer (38.9% vs. 24.1%, respectively; P<.05) were significantly higher in the day 2 embryo transfer group compared with day 3. On the other hand, implantation rates were not different between groups (23.9% vs. 17.2%, respectively; P=.08). CONCLUSION(S): Our results demonstrated that transfering embryos on day 2 could provide an alternative to the management of poor responder patients.

Endometrial fluid visualized through ultrasonography during ovarian stimulation in IVF cycles impairs the outcome in tubal factor, but not PCOS, patients.

BACKGROUND: The aim of the present study was to examine the impact of the presence of endometrial fluid (seen through ultrasound) on the outcome of IVF cycles and its association with the aetiology of infertility, in tubal and polycystic ovary syndrome (PCOS) cases specifically. METHODS: We retrospectively evaluated the charts of all PCOS and tubal factor infertility patients that underwent IVF between June 1, 2001 and May 31, 2002. Twenty-four PCOS and 14 tubal factor infertility patients in whom endometrial fluid was detected were compared with 94 PCOS and 160 tubal factor patients whose stimulation cycles did not show any fluid collection. The main outcome measures were implantation and pregnancy rates. RESULTS: Implantation rates were lower in the tubal factor patients in the presence of endometrial fluid (6.12% and 21.4%, respectively) in comparison with all other tubal factor infertile patients in whom no fluid accumulation inside the cavity was detected. In PCOS cycles there was no significance in patients with presence of endometrial fluid in comparison with the all other PCOS cycles without any fluid accumulation. CONCLUSIONS: When fluid collection inside the endometrial cavity is first seen during ovarian stimulation of PCOS patients undergoing IVF, embryo transfer can be performed safely if the fluid has disappeared and not returned by the day of embryo transfer. However, in tubal factor cycles one should think of either cancellation of the cycle or cryopreservation of all embryos.

The reproductive performance of women with hypogonadotropic hypogonadism in an in vitro fertilization and embryo transfer program.

PURPOSE: To evaluate the outcome of women with hypogonadotropic hypogonadism undergoing in-vitro fertilization (IVF). METHODS: We retrospectively assessed outcomes in 58 women with hypogonadotropic hypogonadism (HH) and, as matched controls, in 116 women with tubal factor (TF) infertility who underwent assisted reproduction treatment (ART). For ovulation induction, human menopausal gonadotropin (hMG) was used in HH patients and a combination of hMG and gonadotropin releasing hormone (GnRH) agonist was used in TF patients. Conception and implantation rates, as well as duration of stimulation and number of oocytes retrieved, were the main outcome measures. RESULTS: Of the 58 HH patients, 53 (91.3%) responded adequately to ovulation induction and underwent ET. A larger amount of gonadotropins and a longer duration of ovarian stimulation were needed in HH patients than in TF patients. The mean number of retrieved oocytes and implantation rates did not differ between the groups. In addition, there were no differences between the HH and TF groups in pregnancy (53.8 vs. 48.6%) and multiple pregnancy (63.4 vs. 48.4%) rates. In the HH group, the miscarriage rate was 3.4%, and none of these patients developed severe OHSS. CONCLUSION: IVF in HH patients, in which there was a background of previous failed ovulation induction, was as successful as in women with TF infertility.

Conception rates following assisted reproduction in poor responder patients: a retrospective study in 300 consecutive cycles.

Poor response to ovarian stimulation for assisted reproduction treatment is a therapeutic challenge. Oocyte donation may be unacceptable to some patients, and many couples opt to continue with treatment despite low follicle numbers. Minimal data are available regarding conception rates in poor responders who elect to undergo oocyte retrieval. This study summarizes the outcome of assisted reproduction treatment in poor responders who produced four or fewer oocytes during ovarian stimulation, in order to provide better counselling to such patients in the future. Embryo transfers were performed in 208 of 300 cycles demonstrating poor ovarian response. Pregnancy rate (PR) (15.9%) was significantly higher in patients in whom four oocytes were retrieved, compared with patients in whom one or two oocytes were retrieved (2.3 and 4.3% respectively). Younger patients (< or =34 years) had significantly higher PR (19.5%) compared with older patients (> or =35 and < or =39 years, PR 7.2% and > or =40 years, PR 1.5% respectively). One hundred and twenty-six age-matched normal responders in whom three embryos were transferred had higher implantation rates (15.3%) and PR (37.3%) compared with poor responders in whom three embryos were transferred (6.6 and 16.6% respectively; P < 0.05). In this regard, patient age, number of oocytes retrieved and number of embryos available for transfer determine prognosis for the success of IVF in patients who respond to ovarian stimulation with four or fewer follicles for assisted reproduction treatment.