Assisted reproductive technology in the United States: 1999 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry

Effect of Endometrial Cavity Fluid On Pregnancy Rate of Fresh Versus Frozen In Vitro Fertilization Cycle

Objective:

This study aims to study the difference in etiology and outcome in terms of implantation rate and abortion rate in fresh (self-stimulated) versus frozen (oocyte donation cycle) in vitro fertilization (IVF) and in transient versus persistent fluid.

Material and Methods:

This retrospective study was conducted in the Department of Reproductive Medicine of tertiary care center from January 2012 to November 2015. Data were collected retrospectively from the departmental files. Twenty-four patients from fresh IVF-stimulated cycles and 24 from frozen oocyte donation cycle with their endometrium prepared by hormone replacement treatment were included in the study. All patients selected in the study had grade-A embryo transfer of day 3–4 with maximum three embryo transferred. Pregnancy was defined by rising serum beta-human chorionic gonadotrophin levels performed after 14 days of embryo transfer and further confirmed by ultrasonographic visualization of gestational sac at 6 weeks. All biochemical pregnancies were included in implantation failure. All pregnant patients were followed till the termination of pregnancy and further noted as live birth or abortion.

Results:

Clinical pregnancy rate was seen more in self-stimulated cycle (62.5%) with live birth rate of 50% than hormone replacement treatment cycle, in which clinical pregnancy rate was 45.83% with live birth rate of 33.33%. Clinical pregnancy rate was highest in group with very less fluid in cavity (1–2 mm) 63% and with live birth of 52.63%. Clinical pregnancy was seen only in two patients of group B with anterior and posterior (AP) diameter of fluid in cavity of 2–3 mm with live birth of only one, whereas in group C, with AP diameter of 3–5 mm, none of the patient conceived. This difference was statistically significant. Clinical pregnancy rate was 65.62% in transient fluid accumulation with live birth rate of 53.25%, which was significantly higher than persistent fluid accumulation (P value − 0.0337 for pregnancy rate and 0.0312 for live birth rate).

Conclusion:

Fluid accumulation seen in fresh cycles are generally associated with better outcome because it may be associated with good prognostic factors – small AP diameter of fluid, with transient fluid accumulation and more with poly cystic ovarian syndrome as an etiological factor; however, in frozen cycle, it can be associated with poor outcome.

Ectopic pregnancy after infertility treatment

Early pregnancy complications are more common in women who conceive after infertility treatment. Most of these occur before 12 weeks of gestation and include miscarriage, vaginal bleeding, intrauterine hematoma, vanishing twin, and ectopic pregnancy (EP). The incidence of EPs following infertility treatment is much higher compared with that in spontaneous pregnancies. The occurrence of an EP is very distressing to an infertile couple, who has lots of hopes pinned on the treatment outcome, especially because of the cost incurred and the physical and mental trauma both have gone through during the treatment process. The association between infertility and EP is complex, as it can be a consequence of infertility as well as a cause. The two principal risk factors for an EP are genital tract infections and tubal surgeries. Though several etiologies are proposed, but patients with tubal factor infertility are at an increased risk of an EP. Earlier diagnosis of EP helps to improve prognosis and optimize subsequent fertility. It is pivotal to evaluate the likelihood of subsequent occurrence of an EP and be too vigilant when treating. The correct choice of the treatment modality should be made to prevent the recurrence. The early prediction of the pregnancy outcome therefore has great importance for both the couple and clinician. Today with the help of sensitive beta human chorionic gonadotropin (β-hCG) assays and transvaginal sonography, one can diagnose an EP prior to symptoms, and conservative treatment for the preservation of the fallopian tube is possible. Conservative management in the form of expectant and medical management should be considered as a first-line treatment modality, provided that the overall clinical picture suggests that it is safe to do so. If not, laparoscopic management of EPs appears to be the favored approach of management as compared to laparotomy.

ICSI: Hype or hazard?

Ever since its introduction in clinical practice more than 10 years ago, intracytoplasmic sperm injection (ICSI) has been the subject of ongoing debate regarding its indications and safety. ICSI is hyped because of its potential to give couples with severe male factor infertility a chance to conceive, and because of its apparently low fertilization failure rate compared with 'classic' in vitro fertilization (IVF). Concerns about ICSI are related to technical, biological and genetic hazards. ICSI has been branded 'the ultimate rape of the oocyte', as the oocyte membrane is mechanically pierced, appearing to bypass all biological and genetic selection. ICSI has been linked in a number of reports to an increased incidence of chromosomal anomalies, congenital abnormalities and perinatal hazards in offspring conceived with this technique. The etiology of the increased risk of chromosomal anomalies in ICSI offspring, especially sex-chromosome anomalies, is thought to be partly multifactorial, partly andrological, related to paternal karyotypic abnormalities and/or abnormal sperm. The majority of studies on ICSI and IVF offspring have, setting aside inconsistencies in methodology and classification, not shown significant differences between the two techniques in terms of congenital abnormalities, however, compared to naturally conceived offspring there does show an increased risk. This risk is attributed mainly to parental factors such as maternal age, poor sperm quality and infertility as an independent risk factor. Perinatal hazards may include low birth weight and perinatal mortality. Behavioural and psychological development is carefully monitored in ICSI and IVF children with no significant differences to the development of naturally conceived children, but many factors are involved including demographics. Follow-up studies are essential to the technique of ICSI. It is our duty to inform patients of the concerns and benefits to this treatment, based on the latest data available.

Does the genetic and familial background of males undertaking ICSI affect the outcome?

Purpose

To investigate whether the success rate of ICSI is (1) related to the etiology of infertility or (2) adversely affected by a family history of potential genetic disorders.

Methods

All men with an ICSI indication in our hospital between 1994 and 2005 were included in our cohort study. Data on the ICSI process, etiology of infertility, and family history were collected. ICSI success rates of infertility subgroups and a subgroup with a positive family history were compared to a group with unknown etiology and a negative family history.

Results

There was no significant difference in clinical pregnancy or delivery rates between the subgroups. Couples achieving a pregnancy underwent significantly more ICSI cycles compared to couples not achieving a pregnancy.

Conclusion

Our results suggest that the success rate of ICSI treatment is not related to the cause of infertility or a family history positive for potential genetic disorders.

Epidemiological factors influencing IVF outcome: Evidence from the Yale IVF program

Age, BMI, lifestyle, menstrual status and obstetric history can modulate the endocrine system and, therefore, have been hypothesised to play a role in in-vitro fertilisation (IVF) outcome. We designed a retrospective study, set in a medical school hospital. We evaluated the medical files of 297 infertile women who underwent laparoscopy and consecutive IVF-ET treatment in the Yale IVF unit between 1996 and 2002. The study group consisted of 151 women who conceived after IVF-ET and the control group of 146 women who underwent 288 IVF-ET cycles without pregnancy. The main outcome measure was the impact of epidemiological factors on the IVF outcome. There was no association between IVF outcome and race, BMI, age at menarche, length of cycle, duration and amount of flow, menstrual symptoms, other medical problems, medical history of allergies, and family history of endometriosis and cancer. We found that the degree of smoking and alcohol use was not a factor when comparing women with and without pregnancy after IVF (34.5% vs 29.5%, and 33.7% vs 27%, respectively). The rate of duration of infertility tended to be lower in pregnant women (35.9+/-23.4 months) vs (42.3+/-30.2) non-pregnant women. As expected, we also confirmed the inverse association between the age of women and IVF outcome. Overall, body attributes, lifestyle, family history, menstrual and reproductive factors were not related to IVF-ET outcome.

Increased messenger ribonucleic acid expression of the cyclin-dependent kinase inhibitor p27Kip1 in cleavage-stage human embryos exhibiting developmental arrest

OBJECTIVE

To quantify p27 messenger RNA (mRNA) levels in human arrested and normally developing embryos and nonfertilized oocytes to determine whether the p27 protein abundance, reported in cleavage-stage embryos exhibiting developmental arrest, is regulated at the mRNA expression level.

DESIGN

Real-time reverse transcription quantitative polymerase chain reaction was used to quantify the expression of p27 in three samples: arrested embryos (group A, n = 29), normally developing embryos (group D, n = 34), and nonfertilized oocytes (group O, n = 20).

SETTING

Research laboratory working closely with a clinical IVF practice.

PATIENT(S)

Oocytes and embryos were obtained from patients undergoing assisted fertilization.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Quantification of mRNA transcripts.

RESULT(S)

The amount of p27 mRNA was statistically significantly higher in group A (mean +/- SEM, 86,143 +/- 42,496 relative units [RU]) compared with groups D (10,680 +/- 3,850 RU) and O (3,555 +/- 1,458 RU). Furthermore, in a group of 13 two- to four-cell arrested embryos, high levels of p27 mRNA (51,481 +/- 31,120 RU) were found in comparison with the nonfertilized oocyte group (3,555 +/- 1,458 RU).

CONCLUSION(S)

Cleavage-stage human embryos exhibiting developmental arrest show increased p27 mRNA expression. This probably is due to increased transcriptional activity.

Low ectopic pregnancy rates after in vitro fertilization: do practice habits matter?

In a 6-year review of ectopic pregnancies (EPs) after fresh and frozen embryo transfers in IVF cycles conducted at a large university-based program, we report an overall 0.9% rate of EP that seems to have increased with the programmatic shift to routine blastocyst transfer, but remains lower than nationally reported rates. Aggressive management of tubal disease may contribute to low rates of EP, whereas blastocyst transfer may increase the rate.

Sperm retention site and its influence on pronucleus stage evaluation following intracytoplasmic sperm injection

Aim:  It has been suggested that the position of the sperm after intracytoplasmic sperm injection (ICSI) has an effect on the development and quality of the embryo. In this study, we retrospectively examined whether pronucleus stage evaluation used through clinical studies in recent years has relevance with regard to sperm location. Methods:  From 2003 to 2005, 1285 oocytes from 459 patients (average age: 36 years) were retrospectively analyzed. The 459 patients underwent ICSI because of fertilization disorders and oligozoospermia. Follicle stimulation was via either Clomid or the long protocol. Human chorionic gonadotropin was administered to induce ovulation and oocyte retrieval was conducted 35 h later. After confirming the presence of a polar body, we immobilized the ovum at the 6 o'clock position, introduced the injection pipette at the 3 o'clock position and carried out ICSI. Results:  When a sperm was located at a position that was opposite to the polar body, both classifications of Scott and Tesarik regarding embryo quality were distinctly low. Furthermore, a good embryo classification ensued when the sperm was located adjacent to the polar body. Conclusion:  The zone in which the sperm was located did not always correlate with embryo quality; however, our study suggested that sperm location affects the synchronization of the nucleolus. When carrying out ICSI, it is important to take into consideration the insertion point of the sperm. (Reprod Med Biol 2007; 6: 171-174).

Assisted reproductive technology in the United States: 2001 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology registry

OBJECTIVE

To summarize the procedures and outcomes of assisted reproductive technologies (ART) that were initiated in the United States in 2001.

DESIGN

Data were collected electronically using the Society for Assisted Reproductive Technology (SART) Clinic Outcome Reporting System software and submitted to the American Society for Reproductive Medicine/SART Registry.

PARTICIPANT(S)

Three hundred eighty-five clinics submitted data on procedures performed in 2001. Data were collated after November 2002 [corrected] so that the outcomes of all pregnancies would be known.

MAIN OUTCOME MEASURE(S)

Incidence of clinical pregnancy, ectopic pregnancy, abortion, stillbirth, and delivery.

RESULT(S)

Programs reported initiating 108,130 cycles of ART treatment. Of these, 79,042 cycles involved IVF (with and without micromanipulation), with a delivery rate per retrieval of 31.6%; 340 were cycles of gamete intrafallopian transfer, with a delivery rate per retrieval of 21.9%; 661 were cycles of zygote intrafallopian transfer, with a delivery rate per retrieval of 31.0%. The following additional ART procedures were also initiated: 8,147 fresh donor oocyte cycles, with a delivery rate per transfer of 47.3%; 14,509 frozen ET procedures, with a delivery rate per transfer of 23.5%; 3,187 frozen ETs employing donated oocytes or embryos, with a delivery rate per transfer of 27.4%; and 1,366 cycles using a host uterus, with a delivery rate per transfer of 38.7%. In addition, 112 cycles were reported as combinations of more than one treatment type, 8 cycles as research, and 85 as embryo banking. As a result of all procedures, 29,585 deliveries were reported, resulting in 41,168 neonates.

CONCLUSION(S)

In 2001, there were more programs reporting ART treatment and a significant increase in reported cycles compared with 2000.

Endometriosis and infertility

Women with endometriosis typically present with pelvic pain, infertility or an adnexal mass. Surgery for persistent adnexal masses may be indicated to remove an endometrioma or other pelvic pathology. Surgical or medical therapy is efficacious for pelvic pain due to endometriosis, but treatment of endometriosis in the female partner of an infertile couple raises a number of complex clinical questions that do not have simple answers.

Preimplantation genetic diagnosis significantly reduces pregnancy loss in infertile couples: a multicenter study

OBJECTIVE

The inicidence of miscarriage is correlated with maternal age. The majority of miscarriages are chromosomally abnormal. The purpose of this study was to determine in a large population of infertility patients (>2000 cycles) if preimplantation genetic diagnosis (PGD) reduced the rate of spontaneous abortions.

DESIGN

Multicenter retrospective controlled study.

SETTING

One hundred IVF centers referring samples to a reference PGD laboratory.

PATIENT(S)

Infertile women.

INTERVENTION(S)

The spontaneous abortion rate after PGD was retrospectively compared to non-PGD cycles from the 2002 American Society for Reproductive Medicine-Society for Assisted Reproduction Technology report on IVF cycles.

MAIN OUTCOME MEASURE(S)

Spontaneous abortions and trisomic offspring rates.

RESULT(S)

The study included 2,279 cycles of PGD. The pregnancy rate per retrieval was 26.7% (average age 39.6). The mean pregnancy loss for the PGD group (0.167) was significantly lower than for the general IVF group (0.215) (P<.001). After PGD, the spontaneous abortion rate was 14.1% for ages 35-40, and 22.2% for women over 40, compared to 19.4% (P=.03) and 40.6% (P<.001), respectively, in controls. The clinical error rate of PGD (1.2%) was significantly lower than expected (4.7%) (P<.001).

CONCLUSION(S)

The data suggests that PGD significantly reduces the risk of spontaneous abortions in women undergoing IVF and PGD, particularly in women over 40. In addition, PGD may also reduce the risk of trisomic offspring.

Is intravenous immunoglobulins (IVIG) efficacious in early pregnancy failure? A critical review and meta-analysis for patients who fail in vitro fertilization and embryo transfer (IVF)

PROBLEM

Intravenous Immunoglobulins (IVIG) are widely used off label in the treatment of early reproductive failure. As IVIG is expensive, and may have side-effects, evidence of efficacy is needed. Previous results have suggested that the pre-conception treatment of primary recurrent abortion patients might be effective, but the data set has been too small for adequate statistical power. More recently it has been suggested that IVIG may improve the success rate of in vitro fertilization and embryo transfer (IVF) in patients with prior IVF failures, but clinical trials have given conflicting results that need explanation. Systematic reviews generating inconclusive results have focused on methodological rigor to the exclusion of biological plausibility.

METHODS

Review of current basic science of design, measurement, and evaluation of clinical trials and basic science mechanisms providing a rationale for treatment. Meta-analysis of published randomized controlled and cohort-controlled trials (updated with two unpublished data sets) evaluating IVIG treatment in IVF failure patients. Live birth rate was used as the most relevant endpoint. The ability of different sources of IVIG to suppress natural killer (NK) cell activity was determined using a standard (51)Cr-release assay in vitro.

RESULTS AND CONCLUSIONS

Meta-analysis of three published randomized controlled trials (RCTs) of IVIG in IVF failure patients shows a significant increase in the live birth rate per woman (p = 0.012; Number Needed to Treat for 1 additional live birth, NNT = 6.0 women). Using live birth rate per embryo transferred, and adding data from two cohort-controlled trials to the meta-analysis further supports this conclusion (overall p = 0.000015, NNT = 3.7 women). Relevant variables appear to include properties and scheduling of the IVIG, and selection of patients with abnormal immune test results. Different IVIG preparations vary significantly in their ability to suppress NK activity in vitro. A rationale for use of IVIG is provided by a review of mechanisms of IVIG action and mechanisms underlying failure of chromosomally normal embryos.

High rates of embryo wastage with use of assisted reproductive technology: a look at the trends between 1995 and 2001 in the United States

OBJECTIVE

To determine what percentage of embryos achieved through assisted reproductive technology (ART) do not result in a live birth and to examine the relationships among the number of embryos transferred, infants delivered, and embryos wasted.

DESIGN

Retrospective correlational study of the U.S. summary data of ART results for the years of 1995-2001.

PATIENTS

Fertility clinics reporting data to the Society of Assisted Reproductive Technology (SART).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Statistics for ART cycles using fresh, nondonor eggs and embryos were derived, and the percentage of embryos wasted each year was calculated. Trends over time were evaluated for percent embryos wasted, the average number of embryos transferred, and the delivery per transfer rate. Correlations between these variables were analyzed.

RESULT(S)

The percentage of embryos transferred that did not produce a live birth was 90.8 in 1995 and decreased to 84.9 in 2001. This trend significantly correlated with a reduction in the number of embryos transferred (from 3.9 to 3.1) and with an improvement in delivery rate per transfer (25% to 33.4%).

CONCLUSION(S)

The vast majority of embryos produced in vitro and transferred fail to develop into an infant, supporting the concept that only a small fraction of embryos has the capacity to become a live birth. Clinicians should strive to reduce embryonic wastage without an adverse effect on delivery rates by perfecting methods of ovarian stimulation and embryo screening, and by transferring fewer embryos.

Prediction of laparoscopic surgery outcomes in tubal infertility

This study aimed to elucidate the predictive value of hysterosalpingography (HSG) and laparoscopy (LS) scores for spontaneous pregnancy after laparoscopic surgery in 50 patients with tubal infertility. During a 1-year follow-up period, 28% of these patients became pregnant. Both scores were informative in prediction of pregnancy with the area under the ROC curve being 0.80 (95% CI 0.67-0.93) and 0.74 (95% CI 0.58-0.89) for LS and HSG scores, respectively.

Defining the typical work environment for assisted reproductive technology laboratories in the United States

OBJECTIVE

To determine time and staffing requirements as they relate to laboratory personnel in the field of assisted reproductive technology (ART).

DESIGN

Descriptive study.

SETTING

Assisted reproductive technology clinics in the United States.

PERSONNEL

All personnel working in ART laboratories, which included laboratory directors and technicians (those laboratory personnel trained in specific areas of embryology, andrology, and endocrinology).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES(S)

Frequencies were determined for time and staffing requirements as they pertained to individuals and procedures (e.g., oocyte retrieval, embryo transfer, semen analysis, hormone assay, etc.) performed in embryology, andrology, and endocrine laboratories.

RESULT(S)

Two different surveys of ART clinics in the United States were combined in this report. The average technician worked 40 hours a week, whereas the average laboratory director worked 49 hours per week. The average embryologist performed 181 procedures (not cases) per year. The average andrologist performed 648 procedures (not cases) per year, while the average endocrinologist completed 2,673 procedures (not cases) per year.

CONCLUSION(S)

This is the first report to describe time and staffing requirements as they relate to the laboratory personnel in an ART facility.

Hormonal effects in infants conceived by assisted reproductive technology

OBJECTIVE

The purpose of this report is to describe 7 infants conceived by assisted reproductive technology (ART) who presented with breast development and/or pubic hair. The clinical presentation in these infants raises awareness that an altered intrauterine hormonal milieu may impact the fetal and infant stages of children conceived by ART.

METHODS

Between May 2001 and April 2004, 7 children between the ages of 5 and 21 months conceived by ART were referred by their pediatricians to the Division of Pediatric Endocrinology at the New York University School of Medicine for evaluation of possible precocious puberty. Patients were evaluated for the possibility of centrally mediated precocious puberty and pseudoprecocious puberty, with a possible ovarian or adrenal origin.

RESULTS

Endocrine evaluation in all patients indicated sex-steroid and hormone levels in the prepubertal range; pelvic sonography confirmed prepubertal ovaries with unstimulated uteri. Clinical follow-up of our patients thus far has not revealed progression of breast development, pubarche, or elevation in sex steroids.

CONCLUSIONS

It is well established that the developing endocrine system in the fetus and maturation of endocrine-control systems are influenced by hormone concentrations in the fetus. Whether ART alters the intrauterine hormonal milieu for the growing fetus conceived by ART is as yet unknown and is an area of ongoing investigation. Patients conceived through ART, including our patients who presented with hormonal manifestations, will need to be monitored throughout childhood and into adolescence and adulthood to determine if any perturbation exists on the timing of puberty and later fertility.

Cumulative live birth rates in cohorts of patients treated with in vitro fertilization or intracytoplasmic sperm injection

OBJECTIVE

Follow-up of IVF/intracytoplasmic sperm injection (ICSI) patients to obtain accurate information concerning chances of live birth as well as early treatment dropout. Comparison of the cumulative pregnancy rates, established in cohorts, with those estimated with life table analysis to determine which method provides the most accurate data without overestimation.

DESIGN

Retrospective longitudinal cohort study.

SETTING

Academic medical IVF center.

PATIENT(S)

All 750 patients from the Leiden IVF center and another 706 patients from cooperating clinics starting IVF/ICSI treatment in the period 1996-2000.

INTERVENTION(S)

All observations were part of standard IVF/ICSI and cryopreservation protocols.

MAIN OUTCOME MEASURE(S)

Endpoints of this study were a first live birth or termination of treatment. Treatment cycles were followed until the end of 2002, pregnancy follow-up through September 2003.

RESULT(S)

The cumulative live birth rate for the Leiden cohort was 59.1%. In yearly cohorts this varied from 54.8% to 67.1%. Cumulative live birth rates were 61.8%-63.2% for unexplained infertility (n = 229), endometriosis (n = 19), and andrologic indication (n = 223). For tubal (n = 129) and hormonal (n = 46) indications the rates were 55.8% and 45.7%, respectively. The group of egg donation or surrogacy (n = 10) reached 40.0%, and patients with two or more indications (n = 84) 56.0%. For women < or = 35 years of age the cumulative live birth rate was 64.6%, for women 36-39 years of age it was 48.7%, and for women 40-42 years of age 31.0%.

CONCLUSION(S)

In contrast to estimation of expected cumulative pregnancy rates the cohort measurement does not overestimate success rates. It accurately reflects chances of both live birth as well as early treatment dropout. The cumulative live birth rate was 59.1%. Over time results improved and the contribution of cryopreservation increased.

Multiple birth resulting from ovarian stimulation for subfertility treatment

Assisted reproductive technologies (ARTs) aim to increase a woman's chances of becoming pregnant by bringing many female and male gametes into close proximity. Techniques to achieve this objective include ovarian hyperstimulation by maturation of several oocytes, intrauterine insemination (IUI) of concentrated sperm, or in-vitro fertilisation (IVF) by bringing gametes together outside the female body. The very nature of ovarian hyperstimulation--with or without IUI--enhances the risk of multiple pregnancy (eg, two or more babies). In most IVF cycles, more than one embryo is transferred, again resulting in an increased chance of multiple pregnancy. Developed societies have witnessed a large rise in prevalence of twin, triplet, and higher order multiple births, mainly resulting from ARTs. The primary aim of this Review is to increase awareness of the many implications of the present iatrogenic epidemic of multiple births. The background of ovarian hyperstimulation, trends supporting current practice, and strategies to reduce the chance of multiple pregnancy are highlighted.

Pregnancy rate, multiple pregnancy rate, and embryo quality: Clues for single blastocyst transfer from double blastocyst transfer in an unselected population

Objective:  Minimizing multiple pregnancy is a priority in assisted reproduction. As implantation rates are critical to success and reduce multiple pregnancy, we investigated whether blastocyst grade determined implantation rate following double blastocyst transfer in unselected cases. Materials and Methods:  We studied 69 three-cleavage stage embryo transfers and 64 two-blastocyst transfers. Two blastocysts, or one when two blastocysts were not available, were transfered after evaluating the grade of blastocysts. The difference in pregnancy and implantation rates to patient age, the number of retrieved oocytes and grade of blastocysts were analyzed. Results:  Blastocyst and grade 3AA rates per fertilized egg were 50.3% and 26.0%, respectively. Following two-blastocyst transfer, pregnancy rate per transfer, implantation rate per embryo, and multiple pregnancy rate per pregnancy were 39.1%, 26.5%, and 24.0%, respectively. Two-blastocyst transfer achieved implantation more often than three-cleavage-stage embryo transfer, but did not reduce multiple pregnancy. Pregnancy, implantation, and multiple pregnancy rates did not reflect maternal age. Higher pregnancy and implantation rates per transfer were attained for with six or more oocytes retrieved or transfer of two-blastocyst graded 3AA or higher especially when two or more blastocysts graded 3AA or higher are available, but the latter showed a high multiple pregnancy rate (38.5%). Conclusions:  Single embryo transfer could be carried out when two or more blastocysts of grade 3AA or higher have been developed. (Reprod Med Biol 2005; 4: 153-160).

The singleton, term gestation, and live birth rate per cycle initiated: a 1-year experience in in vitro fertilization cycles with native and donated oocytes

OBJECTIVE

To investigate the singleton, term gestation, and live birth rate per cycle initiated in our IVF program during a 1-year period.

DESIGN

Retrospective study of all first IVF cycles performed in the year 2002, with or without intracytoplasmic sperm injection (ICSI), with day 2/3 embryo transfer and using native or donated oocytes.

SETTING

Instituto Valenciano de Infetilidad (IVI), Valencia, Spain.

PATIENT(S)

Of 3,158 IVF cycles initially considered, 165 were excluded because of embryo freezing, follow-up loss, or embryo reduction. Of the remaining cycles, only 1,836 were first cycles with day 2/3 embryo transfer; of these, native oocytes were employed in 1,095 and donated oocytes in 741.

INTERVENTION(S)

No patient underwent any additional procedure or intervention.

MAIN OUTCOME MEASURE(S)

The singleton, term gestation, and live birth rate per cycle initiated was used as a primary outcome measure. Results were analyzed according to the origin of the oocytes (native vs. donated) and the woman's age (<37 and > or =37 years old).

RESULT(S)

The ectopic pregnancy rate was higher in the native oocyte group. The singleton, term gestation, and live birth rate per cycle initiated was similar in native and donated oocyte groups (15.3% vs. 13.4%). In the native oocyte group, patients <37 years old showed a significantly better outcome. The singleton, term gestation, and live birth rate per cycle initiated was 16.7% and 10.8% in younger and older women, respectively.

CONCLUSION(S)

The singleton, term gestation, and live birth rate per cycle initiated constitutes an essential parameter for determining the real possibility of a healthy baby for a specific assisted reproduction technology (ART).

Should ICSI be used in non-male factor infertility?

There is general agreement that intracytoplasmic sperm injection (ICSI) should be used in male factor infertility cases, such as oligoasthenoteratozoospermia, presence of anti-sperm antibodies, or azoospermia, these cases being diagnosed through abnormal semen analysis. There are no randomized clinical trials comparing ICSI with IVF (or other interventions) where semen quality is so poor that IVF would not achieve fertilization. It is accepted that ICSI is the only treatment option in those circumstances. The role of ICSI where IVF can be expected to give a reasonable fertilization rate is the question that needs to be answered. The argument is whether or not ICSI should be used for all cases of infertility. This paper proposes and strongly supports the use of ICSI for all indications. Considerations of fertilization and embryo development, cost effectiveness and safety will be clearly discussed.

Changes in the freezing protocol for human zygotes alter embryonic development and pregnancy rates

OBJECTIVE

To determine the effect of various freezing protocols on postthaw development and pregnancy rates resulting from transfer of human zygotes.

DESIGN

Prospective study.

SETTING

Tertiary care center.

PATIENT(S)

Couples undergoing assisted reproductive technology (ART) procedures who wished to have their excess zygotes cryopreserved.

INTERVENTION(S)

We cryopreserved zygotes with one of three protocols.

MAIN OUTCOME MEASURE(S)

Post-thaw survival and development of the zygotes as well as pregnancy rate after transfer of these zygotes.

RESULT(S)

A 3-minute hold time after seeding, followed by a final preplunging temperature of -180 degrees C, resulted in a clinical pregnancy rate of 28.6%. In contrast, a 15-minute postseed hold time and a -30 degrees C final chamber temperature resulted in a 37.3% clinical pregnancy rate. When we combined the protocols to provide a 15-minute postseed holding time and a -180 degrees C before plunging into liquid nitrogen, we achieved a 69.6% clinical pregnancy rate.

CONCLUSION(S)

By increasing the postseeding hold time and decreasing the temperature of the freezing chamber before plunging the zygotes into liquid nitrogen, significant improvements can be made in postthaw development and pregnancy rates.

Multiple gestation and infertility treatment: registration, reflection and reaction—the Belgian project

Multiple pregnancies associated with infertility treatment are recognized as an adverse outcome and are responsible for morbidity and mortality related to prematurity and very low birthweight population. Due to the epidemic of iatrogenic multiple births, the incidence of maternal, perinatal and childhood morbidity and mortality has increased. This results in a hidden healthcare cost of infertility therapy and this may lead to social and political concern. Reducing the number of embryos transferred and the use of natural cycle IVF will surely decrease the number of multiple gestations. Consequently, optimized cryopreservation programmes will be essential. For non-IVF hormonal stimulation, responsible for more than one-third of all multiple pregnancies after infertility treatment, a strict ovarian stimulation protocol aiming at mono-ovulation is crucial. Multifetal pregnancy reduction is an effective method to reduce high order multiplets but carries its own risk of medical and emotional complications. Excellent data collection of all infertility treatments is needed in our discussion with policy makers. The Belgian project, in which reimbursement of assisted reproduction technology-related laboratory activities is linked to a transfer policy aiming at substantial multiple pregnancy reduction, is a good example of cost-efficient health care through responsible, well considered clinical practice.

Endometriosis and infertility

Women with endometriosis typically present with pelvic pain, infertility or an adnexal mass. Surgery for persistent adnexal masses may be indicated to remove an endometrioma or other pelvic pathology. Surgical or medical therapy is efficacious for pelvic pain due to endometriosis, but treatment of endometriosis in the female partner of an infertile couple raises a number of complex clinical questions that do not have simple answers.

Follicle-stimulating hormone and estradiol levels independently predict the success of assisted reproductive technology treatment

OBJECTIVE

To evaluate the relationship between early follicular phase levels of FSH and E(2) and outcomes of therapy with assisted reproductive technologies (ART).

DESIGN

Retrospective cohort study.

SETTING

ART centers in the United States.

PATIENT(S)

Women receiving 19,682 ART procedures performed in 135 clinics.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rates of clinical pregnancy, live birth delivery, and high ovarian response (>/=10 oocytes retrieved after stimulation).

RESULT(S)

The ratio of each FSH or E(2) value to the respective upper limit of normal value for the clinic was computed. Within each age group, rates of pregnancy, live birth, and high ovarian response decreased linearly as FSH levels increased. For example, among women 35 years of age and younger, pregnancy rates (PR) ranged from 41.1% (FSH ratio 0-0.5) to 18.5% (FSH ratio >2.0). The three outcomes exhibited a similar downward trend as E(2) ratios increased. When both hormone ratios were elevated, outcomes were least favorable. These relationships remained statistically significant after we adjusted for diagnosis, number of embryos transferred, previous births, previous ART therapy, and use of GIFT, zygote intrafallopian transfer (ZIFT), intracytoplasmic sperm injection (ICSI), or assisted hatching.

CONCLUSION(S)

The FSH and E(2) ratios predict ART success independent of age and other clinical prognostic factors.

Ectopic pregnancies after infertility treatment: modern diagnosis and therapeutic strategy

Ectopic pregnancy (EP) is a major event in a woman's reproductive life. It complicates infertility treatment and must be recognized early to simplify the treatment strategy, which must always be directed towards optimizing subsequent fertility. Epidemiological findings indicate that tubal history and smoking are the principal risk factors of those EP that are considered reproductive (rather than contraceptive) failures. Adding together the attributable risks for EP allows the construction of a risk scale to determine its probability for any given patient. This risk calculation makes it easier to establish a diagnostic strategy that uses abdominal and transvaginal ultrasound and hCG assays. Progesterone assays are useful only for determining the activity of the pregnancy but do not help to identify its site. Conservative treatment is to be preferred unless the EP occurs on a known hydrosalpinx. All the treatment trials and the Cochrane database meta-analysis show that medical treatment with methotrexate, preferably multidose, is equivalent in efficacy to conservative treatment with laparoscopy in the populations studied. Heterotopic pregnancies, which occur most often after assisted reproduction technology (1-3%), should preferably be treated by salpingectomy except in interstitial sites. There is no consensus that IVF is indicated after EP. The patient's age is probably the determining factor: fertility treatment should not be delayed to an age where the results would be altered, especially with the risk of a recurrent EP.

Female age in ART: when to stop?

With increasing age the probability of ongoing pregnancy established by the use of assisted reproduction technology (ART) decreases. As a result the question arises whether age limits for the application of ART should be established. From a literature review and ongoing research data it appears that the costs per child born greatly increase after the age of 40 for both intrauterine insemination with mild ovarian stimulation and in vitro fertilisation treatment, while in cases of 44 and over, prognosis is flat zero. The willingness to pay for extra costs will greatly determine whether and at what age strict limits should be applied. Fortunately, predictive factors for success, like the antral follicle count, may enable the identification of women over 40 and under 44 that still have favourable prospects, thereby decreasing the necessary costs per childbirth and allowing couples into ART programs that are often denied based solely on female age.

Evaluation of mixed protocols with bravelle® (human-derived FSH) and repronex® (hMG) to assess clinical efficacy (EMBRACE) in women undergoing in vitro fertilization

OBJECTIVE

To compare the efficacy and safety of three different ratios of human-derived follicle-stimulating hormone/human menopausal gonadotropin (human-derived FSH:hMG, Bravelle and Repronex) mixed together in the same syringe and administered subcutaneously once daily, to in vitro fertilization (IVF) patients <34 years or 34 to 40 years of age.

DESIGN

Two randomized, prospective, age stratified, IVF studies.

SETTING

Twenty-one academic and private clinics with experience in IVF/embryo transfer (ET).

PATIENT(S)

Infertile premenopausal women undergoing IVF-ET.

INTERVENTION(S)

Pituitary suppression with leuprolide acetate, randomization to one of three treatment groups, followed by gonadotropin stimulation (GS) for up to 15 days. The human-derived FSH:hMG ratios were the following: Group 1, a 1:1 ratio throughout; Group 2, a 3:0 ratio that was changed to 1:1 after GS day 5; Group 3, a 2:1 ratio that was increased to 3:1, 4:1, or 5:1 after GS day 5, as needed.

MAIN OUTCOME MEASURE(S)

Mean number of oocytes retrieved; peak estradiol levels; dose and duration of stimulation; implantation rates; adverse events; injection site pain; and pregnancy and live birth rates.

RESULT(S)

Overall, women <34 years had higher E(2) levels, more oocytes retrieved, and improved implantation and live birth rates compared with women 34 to 40 years old. Nonetheless, each ratio of human-derived FSH:hMG produced comparable implantation rates, and continuing pregnancy and take-home baby rates.

CONCLUSION(S)

All three ratios of human-derived FSH:hMG in both age groups produced comparable pregnancy and live birth rates with similar safety results.

Fetal Reduction From Twins to a Singleton

OBJECTIVE

In the past, our group took the position that we would not provide multifetal pregnancy reduction to a singleton regardless of starting number except for serious maternal medical indications or as a selective termination for diagnosed fetal anomalies. With evidence of increased safety and more women (many aged 40 years or more) asking for counseling about reduction to a singleton, we reviewed our prior reasoning.

METHODS

We compared outcomes of 52 first-trimester twin-to-singleton for multifetal pregnancy reduction cases performed by a single operator to twin and singleton data from recent national register studies.

RESULTS

Twin-to-singleton reductions represent less than 3% of all cases. Forty of 52 patients were aged 35 years or more, 19 were aged more than 40 years, and 2 were aged more than 50 years (age range 32-54 years). Since 1999, 23 of 28 had chorionic villus sampling before multifetal pregnancy reduction. Fifty-one of 52 reached viability with mean gestational age at delivery of 37.2 weeks. One of 52 patients miscarried (1.9%). Compared with multiple sources of data for twins, the loss rate is lower in twins reduced to a singleton.

CONCLUSION

Until recently, multifetal pregnancy reductions to a singleton were rare. Physicians were concerned about the unknown risks of multifetal pregnancy reduction in this situation. They also had moral doubts about the justification to go "below twins." However, physicians know that spontaneous twin pregnancy losses average 8-10%. Also, with experience, multifetal pregnancy reduction has become very safe in our hands. Our data suggest that the likelihood of taking home a baby is higher after reduction than remaining with twins. We propose that twin-to-singleton reductions might be considered with appropriate constraints and safeguards.

Assisted reproductive technology in the United States: 2000 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry

OBJECTIVE

To summarize the procedures and outcomes of ART initiated in the United States in 2000.

DESIGN

Data were collected electronically using the SART Clinical Outcome Reporting System software and submitted to the American Society for Reproductive Medicine/ Society for Assisted Reproductive Technology Registry.

PARTICIPANT(S)

Three hundred eighty-three programs submitted data on procedures performed in 2000. Data were collated after November 2000 so that the outcome of all pregnancies established would be known.

MAIN OUTCOME MEASURE(S)

Incidence of clinical pregnancy, ectopic pregnancy, abortion, stillbirth, and delivery.

RESULT(S)

Programs reported initiating 99,989 cycles of ART treatment. Of these, 73,406 cycles involved fresh nondonor IVF (46.6% with intracytoplasmic sperm injection [ICSI]), with a delivery rate per retrieval of 29.9%; 549 were cycles of gamete intrafallopian transfer, with a delivery rate per retrieval of 24.7%; 763 were cycles of zygote intrafallopian transfer, with a delivery rate per retrieval of 29.9%. The following additional ART procedures were also initiated: 7,581 fresh donor oocyte cycles, with a delivery rate per transfer of 43.7%; 13,083 frozen embryo transfer procedures, with a delivery rate per transfer of 20.4%; 2,721 frozen embryo transfers using donated oocytes or embryos, with a delivery rate per transfer of 23.5%, and 1,200 cycles using a host uterus, with a delivery rate per transfer of 35.8%. In addition, 326 cycles were reported as combinations of more than one treatment type, 41 cycles as research, and 319 as embryo banking. As a result of all procedures, 25,394 deliveries were reported, resulting in 35,345 neonates, of which 35,031 were live born and 314 stillborn.

CONCLUSION(S)

In 2000, there were more programs reporting ART treatment and a significant (13.5%) increase in reported cycles compared to 1999. In comparable cycle types, overall success rate (deliveries per retrieval) exhibited an actual increase of 0.6%, which represents an increase of 2.2% when compared to the success rate for 1999.

Longevity of donor serum

PURPOSE

To determine the viability of long-term, stored serum, which is used in human in vitro production as a source of energy substrates, amino acids, vitamins, growth factors, and other nutrients.

METHOD

Two-cell mouse embryos were used in this prospective, cohort study. Serum stored for 1-, 5-, 10-, and 12-year intervals was subjected to four replications of mouse-embryo testing.

RESULT(S)

There were no significant differences in blastocyst rates between any of the replicates by year (80-100% blastocyst rate; P > 00.1) or between pooled replicate means by time period.

CONCLUSION(S)

Serum may be frozen up to 12 years.

Evidence-based diagnosis and management of tubal factor infertility

PURPOSE OF REVIEW

The investigation for potential tubal disease is an essential step in the work-up of infertility. This review article provides an evidence-based overview of the diagnosis and management of tubal factor infertility.

RECENT FINDINGS

While laparoscopic chromopertubation remains the gold standard in the diagnosis of tubal disease and hysterosalpingography is still widely used, newer modalities offer some advantages. Sonohysterography with the use of contrast medium is superior to hysterosalpingography and comparable to laparoscopic chromotubation in diagnosing tubal blockage. Chlamydia serology is the most cost-effective and least invasive diagnostic test for tubal disease, and it is comparable to, if not better than, hysterosalpingography. Depending on the nature and degree of tubal dysfunction as well as the age and ovarian reserve of the patient, various treatments for tubal infertility are available. For proximal tubal obstruction, transcervical tubal cannulation with tubal flushing is a reasonable first approach. Surgical techniques for tubal repair, such as salpingostomy or fimbrioplasty for distal tubal obstruction, can provide good results. Still, tubal factor remains a major indication for in-vitro fertilization and embryo transfer, which bypasses the tubal problem altogether. In certain situations, such as the presence of hydrosalpinx, prophylactic surgery can be used in conjunction with in-vitro fertilization and embryo transfer.

SUMMARY

As with infertility in general, the diagnosis and management of tubal infertility should be tailored to the individual patient. Future studies should help to further clarify the role of the various diagnostic tests and therapeutic approaches for tubal infertility.

Disclosure decisions among known and anonymous oocyte donation recipients

OBJECTIVE

The purpose of this study was to compare anonymous and known donor mothers' demographics, knowledge about the donor, and disclosure attitudes.

DESIGN

Cross-sectional survey of oocyte donation parents.

SETTING

Academic medical centers.

PATIENT(S)

Women having a child through oocyte donation in the past 12 years.

INTERVENTION(S)

Subjects completed a survey regarding their oocyte donation experience.

MAIN OUTCOME MEASURE(S)

Donor characteristics and disclosure behavior.

RESULT(S)

Questionnaires were sent to 524 individuals (262 couples); 157 (92 women and 65 men) were returned yielding a response rate of 31.4% (157/500). The average age of the women was 44.7 years and the average age of the child was 2.89 years. Seventy women used anonymous donors and 20 women used known donors. Significantly more known recipients knew their donors' religion, number of children, hobbies, profession, and photograph. Eighty percent of both groups told others about using a donor to conceive. Regarding telling the child, there were also no significant differences with approximately 10% who have told, 49% plan to tell, 31% are not telling, and 10% are unsure.

CONCLUSION(S)

Contrary to conventional wisdom we found no differences in plans to inform the child based on the use of a known or an anonymous donor.

Assisted hatching is associated with a higher ectopic pregnancy rate

In a retrospective analysis of 623 clinical pregnancies conceived after IVF, a 5.4% ectopic pregnancy rate (14/258 clinical pregnancies) was found in cases where assisted hatching (AH) was performed compared to 2.2% (8/365) in the group without assisted hatching. In view of the widespread use of AH, it may be relevant to assess the effect of AH on the incidence of ectopic pregnancy in a large multicenter effort.

Endometriosis and infertility

Women with endometriosis typically present with pelvic pain, infertility or an adnexal mass. Surgery for persistent adnexal masses may be indicated to remove an endometrioma or other pelvic pathology. Surgical or medical therapy is efficacious for pelvic pain due to endometriosis, but treatment of endometriosis in the female partner of an infertile couple raises a number of complex clinical questions that do not have simple answers.

Sonographically guided minimally invasive treatment of unusual ectopic pregnancies

OBJECTIVE

To present our experience with sonographically guided treatment of unusual ectopic pregnancies, defined as heterotopic pregnancies and pregnancies occurring at ectopic locations other than the extracornual portion of the fallopian tube.

METHODS

We retrieved and reviewed all cases of unusual ectopic pregnancies that underwent sonographically guided therapy at our institution. Twenty-seven cases were identified, from 1992 through 2003, including 18 cervical, 6 cornual, 1 tubal heterotopic, and 2 cesarean scar implantations.

RESULTS

All of the cervical ectopic, cornual ectopic, and tubal heterotopic pregnancies were treated by sonographically guided injection of potassium chloride into the ectopic gestational sac or fetus. Guidance was via transvaginal sonography in all 18 cervical pregnancies, 3 of the 6 cornual pregnancies, and the tubal heterotopic pregnancy, and via transabdominal sonography in 3 cornual ectopic pregnancies. One of the cesarean scar pregnancies was treated by transvaginally guided potassium chloride injection, and the other was treated via transabdominally guided dilation and evacuation. Treatment was successful in 25 of the 27 patients, including all 23 patients with an ectopic pregnancy and no concomitant intrauterine pregnancy. Four patients had concomitant intrauterine and ectopic pregnancies (1 cervical, 2 cornual, and 1 tubal); in 3 the intrauterine fetuses resulted in live-born infants, and in the fourth the intrauterine pregnancy was electively terminated. Eight of the 27 patients had subsequent intrauterine pregnancies.

CONCLUSIONS

Sonographically guided minimally invasive treatments of unusual ectopic pregnancies are safe and effective alternatives to surgical and systemic medical therapy. These treatments ablate the ectopic pregnancy, permit normal continuation of a concomitant intrauterine pregnancy, and preserve the uterus for subsequent pregnancies.

In vitro fertilization outcomes: why doesn't anyone get it?

It is not only patients who frequently do not understand the implications of multiple pregnancies and IVF outcomes in general. Physicians, insurers, and governments must share the responsibility for failing to properly address both overall and multiple pregnancy rates after IVF.

Effect of controlled ovarian hyperstimulation in IVF on endometrial gene expression profiles

Controlled ovarian hyperstimulation (COH) used in IVF produces lower implantation rates per embryo transferred compared to natural cycles utilized in ovum donation, suggesting a suboptimal endometrial development. Endometrial receptivity has recently been investigated in natural menstrual cycles with the aid of microarray technology. The aim of this study is to investigate the impact of COH using urinary gonadotrophins with a long protocol with GnRH agonists without progesterone supplementation (similar to the natural cycle) on endometrial gene expression profiles during the window of implantation by comparing the profiles at day hCG + 7 of COH versus LH + 7 of a previous natural cycle in the same women. For this purpose we have used microarray technology by Affymetrix (GeneChip HG_U133A), which allows more than 22,000 genes to be tested simultaneously. Results were validated by semi-quantitative PCR and quantitative PCR experiments. We found that more than 200 genes showed a differential expression of more than 3-fold when COH and normal cycles were compared at hCG + 7 versus LH + 7. We simultaneously re-analysed the LH + 2 versus LH + 7 endometrial gene expression profiles in previous natural cycles in the same subject using this specific GeneChip, the results obtained were consistent with our own published results. This is the first time that gene expression profiles of the endometrium during COH are reported. The large degree of gene expression disturbance is surprising and highlights the need for further efforts to optimize COH protocols.

Damaged babies from assisted reproductive technologies: focus on the BESST (birth emphasizing a successful singleton at term) outcome

The BESST (birth emphasizing a successful singleton at term) statistic per assisted reproductive technolgies (ART) cycle commenced is proposed to help minimize multiple births.