The role of gamete intrafallopian transfer (GIFT) in the treatment of oligospermic infertility

Cumulative experience of percutaneous epididymal sperm aspiration (PESA) with intracytoplasmic sperm injection

OBJECTIVE

Our objective was to evaluate the recovery rate of spermatozoa from the epididymis using a percutaneous aspiration technique and to assess the fertilisation rate after intracytoplasmic sperm injection.

MATERIALS AND METHODS

Fifty-four patients with azoospermia had a total of 59 cycles at IVF with intracytoplasmic sperm injection (ICSI). The cause of the azoospermia was failed vasectomy reversal in 23 cases, congenital absence of the vas in 22 cases, partial testicular failure in 5 cases, and retrograde ejaculation in 2 cases, while the remaining 2 patients had erectile disorders.

RESULTS

A total of 741 oocytes was collected and 521 metaphase II oocytes were subsequently microinjected. Normal fertilisation occurred in 274 oocytes (52.6%), and of these, 234 cleaved (85.4%). In 54 cycles, embryo transfer of more than one embryo occurred (91.5%) and a total of 155 embryos was replaced. The pregnancy rate was 30.5% per cycle and 33.3% per embryo transfer. The implantation rate was 14.2%; failure of fertilisation occurred in two cycles, while in three other cycles the embryos did not cleave.

CONCLUSIONS

Percutaneous epididymal sperm aspiration can be used successfully to retrieve sperm in men with azoospermia due to obstructive, or nonobstructive, disorders. The technique is simple, cost-effective, and associated with fewer complications than an open microsurgical operation.

Comparison between swim-up and glass wool column filtration of human semen in a gamete intrafallopian transfer program

This study compared swim-up and glass wool filtration in both pregnancy outcome and fertilization of excess oocytes in patients undergoing gamete intrafallopian transfer. Gamete intrafallopian transfer patients were retrospectively included in the study group (n = 52). The criteria for inclusion were as follows: Semen had to have been prepared by means of glass wool filtration and at least 2 metaphase II oocytes had to have been transferred. Each patient from this group was then carefully matched with another patient according to specific criteria (number of metaphase II oocytes aspirated and transferred, normal sperm morphology, wife's age, the absence of anti-sperm antibodies, semen preparation by means of the swim-up procedure). Fourteen patients were matched with themselves (groups A1 and A2) and 38 patients were matched with another patient (groups B and C). The results indicate that there was no significant difference in the fertilization and pregnancy probabilities of sperm prepared by means of glass wool filtration or swim-up procedure. The comparative pregnancy rates for the groups were A1 (7.1%) versus A2 (7.1%) and B (28.9%) versus C (31.6%). Factors other than fertilization and pregnancy potential may have a greater influence on choosing the optimum sperm preparation procedure.

Simplified sperm retrieval and intracytoplasmic sperm injection in patients with azoospermia

OBJECTIVE

To evaluate the rate of recovery of spermatozoa from the epididymis using a percutaneous aspiration technique and to assess the fertilization rate following intracytoplasmic sperm injection (ICSI).

PATIENTS AND METHODS

Forty-two patients with azoospermia underwent a total of 46 treatment cycles of in vitro fertilization (IVF) and ICSI. The sperm used for ICSI was retrieved percutaneously by fine-needle aspiration and syringe suction (percutaneous epididymal sperm aspiration, PESA) from the epididymis in 28 patients (mean age 34.9 years), over 32 cycles. Six patients underwent microsurgical sperm aspiration (MESA) and in the remaining eight patients, neither percutaneous aspiration nor MESA yielded suitable sperm and spermatozoa extracted from testicular biopsy were used.

RESULTS

A total of 362 oocytes were collected and of those, 286 (79%) were subjected to ICSI. Of the injected oocytes, 49 (17.2%) were damaged, 138 (48.3%) achieved normal fertilization and, of those, 112 (81.2%) cleaved. A total of 67 embryos were transferred and 18 more were suitable for cryopreservation. Of the 25 cycles with embryo transfer, eight resulted in a pregnancy and of these, one miscarried. The pregnancy rate was 25% per cycle and 32% per embryo transfer. The implantation rate was 12%.

CONCLUSIONS

This extensive series of PESA/ICSI cycles indicates that PESA can be used successfully to retrieve spermatozoa in patients with azoospermia. The technique is simple, cost-effective and is associated with fewer complications compared to an open microsurgical procedure.

Controlled ovarian hyperstimulation and transvaginal intratubal insemination as an alternative to gamete intrafallopian transfer

OBJECTIVE

To evaluate the efficacy of controlled ovarian hyperstimulation (COH) followed by intratubal insemination in the treatment of infertility.

DESIGN

Retrospective analysis of 179 intratubal insemination trials in 78 women over a 48-month period.

SETTING

Reproductive endocrinology practice.

PATIENTS

Seventy-eight women, 26 to 44 years old (34 +/- 4.3 years; mean +/- SD), classified into subgroups according to diagnosis and age (< 40 or > or = 40 years).

INTERVENTIONS

Patients underwent COH and intratubal insemination.

MAIN OUTCOME MEASURES

The rates of pregnancy, delivery, spontaneous abortion, ectopic and multiple gestation, and complications were studied and analyzed statistically.

RESULTS

Overall, there were 36 pregnancies (20.1% of 179 trials), 29 deliveries (16.2%), 5 of 36 first trimester abortions (13.9%), 2 of 36 ectopic pregnancies (5.6%), and 4 twin gestations. There were no serious complications. In 43 women < 40 years without male factor the first trial resulted in 15 pregnancies (34.9%); in 27 women < 40 years with male factor the first trial resulted in 4 pregnancies (14.8%). Male factor reduced significantly the probability of conception. In 19 women < 40 years of age with either ovarian dysfunction or infertility of unknown cause, the first trial resulted in 9 pregnancies (47.4%), which was significantly better than the 10 pregnancies achieved in the first trial in the remaining 51 women < 40 years of age. Peak serum E2 levels and number of mature follicles had a significant effect on pregnancy rates.

CONCLUSIONS

Intratubal insemination yielded pregnancy rates comparable to those published for GIFT at reduced cost and with fewer complications.

Percutaneous epididymal sperm aspiration and intracytoplasmic sperm injection in the management of infertility due to obstructive azoospermia

OBJECTIVE

To evaluate the recovery rate of spermatozoa from the epididymis using a percutaneous aspiration technique and to examine the fertilization rate after intracytoplasmic sperm injection.

DESIGN

Prospective observational study.

SETTING

Private infertility clinic, London.

SUBJECTS

Twenty patients with obstructive azoospermia who each had an attempt at IVF. The sperm used for intracytoplasmic sperm injection was retrieved by percutaneous epididymal sperm aspiration in 16 patients. In one patient, microepididymal sperm aspiration was performed in addition because the quality of the sperm obtained by percutaneous epididymal sperm aspiration was not considered suitable for microinjection. In the remaining three patients, neither percutaneous epididymal sperm aspiration nor microepididymal sperm aspiration resulted in the recovery of sperm, which was obtained by testicular biopsy in one of them.

INTERVENTION

Assisted fertilization with intracytoplasmic sperm injection.

MAIN OUTCOME MEASURES

Normal fertilization and pregnancy rates.

RESULTS

A total of 179 eggs were collected and 157 subsequently were microinjected. Normal fertilization occurred in 22 oocytes (14%) and the total number of embryos cleaved was 30. Twelve patients underwent ET in which three conceived (pregnancy rate 25% per transfer). The implantation rate was 10% and failed fertilization occurred in four cycles.

CONCLUSION

Percutaneous epididymal sperm aspiration can be used successfully to recover sperm in men with obstructive azoospermia for use in assisted fertilization IVF cycles. The technique is simple, effective, and less traumatic compared with an open microsurgical operation.

Appraisal of gamete intrafallopian transfer

OBJECTIVE

To collect results of gamete intrafallopian transfer on a large scale in order to compare treatment indications, results, and factors which influence the success rates; to evaluate whether gamete intrafallopian transfer is well-established and what the real place of this procedure is among other assisted reproduction techniques.

DESIGN

Data relating to gamete intrafallopian transfer were collected from World Reports, national registries of different countries and meta-analysis of medical publications during the years 1986-1991.

SUBJECT

Official registries reported 47,200 treatment cycles and 18,759 treatment cycles were analysed from ten medical publications.

RESULTS

The procedure accounts for 13.5% of all assisted reproduction techniques but its popularity varies significantly among countries. The same indications for gamete intrafallopian transfer are followed by all countries, but great differences exist with regard to the proportional share of each etiology. Also, the share has changed considerably over the years. TREATMENT OUTCOME: 10,667 clinical pregnancies were reported which represent 24% of treatment cycles and 29% of ovum pick-up. The live birth rate was 23.3%; abortion rate, 22%; and ectopic pregnancy rate, 5.5%. The stillbirth rate was 2.3% and the malformation rate was 2.8%, not confined to specific organs or systems. There were 19.5% twins, 4.6% triplets and 0.3% quadruplets or more. The number of transferred oocytes influenced pregnancy rates: 28% for transfer of four oocytes and only 10% following transfer of one oocyte. The cause of infertility might influence the results and the poorest results are obtained for male factor infertility. In most cases correlation of success rates reported by leading units through medical publications closely resembles the overall national registries results. Indications for this treatment were broadened over the years, but its role among other assisted reproduction technologies is not agreed upon, especially for male factor and unexplained infertility.

CONCLUSIONS

Gamete intrafallopian transfer carries an overall higher pregnancy rate than in vitro fertilization. Quality control by professional or public associations should be established and more research employed over indications for treatment and results in order to establish when GIFT is the treatment of choice and when other modes of treatment should be preferred.

Gamete intrafallopian transfer: ethical considerations, historical development of the procedure, and comparison with other advanced reproductive technologies

OBJECTIVE

To report on ethical considerations regarding GIFT as well as the developmental history of the procedure and to review the literature and compare it with other advanced reproductive technologies (ARTs).

DESIGN

Indications, patient screening, recent evaluations, methods of ovarian hyperstimulation and oocyte retrieval-assessment, gamete transfer and pregnancy outcome are discussed in this review. A comparison of GIFT with other ARTs is also attempted.

MAIN OUTCOME MEASURES

Gamete intrafallopian transfer pregnancy determination and outcome.

CONCLUSIONS

Gamete intrafallopian transfer is an ethically acceptable procedure by different religious groups. In a selected group of patients, GIFT is an acceptable and, in some occasions, a preferable procedure to other ARTs.

The role of gamete intrafallopian transfer (GIFT) and tubal embryo transfer (TET) in the treatment of patients with patent tubes associated with male infertility factor

PURPOSE

The relative effectiveness of gamete intrafallopian transfer (GIFT) and tubal embryo transfer (TET) combined with superovulation in the treatment of infertile patients with patent tubes were compared. Four hundred fifty consecutive cycles were divided into two periods. During the first period (216 cycles), the only technique employed was GIFT, couples being divided into two groups: group A, couples with normospermic partners (118 cycles); and group B, couples with male infertility factor (98 cycles). During the second period (234 cycles), 140 cycles of GIFT were performed in couples with normospermic partners (group C). TET was utilized in 94 cycles (group D), in the case of couples with male infertility factor.

RESULTS

Results demonstrate that the pregnancy rate with GIFT in the case of oligoasthenospermic partners (group B) is significantly lower than that of normospermic partners (groups A and C) (P = 0.0001) and than that with TET in the case of oligoasthenospermic partners (group D) (P = 0.0001).

CONCLUSION

The implantation rate is also significantly different between these groups (B vs A, P = 0.0001; B vs C, P = 0.0001; B vs D, P = 0.01).

After superovulation-intrauterine insemination fails: the prognosis for treatment by gamete intrafallopian transfer/pronuclear stage transfer

OBJECTIVE

To determine the prognosis for gamete intrafallopian transfer (GIFT)/pronuclear stage transfer (PROST) treatment after prior superovulation-intrauterine insemination (IUI).

DESIGN

Matched, retrospective.

SETTING

Outpatient university endocrine-infertility program.

PATIENTS, PARTICIPANTS

One hundred forty-four women matched for infertility factors and age were studied according to the following three treatment groups: superovulation-IUI only, GIFT/PROST only, or GIFT/PROST after superovulation-IUI.

MAIN OUTCOME MEASURES

Per cycle and cumulative pregnancy rates (PRs) were compared utilizing life table analysis.

RESULTS

Cumulative PRs (0.408) for superovulation-IUI only were lower than initial (0.469) and cumulative (0.802) cycle fecundity of GIFT/PROST (P = 0.002). Per cycle and cumulative PRs did not differ between GIFT/PROST only versus GIFT/PROST after superovulation-IUI.

CONCLUSIONS

Gamete intrafallopian transfer/PROST may be cost-effective when compared with superovulation-IUI. The prognosis for GIFT/PROST success is not negatively affected by earlier superovulation-IUI treatment failure.

The laparoscope in follicular oocyte collection and gamete intrafallopian transfer and fertilization (GIFT)

Laparoscopic recovery of bovine follicular oocytes was studied. The collection of oocytes from the superovulated bovine ovary was maximized by standardizing the collection technique. The technique was highly successful, with a 79% oocyte recovery rate of the follicles aspirated. Collected oocytes were transferred to the inseminated recipient's oviduct with a minimum of trauma through the laparoscope. This gamete intrafallopian transfer and fertilization (GIFT) resulted in multiple embryo recovery in the cow. Oviductal catheterization and the potential of GIFT are described and discussed.

Placebo-controlled trial of high-dose Mesterolone treatment of idiopathic male infertility

The possible effect of Mesterolone (Schering N.V., Brussels, Belgium) (1 alpha-methyl-5-alpha-androstane-17 beta-ol-3-one) on semen quality and fertility of men with idiopathic oligoasthenospermia and/or teratozoospermia has been evaluated in a double-blind trial. The study included 52 patients who were treated during 12 months with either 150 mg/d of Mesterolone or placebo. The overall pregnancy rate was similar in the Mesterolone-treated cases (26%) and in the placebo control cases (48%), although a significant increase in motility and in the proportion of spermatozoa with normal morphology was recorded in the Mesterolone-treated cases. Because similar semen improvement also occurred in the placebo controls, our findings cast doubt on the possible usefulness of high-dose Mesterolone treatment of idiopathic male infertility.

Gamete intrafallopian transfer: assessment of the optimal number of oocytes to transfer

The optimum number of oocytes that should be transferred at the time of gamete intrafallopian transfer (GIFT) is important information. Nonessential oocytes can be inseminated and frozen for later use or the extra oocytes can be donated to another women. In this preliminary study, the results of 399 consecutive GIFT procedures were evaluated retrospectively as a function of the number of oocytes transferred. Women who received four or more oocytes were three times more likely to achieve a clinical pregnancy than those who received three or less. There was no statistically significant difference in pregnancy rates between patients who received five, six, seven, or eight oocytes. Oocytes in excess of five may be more effectively used if they are fertilized and frozen as embryos for later transfer rather than replacing them all at the time of GIFT.

The cryopreservation of donor semen by a simplified method: use in an IVF and GIFT programme

The cryopreservation of semen used in assisted reproduction procedures was carried out exclusively by a simplified method in which a mixture of semen and cryoprotectant was contained in 1-ml tuberculin syringes and plunged directly into liquid nitrogen. Donor semen samples halved and frozen in syringes and in straws in a controlled-rate freezer showed no significant difference in post-thaw motility (P = 0.217) or survival (P = 0.217) after 30 min. However, after 180 min the survival rate showed a significant reduction in syringes (P = 0.045). A significant difference (P less than 0.00008) in the rate of fertilization of oocytes was seen in IVF cycles using frozen-thawed donor sperm (58/142, 42%) when compared to fresh sperm from husbands (2315/3926, 59%). A significant reduction (P less than 0.00005) in fertilization rate was also observed in the case of supernumerary oocytes in GIFT cycles with the cryopreserved donor sperm (29/132, 22%) compared to the husbands' sperm (239/514, 46%). However, the pregnancy rate following IVF and embryo replacement was the same after fertilization with fresh sperm (75/351, 21%) as opposed to frozen sperm (3/14, 21%). Furthermore, a higher pregnancy rate was observed in GIFT with frozen donor sperm (9/19, 47%) than with fresh sperm from husbands (28/103, 27%), though this was not statistically significant (P = 0.079). These results show this simplified methods of semen cryopreservation to be effective when used in an IVF and GIFT programme, giving pregnancy rates comparable to fresh normospermic semen samples. The method is simple, quick and inexpensive.

Outpatient gamete intrafallopian transfer: a clinical analysis of 710 cases

From February 1986 to June 1989 445 infertile couples were treated with a total of 710 treatment cycles involving laparoscopic gamete intrafallopian transfer (GIFT). The median age of the female partner was 33.5 years (range, 24 to 49 years) and the median duration of infertility was 4 years (range, 2 to 20 years). The final outcome of all 217 clinical pregnancies is known. There were 150 live births among which all but one baby survived, comprising 112 singleton births, 28 twin births, nine triplet births and one quadruplet birth. There were no still births, but there were two premature, multiple live births (one triplet, one quadruplet) among which no babies survived the neonatal period. Overall, 40 of the 152 potentially viable pregnancies were multiple (26.3%). Three of 206 potentially viable babies were born with congenital anomalies (1.5%). There were 50 clinical spontaneous abortions (24.8% of uterine pregnancies), one termination of pregnancy for Down's syndrome, and 14 ectopic pregnancies rate was 30.6% per laparoscopy and, among 740 initiated cycles, a live and surviving birth-per-initiated-cycle rate of 20.2%, or 33.7% to date per couple entering the programme. The 710 laparscopies resulted in two serious complications (0.3%), one of which required laparotomy. Eight other patients were admitted to hospital for rest and observation because of painful ovarian enlargement in the luteal phase. The total inpatient admission rate was 1.4%. Outpatient laparoscopic GIFT under general anaesthesia is a safe and effective procedure when conventional treatment for infertility has been unsuccessful.

Influence of pentoxifylline in severe male factor infertility

Two in vitro fertilization sperm preparation protocols using pentoxifylline (long and short exposure before insemination) were studied in 57 couples (61 cycles) with male factor infertility. For each cycle, oocytes were divided into two groups for insemination using either pentoxifylline-treated or control semen. Fertilization rates improved over controls in the short protocol (P less than 0.001) and fewer couples experienced fertilization failure (P = 0.02). Sixteen pregnancies ensued (30% per collection with the short protocol), and 4 were from cases with less than 1.0 X 10(6) progressively motile sperm count per milliliter, 1 being as low as 0.2 X 10(6) progressively motile count per milliliter. Seventeen healthy infants have now delivered and pregnancy wastage is not increased. Pentoxifylline is thus a useful sperm treatment for cases of male factor infertility.

The importance of egg and sperm factors in predicting the likelihood of pregnancy from gamete intrafallopian transfer

The relative contribution of factors affecting the probability of pregnancy from gamete intrafallopian transfer was estimated using data from 218 cycles performed in San Antonio, Texas, and Orange, California. Mature eggs, all of which contained an expanded cumulus, were subclassified according to the corona radiata; those with a starburst corona were considered the most fully mature. Sixty-two clinical pregnancies were established, representing a pregnancy rate of 28.4%. Excluding 49 cases of male factor infertility, the pregnancy rate was 34.9%. Pregnancy rates were not significantly different according to age, cause of female factor infertility, parity, duration of infertility, stimulation protocol, or estradiol level. The only variables having a strong association with pregnancy were sperm and egg parameters. Sperm motility and morphology were statistically more important than sperm density. Based on odds ratios calculated from multiple logistic analysis, pregnancy was 3.80 times more likely if three or more fully mature eggs were transferred, 0.34 times as likely if motility were less than or equal to 30%, and 0.22 times as likely if normal morphology was less than or equal to 50%, controlling for other egg and sperm factors. If all egg and sperm factors in a given cycle were unfavorable, the probability of pregnancy estimated by the logistic model was 4%, whereas if all were favorable the probability of pregnancy in that cycle was 59%.

Gamete intrafallopian transfer vs superovulation with intrauterine insemination for the treatment of infertility

Superovulation with intrauterine insemination (SO-IUI) has been suggested as an alternative to gamete intrafallopian transfer (GIFT), despite the absence of controlled or comparative trials. We retrospectively analyzed all GIFT and SO-IUI cycles performed concurrently from January 1985 to August of 1987 at a single university center. Pregnancy rates were significantly better for GIFT than SO-IUI (P less than 0.001), with an odds ratio of 3.25 (P = 0.001). Stepwise multiple logistic regression identified factors that correlate with pregnancy: absence of endometriosis (P = 0.05), infertility less than 3 years' duration (P = 0.002), TMS greater than or equal to 30 X 10(6) (P = 0.005), and treatment with GIFT rather than SO-IUI (P = 0.001). These data give a first approximation of the increased efficacy of GIFT versus SO-IUI and provide valuable insight into significant confounding variables to be considered when planning a randomized, prospective trial to evaluate these techniques.

Routine gamete intrafallopian transfer (GIFT): a highly successful option for treatment of non-tubal infertility

Gamete intrafallopian transfer (GIFT) is increasingly accepted as a realistic alternative to in vitro fertilization (IVF), or intrauterine insemination (IUI) for treatment of non-tubal infertility. The lack of information on fertilization capacity of the gametes, the greater cost relative to IUI, and the partly unsubstantiated claims of higher success rates, caused us some concern with the readiness with which GIFT had been accepted as a standard infertility treatment. So we undertook a provisional GIFT programme with these considerations in mind, and we report on the first 91 GIFT cycles performed in our clinic. Sixty of the patients (62 cycles) treated suffered from idiopathic infertility, 12 from minimal endometriosis, 9 from male factor infertility, and 8 from ovulatory dysfunction. An initial clinical pregnancy rate of 41% (38/91) was achieved; pregnancy loss was 23% (9/38), giving a continuing pregnancy rate of 32% (29/91). Given this undeniably encouraging result, and the potential for diagnostic IVF, embryo freezing, and ovum donation with surplus oocytes collected from this GIFT programme, we now have adopted GIFT permanently as a treatment to complement our IVF and IUI programmes.

Fallopian replacement of eggs with delayed intrauterine insemination (FREDI): an alternative to gamete intrafallopian transfer (GIFT)

This report contains details of what is the first group of patients with nontubal infertility to undergo fallopian replacement of eggs with delayed intrauterine insemination (FREDI). Twenty-three patients suffering from idiopathic or immune infertility, polycystic ovarian disease (PCOD), or mild endometriosis underwent follicular stimulation with human menopausal gonadotropin and/or pure follicle-stimulating hormone plus human chorionic gonadotropin prior to laparoscopic pickup of eggs of varying maturity. Eggs without spermatozoa were transferred at the time of laparoscopy. Subsequent high intrauterine insemination (IUI) of washed spermatozoa at a time when egg maturation within the tubes was judged to be complete enabled a cohort of fully capacitated spermatozoa to meet fully mature eggs in a totally physiological manner. Eight clinical pregnancies arose from this group, one healthy, male infant has been delivered, and four pregnancies remain ongoing. Although based on a small population of patients, it does seem that in vivo egg maturation following replacement in the fallopian tube is an effective alternative to in vitro maturation and, with the increased control over timing of egg insemination, leads us to propose FREDI as a flexible new therapeutic approach for the treatment of nontubal infertility.

Fertilization of human oocytes in vitro by spermatozoa from oligozoospermic and normospermic men

Sperm were isolated from the semen of oligozoospermic (less than 20 x 10(6) sperm/ml) and normospermic (greater than or equal to 20 x 10(6) sperm/ml) men in an in-vitro fertilization (IVF) programme. Oocytes from the female partners were inseminated with either 75 or 100 x 10(3) motile sperm and checked for fertilization after 16-20 h. A significant reduction in the overall fertilization rate of oocytes was seen for the oligozoospermic group compared to the normospermic group, at both insemination concentrations. In the oligozoospermic group, a fertilization rate of 31% (19/61) was achieved when oocytes were inseminated with 75 x 10(3) sperm, and 38% (9/24) when inseminated with 100 x 10(3) sperm. This compared with rates of 57% (397/696) and 64% (650/1018), respectively, for normospermic cases at both insemination concentrations. No evidence of fertilization was seen in 36% (4/11) and 67% (4/6) of oligozoospermic cases when 75 or 100 x 10(3) sperm were used, compared with values of 13% (17/133) and 9% (20/212), respectively, in normospermic cases. After excluding zero cases, the fertilization rate of oocytes for the oligozoospermic group (75%; 9/12) was similar to the normospermic group (70% 650/935) when 100 x 10(3) sperm were used. However, when 75 x 10(3) sperm were used, the fertilization rate for the oligozoospermic group (41%; 19/46) was significantly lower than that of the normospermic group (62%; 397/645). Following the transfer of embryos into the female partner, clinical pregnancies were diagnosed in 2/7 (29%) oligozoospermic cases and 27/267 (10%) normospermic cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between the results of sperm analysis and GIFT

In vitro fertilization (IVF) and GIFT have been proposed as therapeutic approaches in infertile couples where a significant male factor is present. To date, few published data are available relating the success rate of GIFT to the severity of the male factor. In this report the results of the first 172 GIFT cases were analyzed. The overall pregnancy rate was 18.0%. The relationship between the occurrence of pregnancy and sperm count (millions/ml), total sperm count (millions/ejaculate), % motility, motile sperm count (millions/ml) and total motile sperm count (millions/ejaculate) were examined. Significant direct correlations were observed between the clinical pregnancy rate and sperm count, total sperm count, motile sperm count and total motile sperm count. Motile sperm count and total motile sperm count had the best correlations with clinical pregnancy rates, which were over 24.0% in groups with motile sperm counts exceeding 40 X 10(6) cells/ml or total motile sperm counts greater than 100 X 10(6)/ejaculate. The clinical pregnancy rates were 12.5% and 7.7%, respectively, for groups with motile sperm counts under 10 X 10(6)/ml and total motile sperm counts below 25 X 10(6)/ejaculate. No correlation was found between percent motile cells and pregnancy rate. Results of the sperm penetration assay using zona-free hamster eggs were available in a subpopulation of 27 patients. No significant correlation between this sperm penetration assay and pregnancy rate could be demonstrated. The incidence of chemical pregnancy showed a significant negative correlation with the total motile sperm count, indicating a higher incidence of early pregnancy wastage in cases of oligozoospermia.(ABSTRACT TRUNCATED AT 250 WORDS)

Success rate in gamete intrafallopian transfer using low and high concentrations of washed spermatozoa

The effect of a reduced number of spermatozoa on pregnancies and miscarriages was studied retrospectively in 307 consecutive gamete intrafallopian transfer (GIFT) cycles. The number of spermatozoa introduced per GIFT in each group was as follows: 100,000 (group I), 50,000 (group II), 10,000 (group III), 5,000 (group IV), and 2,500 (group V), which gave a pregnancy rate of 20%, 38%, 37%, 30%, and 24%, respectively (differences were not significant). With respect to the pregnancies, no correlation was found between the number of spermatozoa transferred and the cause of infertility. In the male factor group also no significant difference was observed in the pregnancy rate when the sperms were reduced from 100,000 to 2,500. Lowering the number of sperms in GIFT did not reduce the abortion rate, which remained around 33%. It was the patients with unexplained infertility who benefited most from the GIFT procedure. Their pregnancy rate was significantly higher than the pregnancy rate of those who had endometriosis, or andrologic or immunologic disorders.

Early pregnancy wastage after gamete manipulation

The outcome of 1034 pregnancies in women who conceived after referral for infertility management in seven treatment groups is detailed. The mean early pregnancy wastage (before 20 weeks gestation) was 27% and ranged from 18% after AID (artificial insemination by donor semen) to 33% after IVF-ET (in-vitro fertilization and embryo transfer). These differences were not due to maternal age which was similar in all groups (means between 29.7 and 32.7 years). Excluding the AID group, there was a high rate of ectopic pregnancy which was significantly higher after GIFT (gamete intrafallopian transfer) and was only partly related to underlying tubal disease. Blighted ova was the main category of early pregnancy loss and was highest after AIH (artificial insemination by husband's semen). There was a higher rate of biochemical pregnancies after GIFT, PROST (pronuclear stage tubal transfer) and IVF-ET. Our findings confirm a high pregnancy wastage rate in subfertile women and highlight deficiencies in the sperm separation, gamete handling and IVF/embryo culture techniques.

Tubal embryo transfer as a treatment for infertility due to male factor

Transvaginal follicular aspiration (TVA) with ultrasonically guided needles allows the transfer of in vitro generated embryos to the fallopian tubes (TET), performing only one surgical procedure in the process. Up to now, this approach has been used to treat 16 couples with infertility due to severe male factor. Follicular development was induced with a combination of clomiphene citrate and human menopausal gonadotropin (hMG) or follicle-stimulating hormone and hMG. Follicles were aspirated by TVA 36 hours after an injection of human chorionic gonadotropin 10,000 IU intramuscularly. A total of 169 oocytes were recovered (10.5 +/- 6.9 X +/- SD) from the 16 patients. There was failure of fertilization in 6 cases. In the remaining 10, a TET was performed 44 to 50 hours after TVA, utilizing embryos at the pronuclear stage. Six pregnancies resulted from the 10 transfers. This technique combines the advantages of proof of fertilization with a more adequate tubal embryo development and entrance to the uterine cavity that may determine and increase chance of implantation.

Corrective measures and pregnancy outcome in in vitro fertilization in patients with severe sperm morphology abnormalities

Sperm morphology evaluated by new, strict criteria is a good predictor of outcome in in vitro fertilization (IVF). This study aimed (1) to determine whether the fertilization rate of preovulatory oocytes in patients with abnormal morphology can be improved by increasing insemination concentration at the time of IVF and (2) to evaluate the pregnancy outcome in patients with abnormal sperm morphology. Three groups were studied: (1) normal morphology, (2) good prognosis pattern, and (3) poor prognosis pattern. All other sperm parameters were normal. Group 3 had a lower overall fertilization rate, lower pregnancy rate/cycle, and lower ongoing pregnancy rate/cycle. Groups 2 and 3 showed a higher miscarriage rate, although not significantly different from group 1. By increasing insemination concentration from 2- to 10-fold, the fertilization rate in group 3 increased from 14.5% to 62.6%. However, pregnancy outcome did not improve. We conclude that patients with severe sperm head abnormalities have a lower ability to establish successful pregnancies, even though fertilization may be achieved.

The relative chance of pregnancy following tubal or uterine transfer procedures

In a 7-month study period, a total of 113 pregnancies were generated in 380 women (30%) undergoing transfers in one of four assisted conception procedures: gamete intrafallopian transfer (GIFT), pronuclear stage tubal transfer (PROST), tubal embryo stage transfer (TEST), and in vitro fertilization and embryo transfer (IVF-ET). It was shown that both the pregnancy rate per transfer procedure and the number of pregnancy sacs arising per embryo transferred were significantly higher among the groups having tubal transfer (P less than 0.001). There were no significant differences in the pregnancy or implantation rates among the three groups having tubal transfer procedures when the GIFT results were adjusted for a 72% fertilization rate noted in the combined IVF-ET and PROST groups. Early pregnancy wastage showed a similar pattern among the four groups and, overall, 67% of pregnancies advanced beyond 20 weeks.

Pregnancies following pronuclear stage tubal transfer

Pronuclear stage tubal transfer (PROST) is a technique that involves in vitro fertilization (IVF) of oocytes, followed by the transfer of pronuclear oocytes into the fallopian tubes. It has been developed for its prognostic value of confirming fertilization in couples with oligospermia or asthenospermia and enabling fertilization in cases with antispermatozoal antibodies (ASAB). PROST has provided useful diagnostic information in the management of couples who have failed to conceive in other treatment programs and has particular advantages over IVF for those receiving fresh donated oocytes for ovarian failure. Fourteen pregnancies resulted from 52 transfers, providing a pregnancy rate of 27% per transfer. The pregnancy rates were higher than a matched IVF series in the male factor and female ASAB groups and reached statistical significance for the ovum donation group. It is anticipated that both pregnancy rates and fetal wastage will be improved over conventional IVF and embryo transfer for the described infertility groups.