Individual implantation rate: proposal for a new index for evaluation of assisted reproduction results

Live birth rates in various subgroups of poor ovarian responders fulfilling the Bologna criteria

The European Society of Human Reproduction and Embryology published Bologna criteria to generate a definition of poor ovarian responders (PORs). However, there are few data on whether PORs are homogenous for ovarian response or live birth rates (LBRs). In this retrospective study, 821 patients fulfilling Bologna criteria and undergoing intracytoplasmic sperm injection were stratified into four groups: Group A: female age ≥40 with a previous poor response (cycle cancelled or ≤3 oocytes) (105 patients, 123 cycles); Group B: female age ≥40 with an antral follicle count (AFC) < 7 (159 patients, 253 cycles); Group C: AFC <7 with a previous poor response (350 patients, 575 cycles); and Group D: female age ≥40 with an AFC <7 and previous poor response (207 patients, 306 cycles). Cluster data analysis was performed. Although median number of oocytes was higher in Group B (P < 0.001), higher implantation (P = 0.024) and LBR per embryo transfer (P < 0.001) or cycle (P = 0.001) were noted in Group C. We conclude that, once a patient fulfils Bologna criteria, prognosis is poor, with fewer than 10% recorded LBRs per cycle. However, the LBRs are not homogenous and 'young proven' PORs have the most favourable pregnancy outcome.

Regulation of matrix metalloproteinase-9 (MMP-9), tissue inhibitor of MMP, and progesterone secretion in luteinized granulosa cells from normally ovulating women with polycystic ovary disease

OBJECTIVE

To investigate the regulation of MMP-9, TIMP-1, and progesterone via three signal transduction pathways in luteinized granulosa cells from normal ovulatory and PCOD women.

DESIGN

In vitro study.

SETTING

Laboratory for Research in Reproductive Sciences, Department of Obstetrics and Gynecology, Ha'Emek Hospital, Afula, Israel.

PATIENT(S)

Ten normal ovulatory and 10 women with polycystic ovary disease (PCOD) treated in an assisted reproduction program.

INTERVENTION(S)

Cultured cells were exposed to phorbol 12-myristate 13-acetate (TPA), acting via protein kinase C (PKC), to epidermal growth factor (EGF), acting via protein tyrosine kinase (PTK), and to forskolin, acting via protein kinase A (PKA).

MAIN OUTCOME MEASURE(S)

Secretion of MMP-9, TIMP-1, and progesterone.

RESULT(S)

Phorbol 12-myristate 13-acetate elicited an increase in MMP-9 and TIMP-1 secretion in both groups and apparently did not affect progesterone secretion. Epidermal growth factor did not change significantly neither MMP-9 nor TIMP-1 secretion but dose dependently decreased MMP-9-TIMP-1 ratio and increased progesterone secretion in the PCOD group. Forskolin inhibited MMP-9 activity and increased TIMP-1 and progesterone secretion in both groups. Progesterone production was inversely related to the ratio of MMP-9-TIMP-1 regardless of cell origin.

CONCLUSION(S)

In this preliminary study, similar and divergent patterns have emerged in the regulation of MMP-9 and TIMP-1 in human luteinized granulosa cells. Repressing MMP-9-TIMP-1 ratio may have an important modulatory effect on progesterone secretion.

Can we abandon routine evaluation of serum estradiol levels during controlled ovarian hyperstimulation for assisted reproduction?

OBJECTIVE

To assess whether abandoning measurement of serum estradiol (E2) and spacing ultrasound evaluations at greater intervals had an effect on the results of assisted reproduction technology (ART).

DESIGN

A retrospective comparison of two consecutive periods.

SETTING

Division of Assisted Reproduction Technology, Department of Obstetrics and Gynecology, Ha'Emek Medical Center, Afula, Israel.

PATIENT(S)

One thousand nine hundred and eighty-five controlled ovarian hyperstimulation (COH) cycles for ART were initiated during the years 1996 to 1999.

INTERVENTION(S)

During the first 2 years an intensive follow-up protocol was used that included E2 blood levels measurements. In the next 2 years a less intensive protocol was adopted that did not use E2 measurements.

MAIN OUTCOME MEASURE(S)

ART results and the rate of ovarian hyperstimulation syndrome (OHSS).

RESULT(S)

The patients' background characteristics did not differ between the two periods. The cancellation rate was not different (9.8% vs. 7.2%). There was no difference in the duration of stimulation or the amount of gonadotropins used. The number of oocytes retrieved (12.1 +/- 9.3 vs. 9.6 +/- 6.3), fertilization rates (74% vs. 75%), and clinical pregnancy rates (26.2% vs. 27.9%) did not differ. The incidence of severe ovarian hyperstimulation syndrome was not significantly different between the two periods.

CONCLUSION(S)

Controlled ovarian hyperstimulation for ART can be done reliably without routine, serial serum E2 measurements without compromising the treatment results.

The origin of spermatozoa does not affect intracytoplasmic sperm injection outcome

OBJECTIVE

To assess whether the origin of spermatozoa, ejaculate or testicular, affects intracytoplasmic sperm injection (ICSI) outcome.

STUDY DESIGN

Retrospective study of 890 consecutive first ICSI and embryo transfer cycles done for male infertility. The ICSI outcome of ejaculated spermatozoa (n=780) and testicular spermatozoa retrieved from patients with obstructive azoospermia (n=43), non-obstructive azoospermia (n=53) and severe oligoasthenoteratozoospermia (n=14) were compared by using chi-square test, independent t-test and ANOVA with Bonferroni test.

RESULTS

All azoospermic males had a diagnostic testicular biopsy at least 6 months before the ICSI procedure. Spermatozoa were successfully retrieved in all 43 patients with obstructive azoospermia and in 72.6% of 73 non-obstructive cases. The cycle characteristics of the four groups were similar apart from a younger mean female age in the non-obstructive azoospermia group when compared with the ejaculated spermatozoa group. The fertilization, implantation and clinical pregnancy rates were comparable among the four groups.

CONCLUSION

Testicular spermatozoa recovered from patients with obstructive and all types of non-obstructive azoospermia were as much as effective as ejaculated spermatozoa in ICSI.

Chorionic villus sampling before multifetal pregnancy reduction

OBJECTIVE

This study was undertaken to determine the technical feasibility and accuracy of chorionic villus sampling before multifetal pregnancy reduction and to determine whether sampling increases the pregnancy loss rate after the reduction procedure.

STUDY DESIGN

Between January 22, 1986, and January 20, 2000, a total of 1183 patients underwent first-trimester multifetal pregnancy reduction at Mount Sinai Medical Center. Chorionic villus sampling was attempted in 86 patients before the reduction procedure. Information on the technical success and accuracy of chorionic villus sampling, as well as pregnancy outcome, was collected on all patients. Pregnancy loss rates before 24 weeks' gestation in patients undergoing chorionic villus sampling before multifetal pregnancy reduction were compared with rates in patients not undergoing sampling.

RESULTS

Chorionic villus sampling was successfully completed in 85 (98.8%) of 86 patients in whom sampling was attempted. Of 166 fetuses, 165 (99.4%) were successfully sampled. Of 165 fetuses, 3 (1.8%) had karyotypic abnormalities. Sampling errors were probably made in 2 (1.2%) of 165 fetuses. Of the 73 patients who have been delivered or are beyond 24 weeks' gestation, only 1 patient (1.4%) had a pregnancy loss after the multifetal pregnancy reduction.

CONCLUSIONS

Chorionic villus sampling before multifetal pregnancy reduction is technically feasible and accurate, with an acceptably low sampling error rate. Chorionic villus sampling before multifetal pregnancy reduction appears to be safe and does not increase the risk of loss after the reduction procedure.

Intracytoplasmic sperm injection versus in vitro fertilization for patients with a tubal factor as their sole cause of infertility: a prospective, randomized trial

OBJECTIVE

To compare the efficacy of intracytoplasmic sperm injection and IVF in women with a tuboperitoneal factor as their sole cause of infertility.

DESIGN

Prospective, randomized study.

SETTING

Hacettepe University Assisted Reproduction Unit, Ankara, Turkey.

PATIENT(S)

Seventy-six consecutively seen patients with tuboperitoneal factor infertility were randomized on an alternate basis to undergo either intracytoplasmic sperm injection (38 patients and cycles) or IVF (38 patients and cycles).

INTERVENTION(S)

Intracytoplasmic sperm injection and IVF.

MAIN OUTCOME MEASURE(S)

Fertilization, implantation, and clinical pregnancy rates.

RESULT(S)

A comparable number of oocytes and embryos were obtained with intracytoplasmic sperm injection and IVF. The two-pronuclei fertilization rates per metaphase II oocyte or mature cumulus-oocyte complex were similar in the two groups. The numbers of total and grade I embryos transferred also were similar. Comparisons of intracytoplasmic sperm injection and IVF did not reveal any statistically significant differences in individual implantation rates (38.75% +/- 24.46% and 34.58% +/- 16.97%, respectively) clinical pregnancy rates per cycle (21.05% and 21.05%, respectively), or take-home infant rates (18.42% and 15.79%, respectively). The type of procedure performed was not a significant predictor of clinical pregnancy.

CONCLUSION(S)

When a decision is made to proceed with an assisted reproductive technique in patients with a tubal factor as their sole cause of infertility, IVF should be the initial treatment of choice.