Recent trends in assisted reproductive techniques and associated outcomes

Supernumerary blastocyst cryopreservation: a key prognostic indicator for patients opting for an elective single blastocyst transfer (eSBT)

OBJECTIVE

To determine if patients, less than 40 years of age with or without day 5 cryopreservation (d5 cryo), compromise their pregnancy rate (PR) by choosing an eSBT.

DESIGN

Retrospective analysis

SETTING

University IVF center

PATIENTS

2,203 non-donor fresh IVF cycles in women <40 years of age from January 2004 to January 2010.

INTERVENTIONS

None

MAIN OUTCOME MEASURE(S)

Eggs retrieved, Embryos cryopreserved, Implantation Rates, Clinical Pregnancy Rates, Live Birth Rates, Spontaneous Abortion Rates

RESULTS

Pregnancy outcomes in women <40 years with or without d5 cryo were compared according to whether patients underwent an eSBT versus a 2BT in non-donor fresh IVF cycles. Overall, eSBT was associated with elimination of twinning while maintaining a high clinical pregnancy rate in both groups with d5 cryo (75 % eSBT versus 72 % 2BT) and groups without d5 cryo (48 % eSBT versus 56 % 2BT).

CONCLUSIONS

In this study, patients <40 years of age have eliminated twinning by electively choosing to transfer a single blastocyst without compromising their PR if embryos are available for d5 cryo, and suffer only a non-statistically significant drop in their PR if there are no embryos available for d5 cryo in exchange for the benefit of eliminating the obstetrical risk of twinning.

In-vitrofertilisation treatment: Factors affecting its results and outcome

The objective of this study was to determine factors affecting results and outcome of in-vitro fertilisation (IVF). In this retrospective study, a total of 891 infertile women underwent IVF/ICSI cycles at the King Hussein Medical Center (KHMC) between January 2001 and December 2002. Conventional IVF treatment was performed in 64.6% of women and intracytoplasmic sperm injection (ICSI) in 35.4%, using a standardised long luteal protocol. Pregnancy rate was analysed according to age, type of infertility, cause of infertility, duration of infertility, number of eggs collected and follicle stimulating hormone (FSH) levels. A total of 126 cycles (14.1%) were cancelled. Among 765 cycles continued, fertilisation rate was 73.9%, implantation rate was 15.1% and pregnancy rate was 29.8%. Pregnant women had a multiple pregnancy rate of 28.9%, abortion rate of 13.6% and ectopic pregnancy rate of 1.3%. Duration and type of infertility had no significant effect on the pregnancy rate. Factors which appear to affect significantly the outcome of treatment include the woman's age, cause of infertility, basal concentrations of FSH, adequate ovarian responsiveness and the number of eggs collected. In some cases with poor outcome, the understanding of these factors may predict the results and lead to the development of new strategies to improve the outcome of IVF treatment.

Comparison of pregnancy outcomes in elective single blastocyst transfer versus double blastocyst transfer stratified by age

OBJECTIVE

To determine whether there is a difference in pregnancy outcomes, stratified by age, between women undergoing elective single blastocyst transfer (eSBT) versus those undergoing double blastocyst transfer (2BT).

DESIGN

Retrospective analysis.

SETTING

University IVF center.

PATIENT(S)

A total of 1,141 nondonor IVF cycles in women aged <40 years from January 2004-March 2007.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Eggs retrieved, embryos cryopreserved, implantation rates, clinical pregnancy rates (PR), live birth rates (LBR), spontaneous abortion rates (SAB).

RESULT(S)

Pregnancy outcomes in 52 cycles of women <40 years of age who underwent eSBT were compared with 1,086 cycles of women who underwent 2BT in fresh IVF cycles from January 2004-March 2007. Overall, the eSBT was associated with a statistically significant 92% reduction in the twinning rate (from 25%-2%) while maintaining a high clinical PR (63% in the eSBT group vs. 61% in the 2BT group).

CONCLUSION(S)

Women who are <40 years of age undergoing nondonor fresh IVF cycles can electively choose to transfer a single blastocyst for the purpose of significantly reducing their risk of multiples without compromising their PR.

A proteomic analysis of IVF follicular fluid in women <or=32 years old

OBJECTIVE

To address the lack of predictors of IVF success by using proteomic biometrics.

DESIGN

Experimental study of follicular fluid specimens from a prospective cohort of IVF patients.

SETTING

Academic research laboratory and IVF program.

PATIENT(S)

Women <or=32 years old with <11 oocytes retrieved and no pregnancy were matched to women who had >or=11 oocytes and live birth (10 pairs). Year of cycle start and IVF down-regulation protocol were also matched.

INTERVENTION(S)

Follicular fluid was separated by two-dimensional polyacrylamide gel electrophoresis followed by Sypro Ruby staining and comparison with PDQuest software. Logistic regression was incorporated to calculate the likelihood of live birth in relation to the protein spot of interest.

MAIN OUTCOME MEASURE(S)

Protein markers.

RESULT(S)

Liquid chromatography-tandem mass spectrometry and searching of sequence databases revealed 11 potential protein candidates. Haptoglobin alpha, predominantly fetal expressed T1 domain, mitochondrial integrity genome (ATPase), apolipoprotein H (beta-2 glycoprotein I), dihydrolipoyl dehydrogenase, lyzozyme C, fibrinogen alpha-chain, and immunoglobulin heavy chain V-III (region BRO) were found to have increased expression in the live birth group, whereas antithrombin, vitamin D-binding protein, and complement 3 were decreased. An ELISA confirmed a significantly lower level of antithrombin.

CONCLUSION(S)

Proteomic evaluation of follicular fluid is able to identify potential biomarkers of good versus poor responders in matched pairs of IVF patients.

Elective single embryo transfer: a 6-year progressive implementation of 784 single blastocyst transfers and the influence of payment method on patient choice

OBJECTIVE

To evaluate efforts to reduce twin pregnancies through progressive implementation of elective single embryo transfer (eSET) among select patients over a 6-year period.

DESIGN

Retrospective review.

SETTING

Private practice IVF center.

PATIENT(S)

Infertile women undergoing 15,418 consecutive IVF-ET cycles.

INTERVENTION(S)

IVF-ET, including blastocyst-stage eSET among select patients with good prognosis and high risk of multiple pregnancy.

MAIN OUTCOME MEASURE(S)

Pregnancy, multiple pregnancy, method of payment.

RESULT(S)

Pregnancy rates were similar for autologous eSET versus double-blastocyst transfer (65% vs. 63%), while twin rates were much lower (1% vs. 44%). For recipients of donor oocytes, pregnancy rates were slightly lower with eSET (63% vs. 74%), while twin rates were much lower (2% vs. 54%). There was no decrease in overall pregnancy rates, despite a dramatic rise in eSET use over time (1.5% to 8.6% of all autologous transfers and 2.0% to 22.5% of all transfers to donor oocyte recipients between 2002 and 2007). Overall singleton pregnancy rates increased, while twin pregnancy rates declined significantly over time. Use of eSET was significantly more common among patients with insurance coverage or who were participating in our Shared Risk money-back guarantee program.

CONCLUSION(S)

Selective eSET use among good-prognosis patients can significantly reduce twin pregnancies without compromising pregnancy rates. Patients are more likely to choose eSET when freed from financial pressures to transfer multiple embryos.

Impact of duration and dose of gonadotrophins on IVF outcomes

In order to examine whether the duration of the follicular phase and changes in daily gonadotrophin dosages impact IVF outcome, a retrospective analysis of women who underwent oocyte retrieval and fresh embryo transfer was performed. Among the parameters assessed were the number of days of gonadotrophin stimulation, changes in the daily dosage of gonadotrophins, total ampoules of gonadotrophins, embryo implantation rates, clinical pregnancy rates and ongoing pregnancy rates. The number of days of gonadotrophin stimulation, as determined by standard follicular size criteria did not appear to influence IVF outcomes. There was no significant difference in pregnancy rates between women who were stimulated for <9 days, 10-11 days or >12 days. When grouped by amount of starting daily dose of gonadotrophins there was a significant inverse relationship between gonadotrophin requirements and pregnancy rates (P=0.02). The data suggest that the success of an IVF cycle depends on the ovaries' ability to develop follicles of the appropriate size, not the speed at which the ovaries perform this function.

LH in the follicular phase: neither too high nor too low

The role of LH in the natural menstrual cycle is not disputed. However, there are a variety of opinions regarding the potential role of exogenous LH in ovulation induction and whether it is actually needed. Recent years have seen renewed interest in this issue for several reasons. First, ovulation-inducing drugs are increasingly being administered to normally ovulating women. Second, recombinant human FSH products completely devoid of LH activity are now available. Third, gonadotrophin-releasing hormone (GnRH) analogues (agonists and antagonists) prevent the untimely LH surge but also suppress endogenous LH activity during the follicular phase. This review analyses whether or not all patients need LH for follicular growth stimulation and new opportunities for improved treatment as a result of the availability of recombinant human LH both in patients with ovulatory disorders (World Health Organization (WHO) groups I and II anovulatory patients) and those undergoing multiple follicular development for assisted reproduction.

Human progesterone receptor polymorphisms and implantation failure during in vitro fertilization

OBJECTIVE

Polymorphic variants of the human progesterone receptor gene have been described, but their potential influence on in vitro fertilization outcome have not been studied.

STUDY DESIGN

DNA was available from 317 women (cases) who had >or=2 embryo transfers without a clinical pregnancy and from 288 women (control subjects) who became pregnant after 1 in vitro fertilization attempt. With protocols that were specific for H770H (C/T genotype) and +331G/A polymorphism, amplification of polymorphism fragments, digestion with restriction enzymes, and gel visualization were performed.

RESULTS

Allele frequencies for the 2 variants were 15.5% for H770H T and 4.1% for +331A in cases and 17.9% and 3.6% in control subjects, respectively. Both polymorphisms were rare among non-white subjects. Possession of a H770H T allele was associated with a decreased risk for implantation failure, which was nonsignificant overall but significant in women aged <35 years (adjusted relative risk, 0.52 [95% CI, 0.28, 0.97]). Possession of a +331A allele was associated with an increased risk of implantation failure, which was nonsignificant overall but significant in women who weighed <135 pounds (adjusted relative risk, 3.85 [95% CI, 1.20, 12.30]). The +331G/A polymorphism tended to increase the risk for implantation failure in women with an H770H C/C genotype, but not in women with a C/T or TT genotype (P=.09). Among white women who were H770H C/C, there was a significant trend (P=.03) in the proportion of +331G/A carriers as the number of implantation failures increased, from 8.6% of women with 0 failed attempts to 40% among women with >or=5 failed attempts.

CONCLUSION

Although human progesterone receptor polymorphisms do not clearly affect the risk for implantation failure in most women who undergo in vitro fertilization, the likelihood that a woman carries the +331G/A human progesterone receptor polymorphism increases with the number of failed attempts at implantation.

Social stigma and compounded losses: quality-of-life issues for multiple-birth families

OBJECTIVE

To determine the quality-of-life domains most impacted by multiple births.

DESIGN

Focus groups, qualitative research.

SETTING

Human volunteers in a medical research environment.Forty-three mothers, 29 raising multiple-birth children, 13 raising singletons, identified from random and convenience samples.

INTERVENTION

None.

MAIN OUTCOME MEASURE(S)

Maternal self-reports of the psychosocial sequelae of multiple or singleton births, based on qualitative data analysis of transcribed group discussions.

RESULT(S)

The quality-of-life domains that were most impacted by raising multiple birth children were social stigma, pregnancy loss, marital satisfaction, children's health, unmet family needs, parenting stress, maternal depression, and the infertility experience.

CONCLUSION(S)

Qualitative methods identified two novel quality-of-life domains in iatrogenic multiple birth families: social stigma and compounded losses. An unexpected finding was the potential for increased marital solidification as parents coped with the inordinate stresses of multiple births. As anticipated, children's health, unmet family needs, maternal depression, and parental stress were key areas of concern. In addition, the infertility experience had a lasting impact. These findings are significant, given that at least 38% of all assisted conceptions result in a multiple birth. This study lays the groundwork for further research on the impact of iatrogenic multiple births.

Is luteinizing hormone needed for optimal ovulation induction?

The role of luteinizing hormone in the natural menstrual cycle is not disputed. There are, however, a variety of opinions regarding the potential role of exogenous luteinizing hormone in ovulation induction and whether it is actually needed. The recent introduction into clinical practice of recombinant gonadotropins has been paralleled by recent advances in the knowledge of the endocrine and paracrine mechanisms that regulate human folliculogenesis. On this basis, this review analyses whether or not all patients need luteinizing hormone for follicular growth stimulation. In addition, new opportunities for improved treatment are considered as a result of the availability of recombinant human luteinizing hormone both in patients with ovulatory disorders and those undergoing multiple follicular development for assisted reproduction.

Viewpoint: medical infertility care in low income countries: the case for concern in policy and practice

Based on published, 'grey' and anecdotal information, this paper explores some aspects of infertility, its medical treatment and their burden in poor countries. Many cases of infertility result from sexually transmitted infections (STI) and unsafe abortion and there is no doubt that their prevention and adequate treatment are of utmost importance, especially as effective infertility treatment, if any, comes at a high price for the consumer, materially as well as physically. Medical infertility interventions are apt to fail a free market of provision because of major information asymmetry. This renders patients in low-resource countries prone to exploitation, potentially damaging practices and waste of their savings. The authors argue that in countries struggling with limited funds and a range of pressing public health problems, public investment in infertility treatment should not have priority. But governments should take an active role in quality control and regulation of treatment practice, as well as invest in counseling skills for lower-level reproductive health staff to achieve rational referral of patients.