Ultrasound-guided peritoneal oocyte and sperm transfer (POST)

A historical perspective of the clinical evolution of the assisted reproductive technologies

The practice of assisted reproduction technology today is the result of the dedicated patient care, observation, research, and experimentation undertaken by previous generations of physicians. The building blocks of progress have been assembled over past decades, by scientists whose primary objective has been to push forward the frontiers of knowledge, in order to offer more effective methods of infertility treatment. And fortunately that process continues today. Amongst the many scientific developments that have led to the modern practice in assisted reproductive technology, a small number stand out as having had a unique importance. This historical review redraws the path through which in vitro fertilization went from an experimental to an accepted infertility treatment.

Follicle aspiration, sperm injection, and assisted rupture (FASIAR): a simple new assisted reproductive technique

OBJECTIVE

To describe the first successful application of a new fertility-enhancing technique.

DESIGN

Case report.

SETTING

Academic fertility program.

PATIENT(S)

A 36-year-old nulligravid woman undergoing inseminations with frozen-thawed donor sperm.

INTERVENTION(S)

Ovarian superovulation, follicle aspiration, sperm injection, and assisted follicular rupture.

MAIN OUTCOME MEASURE(S)

Assessment of feasibility of technique and pregnancy outcome.

RESULT(S)

After failing to conceive during 16 cycles of IUI, the patient successfully achieved an ongoing pregnancy during the second follicle aspiration, sperm injection, and assisted rupture (FASIAR) attempt.

CONCLUSION(S)

Follicle aspiration, sperm injection, and assisted rupture combines the concepts of superovulation, IUI, and peritoneal oocyte and sperm transfer to obviate the possibility of luteinized unruptured follicle syndrome, assist oocyte release, and ensure gamete intermixing. It also can be used to reduce the number of ovulating oocytes and thus to reduce the risk of multiple gestations. Follicle aspiration, sperm injection, and assisted rupture is a new, simple, office-based procedure that does not require embryologic expertise beyond sperm preparation as for IUI, yet promises to be more successful than IUI.

Transvaginal peritoneal oocyte and sperm transfer for the treatment of nontubal infertility

OBJECTIVE

To investigate if peritoneal oocyte and sperm transfer (POST) performed transvaginally is an effective treatment for nontubal infertility.

DESIGN, SETTING, AND PATIENTS

Prospective study of 18 patients (4 with unexplained infertility, 13 with failed donor insemination, and 1 with male factor infertility) having 20 cycles of transvaginal POST in a specialist infertility unit.

INTERVENTIONS

Ovarian stimulation was achieved with human menopausal gonadotropin (hMG) alone, hMG and clomiphene citrate, or gonadotropin-releasing hormone agonist with hMG. Oocyte recovery was performed transvaginally under ultrasound guidance, the pouch of Douglas rinsed repeatedly and an embryo transfer catheter used to transfer 4 x 10(6) progressively motile sperm in 1 mL and up to four oocytes into the pouch of Douglas. Luteal support was provided with human chorionic gonadotropin injections given 2 and 5 days later.

RESULTS

The mean age of the patients was 32.65 +/- 5.0, and the mean length of infertility 5.07 +/- 2.32 years. The mean number of oocytes transferred was 3.53 +/- 0.87. Three pregnancies were achieved in the failed donor insemination group and 1 each in those with unexplained and male factor infertility, giving overall clinical pregnancy and live birth rates of 25% and 20% per initiated cycle. All pregnancies were achieved in those who had three or four oocytes transferred.

CONCLUSION

Transvaginal POST is a useful assisted conception technique for the treatment of nontubal infertility.

Pregnancy rates after peritoneal ovum-sperm transfer

We present the technique of peritoneal ovum-sperm transfer as an option for treatment in couples with unexplained infertility factors. In 1989 we reported the first successful pregnancy, in the United States, after transferring sperm and oocyte into the peritoneal cavity. We now report the results of a prospective study of this procedure. Twelve women with unexplained infertility underwent 23 cycles of peritoneal ovum-sperm transfer. Ovulation stimulation was achieved with human menopausal gonadotropin. Ultrasonographically directed oocyte recovery was performed by the transvaginal route with the patient under local anesthesia and sedation. After oocyte recovery, 4.5 +/- 0.4 (mean +/- SE) oocytes and 13.3 +/- 1.0 (mean +/- SE) x 10(6) motile spermatozoa were transferred into the pouch of Douglas. Six clinical pregnancies occurred in 23 stimulated cycles for a pregnancy rate of 26% per cycle. This value compares with the overall pregnancy rates of 16% for in vitro fertilization and 27% for gamete intrafallopian transfer reported by the In Vitro Fertilization Registry. Thus these preliminary data suggest that peritoneal ovum-sperm transfer is at least as successful as in vitro fertilization and gamete intrafallopian transfer. Advantages of peritoneal ovum-sperm transfer over gamete intrafallopian transfer include its being an office nonsurgical procedure not necessitating a general anesthetic and decreased cost. Therefore peritoneal ovum-sperm transfer is a reasonable first approach in couples with unexplained infertility.

Experience with peritoneal oocyte and sperm transfer as an outpatient-based treatment for infertility

Fifty-nine patients underwent 74 peritoneal oocyte and sperm transfer procedures. Forty-nine had previously failed treatment with inseminated frozen donor sperm and 10 had unexplained infertility. All procedures were carried out under ultrasound direction on an outpatient basis without general anesthetic by the transabdominal or vaginal route. Eighteen (24%) procedures resulted in pregnancy. Of these patients, 16 have delivered live infants (1 set of triplets, 2 twins, and 13 singletons) and 2 miscarried. Peritoneal oocyte and sperm transfer offers an outpatient-based alternative to gamete intrafallopian transfer (GIFT) for in vivo conception. It can also be used in patients scheduled for intrauterine insemination where stimulation is excessive because the number of oocytes replaced can be limited.

Sperm antibodies after intraperitoneal insemination of sperm: a preliminary report

To test the hypothesis that intraperitoneal insemination of sperm induces the expression of anti-sperm antibodies a prospective study was designed. Fifteen women undergoing intraperitoneal insemination (with or without oocyte transfer) were studied with 11 women having evaluation of anti-sperm antibodies. Sperm antibodies were detected by the immunobead test prior to intraperitoneal insemination and after each treatment cycle. Two criteria were used to assess positivity: the first based upon negative controls and the second based upon the evaluation of 20 fertile control couples. Using the first criteria, of 11 of the women undergoing IPI for the first time, 7 were initially negative and 4 were initially positive for at least 1 isotype. After treatment, 3 additional patients were positive (for a total of 7) and 4 patients remained negative. This alteration in sperm antibody frequency was not different (P = .4) as determined by the Fisher's Exact Test. Four of the 11 patients underwent a second cycle of IPI. All 4 patients were negative prior to the first treatment and 3 were negative prior to the second treatment. Subsequent to the second exposure, all 4 of these women were positive for at least 1 isotype. This shift in frequency distribution after 2 cycles was significant (P = .01). The frequency of antisperm antibodies for the same 11 patients was evaluated by using fertile control values as the basis of positivity. Two patients (18%) were positive for anti-sperm antibodies prior to intraperitoneal insemination. There was no change in the frequency of positivity after 1 cycle of IPI.(ABSTRACT TRUNCATED AT 250 WORDS)

Pregnancy resulting from peritoneal ovum sperm transfer procedure

This is the first reported transvaginal ultrasound-guided POST pregnancy in the United States. Advantages over the GIFT procedure include it being an office procedure done under local anesthesia and IV sedation, and decreased cost. Larger series are needed to compare pregnancy rates.