Predictive value of plasma human chorionic gonadotrophin following assisted conception treatment

The POPI-Plus tool: prediction model of outcome of pregnancy in in vitro fertilization from a large retrospective cohort

OBJECTIVE

To create a tool that accurately predicts live birth chances after a positive pregnancy test after elective single embryo transfer (ET).

DESIGN

Retrospective cohort.

SETTING

CHUM hospital and Ovo clinic in Montreal, Canada.

PATIENT(S)

Patients with a positive pregnancy test result who underwent their first single ET after in vitro fertilization (IVF) at the CHUM hospital and Ovo clinic in Montreal, Canada, from 2012 to 2016 were selected. A total of 1,995 patients were included in this study.

INTERVENTION(S)

The data from both centers were combined and divided into training (70%, n = 1,398) and validation (30%, n = 597) sets. The predictive model was developed using backward selection method for the following variables: age of patient at egg retrieval; log β-human chorionic gonadotropin (β-hCG) (β-hCG) 1; log β-hCG 2; and IVF treatment type. Moreover, the classification tree, random forest, and neural network models were generated.

MAIN OUTCOME MEASURE(S)

The measured outcomes were live birth (live fetus ≥24 weeks of gestation) and nonviable pregnancies. The performance of all models was evaluated by area under the receiver operating characteristic curve (AUC).

RESULT(S)

Advancing age was negatively correlated with live birth. The odds ratio (OR) of age of patient at the time of egg retrieval was 0.95 (95% confidence interval [CI], 0.91-0.99). The log β-hCG 1 and log β-hCG 2 were positively correlated with live birth in the univariate analysis (OR, 4.15 [95% CI, 3.19-5.39], and OR, 3.84 [95% CI, 2.99-4.93], respectively). The β-hCG 1 level needed for a successful pregnancy was lower in frozen ET and modified natural IVF than in simulated IVF (OR, 0.55 [95% CI, 0.34-0.91], and OR, 0.49 [95% CI, 0.26-0.95], respectively). The best performance in terms of the AUC was the updated logistic model: POPI-Plus. The AUC values were 0.76 (95% CI, 0.73-0.79) and 0.78 (95% CI, 0.74-0.82) for the training and validation data, respectively. The other models (classification tree, random forest, and neural network) also performed adequately, with an AUC of ≥0.7, but remained below POPI-Plus. An open-access calculator was generated and can be found on the website of the University of Montreal on the following link: https://deptobsgyn.umontreal.ca/departement/divisions/medecine-et-biologie-de-la-reproduction/the-popi-plus-tool/.

CONCLUSION(S)

The POPI-Plus tool offers individualized counseling for patients after an initial positive β-hCG test result. Future studies will assess its impact on patient anxiety while awaiting viability ultrasound and perform prospective validation on new patients.

Laparoscopic management of second trimester ruptured cornual heterotopic pregnancy with subsequent live birth delivery: A case report and literature review

OBJECTIVE

Heterotopic pregnancy (HP) is the coexistence of extra- and intrauterine gestation implantation sites. A rare case of a second-trimester ruptured cornual HP (CHP) treated with laparoscopic cornual resection with the primary repair is presented. Risk factors, clinical presentations, treatments, and outcomes of CHPs are also reviewed.

CASE REPORT

A 35-year-old pregnant woman with CHP presented with lower abdominal pain with hemoperitoneum and her hemoglobin level dropped. Laparoscopic management of a ruptured HP was performed, leaving the surplus intrauterine fetus intact. She delivered a 2360 g male infant via cesarean section at 34 weeks' gestation due to preterm premature rupture of membranes. We found a well-healed wound over the left uterine cornua during the cesarean section.

CONCLUSION

Ruptured CHP is a rare but life-threatening complication of an obstetric emergency. Although the pregnant uterus becomes congested and fragile, using reliable laparoscopic energy devices and barbed sutures, successful treatment is feasible.

Combined analysis of human chorionic gonadotrophin concentrations at different time points after frozen-thawed blastocyst transfer can improve our ability to predict the pregnancy outcomes of single gestations

In this study, we conducted a retrospective single-centre study of 1664 singleton pregnancies derived from frozen-thawed blastocyst transfer between January 2017 and December 2018. Analysis showed that there were 596 early pregnancy losses and 1068 ongoing pregnancies. We compared serum HCG (human chorionic gonadotophin) concentrations on days 12, 14, 19, and 21, between the pregnancy loss group and the ongoing pregnancy group. The cut-off level of HCG at each time point was calculated to predict pregnancy outcome. Joint analysis of two single HCG levels taken one week apart was carried out to improve predictive accuracy. The levels of HCG at four time points were significantly lower in the early pregnancy loss group than in the ongoing pregnancy group. According to the area under ROC (receiver operating characteristic curve) curves, all levels of HCG taken at four time points showed good ability to predict the outcome of pregnancy. The joint analysis of two single HCG levels taken one week apart further improved the accuracy of prediction.Impact statementWhat is already known on this subject? Multiple studies have shown that the maternal level of serum HCG is the best parameter for predicting the course of pregnancy.What do the results of this study add? The levels of HCG on days 12, 14, 19 and 21 were significantly lower in the early pregnancy loss group than in the group of ongoing pregnancies. According to the area under ROC curves, all levels of HCG taken at four time points showed a good ability to predict the outcome of pregnancy.What are the implications of these findings for clinical practice and/or further research? The joint analysis of two single HCG levels, taken one week apart, further improved the accuracy of prediction.

Killer Timing: The Temporal Uterine Natural Killer Cell Differentiation Pathway and Implications for Female Reproductive Health

Natural killer (NK) cells are the predominant maternal uterine immune cell component, and they densely populate uterine mucosa to promote key changes in the post-ovulatory endometrium and in early pregnancy. It is broadly accepted that (a) immature, inactive endometrial NK (eNK) cells in the pre-ovulatory endometrium become activated and transition into decidual NK (dNK) cells in the secretory stage, peri-implantation endometrium, and continue to mature into early pregnancy; and (b) that secretory-stage and early pregnancy dNK cells promote uterine vascular growth and mediate trophoblast invasion, but do not exert their killing function. However, this may be an overly simplistic view. Evidence of specific dNK functional killer roles, as well as opposing effects of dNK cells on the uterine vasculature before and after conception, indicates the presence of a transitory secretory-stage dNK cell (s-dNK) phenotype with a unique angiodevelopmental profile during the peri-implantation period, that is that is functionally distinct from the angiomodulatory dNK cells that promote vessel destabilisation and vascular cell apoptosis to facilitate uterine vascular changes in early pregnancy. It is possible that abnormal activation and differentiation into the proposed transitory s-dNK phenotype may have implications in uterine pathologies ranging from infertility to cancer, as well as downstream effects on dNK cell differentiation in early pregnancy. Further, dysregulated transition into the angiomodulatory dNK phenotype in early pregnancy will likely have potential repercussions for adverse pregnancy outcomes, since impaired dNK function is associated with several obstetric complications. A comprehensive understanding of the uterine NK cell temporal differentiation pathway may therefore have important translational potential due to likely NK phenotypic functional implications in a range of reproductive, obstetric, and gynaecological pathologies.

High BMI and Insulin Resistance Are Risk Factors for Spontaneous Abortion in Patients With Polycystic Ovary Syndrome Undergoing Assisted Reproductive Treatment: A Systematic Review and Meta-Analysis

Background

The risk of spontaneous abortion in patients with polycystic ovary syndrome (PCOS) undergoing assisted reproductive treatment (ART) is higher than that in patients without PCOS, however, no definitive risk factors have been confirmed to associate with the high spontaneous abortion rate in PCOS patients undergoing ART. This study was performed to assess the impact of relevant risk factors on spontaneous abortion in patients with PCOS. Clinical questions were formulated and organized according to the PICOS principle.

Methods

A systematic review and meta-analysis were conducted on all published studies on PCOS and spontaneous abortion in Embase, PubMed, Web of Science and Cochrane Library. Related risk factors included body mass index (BMI), age, insulin resistance (IR), hyperandrogenism, and chromosome aberrations. All patients were diagnosed as PCOS using the Rotterdam criteria. The primary endpoint was miscarriage and live birth rate. Fixed-effect models were used to analyze homogeneous data, and subgroup and sensitivity analyses were performed on heterogeneous data. The source of heterogeneity was evaluated, and the random effect model was used to summarize the heterogeneity.

Results

Among 1836 retrieved articles, 22 were eligible and included in the analysis with 11182 patients. High BMI (OR = 1.48, 95% CI [1.32, 1.67], MD = 1.35, 95% CI [0.58,2.12]) and insulin resistance (MD = 0.32, 95% CI [0.15, 0.49]) were associated with an increased risk of spontaneous abortion in PCOS patients undergoing ART. Older age (OR = 0.29, 95% CI [0.29, 0.44], MD = 2.01, 95% CI [0.04, 4.18]), embryonic chromosomal aberrations (OR = 0.75, 95%CI [0.31,1.77]), and hyperandrogenism (MD = 0.10, 95% CI [- 0.02, 0.22]) were not associated with the high spontaneous abortion rate in patients with PCOS. A subgroup analysis of BMI showed that there was no statistically significant difference in the effect between overweight and obesity on spontaneous abortion in PCOS patients undergoing ART (OR = 1.34, 95% [0.97, 1.85]).

Conclusion

High BMI and insulin resistance are two risk factors for an increased risk of spontaneous abortion in PCOS patients undergoing ART, and losing weight and mitigating insulin resistance may decrease the spontaneous abortion rate in these patients undergoing ART.

Trends in primeval β-hCG level increment after fresh and frozen-thawed IVF embryo transfer cycles

Mid-trimester beta-human chorionic gonadotropin (BHCG) levels are considerably higher in pregnancies resulting from frozen embryo transfer (FET) compared with fresh (FRET), leading to a higher false positive rate in aneuploidy screening tests. We aimed to investigate the dynamics of BHCG increment and its predictive value for cycle outcome. A retrospective analysis of FRET and FET cycles. BHCG values on days 14 and 16 post embryo transfer were compared and stratified according to the number of sacs demonstrated on US scan at six weeks gestation, and pregnancy outcome (biochemical pregnancy, ectopic pregnancy, spontaneous abortion, and a singleton or twin birth). A prediction model for live birth was built. A total of 430 treatment cycles were analyzed. The average BHCG levels were significantly higher in FET compared with FRET group in nonviable pregnancies on day 14, 450 vs. 183 IU/L, p < .05 and day 16, 348 vs. 735 IU/L, p < .05, respectively. The increment of BHCG was significantly steeper in the FET compared with FRET group in biochemical pregnancies (F = 6.485, p = .012*). Optimal cutoff level for live birth prediction in the FRET group was 211 IU/L (sensitivity 84%, specificity 76.2%) for day 14 and 440 IU/L (sensitivity 86.0% and specificity 72.5%) for day 16. The increment in BHCG differed significantly between the FRET and FET cycles in nonviable pregnancies. Nevertheless, the difference in BHCG levels observed in the second trimester in pregnancies conceived after FRET and FET cycle may begin as early as the fourth week of pregnancy.

What is the effect of embryo morphology on serum β-hCG levels?

OBJECTIVE

To determine the effect of embryonic factors on serum beta human chorionic gonadotropin (β-hCG) levels in pregnancy and live birth resulting after a single fresh cleavage embryo and blastocyst transfer.

STUDY DESIGN

This was a retrospective cohort study conducted at a tertiary care hospital. All fresh single embryo transfers (sETs) between September 2011 and December 2016 were included. The correlation analysis was performed to determine the association of embryo morphological parameters on mean serum β-hCG levels on day 12 after the transfer of a fresh single cleavage embryo and a fresh single blastocyst embryo.

RESULTS

Out of a total of 455 fresh sETs, 60 positive β-hCG results after the transfer of a single fresh cleavage-stage embryo and 82 after the transfer of a single fresh blastocyst. The mean β-hCG level resulting from a single fresh blastocyst ET was 371.7 ± 52.7 IU/L, which was similar to the mean β-hCG level resulting from a cleavage ET (314.5 ± 36.9 IU/L) (p = .70). Interestingly, serum β-hCG levels resulting from a single fresh blastocyst ET showed a correlation with day 5 blastocoele expansion, trophectoderm cell number and blastocyst quality score in ongoing pregnancy (r = .33, p = .02; r = .29, p = .04; and r = .31, p = .03, respectively). Moreover, day 5 blastocoele expansion and blastocyst quality score showed a correlation with the serum β-hCG levels resulting from a single fresh blastocyst ET in live birth (r = .36, p = .02; r = .31, p = .04, respectively).

CONCLUSION

Our study suggests that serum β-hCG levels resulting from a single fresh blastocyst ET showed a correlation with day 5 blastocoele expansion and blastocyst quality score in both ongoing pregnancy and live birth.

Predictive value of plasma human chorionic gonadotropin measured 14 days after Day-2 single embryo transfer

INTRODUCTION

Prediction of pregnancy outcome after in vitro fertilization is important for patients and clinicians. Early plasma human chorionic gonadotropin (p-hCG) levels are the best known predictor of pregnancy outcome, but no studies have been restricted to single embryo transfer (SET) of Day-2 embryos. The aim of the present study was to investigate the predictive value of p-hCG measured exactly 14 days after the most commonly used Day-2 SET on pregnancy, delivery, and perinatal outcome.

MATERIAL AND METHODS

A retrospective analysis of prospectively collected data on 466 women who had p-hCG measured exactly 14 days after Day-2 SET during a randomized trial including 1050 unselected women (aged 18-40 years) undergoing their first in vitro fertilization/ intracytoplasmic sperm injection treatment.

RESULTS

The p-hCG predicted clinical pregnancy [area under the curve (AUC) 0.953; 95% CI 0.915-0.992] significantly better than ongoing pregnancy (AUC 0.803, 95% CI 0.717-0.890) and delivery (AUC 0.772, 95% CI 0.691-0.854). Women with p-hCG levels in the lowest quartile had significantly lower clinical pregnancy, ongoing pregnancy, and delivery rates (p < 0.001), whereas the pregnancy outcome and post-clinical pregnancy loss remained similar throughout the three highest p-hCG quartiles. The p-hCG level was related to neither birthweight nor gestational age at delivery.

CONCLUSIONS

Clinical pregnancy is significantly better predicted by p-hCG compared with ongoing pregnancy and delivery. Clinical pregnancy rates, ongoing pregnancy rates, and delivery rates remained similar throughout the three highest p-hCG quartiles with no trend towards "the higher the better".

Value of Post-transfer Day-12 Beta Human Chorionic Gonadotropin Levels for Pregnancy Outcome Prediction of Intracytoplasmic Sperm Injection Cycles

BACKGROUND

Several markers were studied previously in order to predict the pregnancy outcome of assisted reproductive techniques; however, serum beta human chorionic gonadotropin was found to be the most predictive marker.

AIMS

To evaluate the value of serum beta human chorionic gonadotropin levels in discriminating biochemical and clinical pregnancies 12 days after embryo transfer, while determining the factors predicting ongoing pregnancy was established as the secondary aim.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

A total of 445 pregnant cycles were retrospectively analysed in 2359 embryo transfer cycles. Patients were divided into two groups according to the outcome of pregnancy: biochemical and clinical.

RESULTS

The cut-off value of beta human chorionic gonadotropin levels on day 12 in predicting clinical pregnancies was 86.8 IU/mL with 65.1% sensitivity and 74.7% specificity [CI: 0.76 (0.71-0.81). Receiver operating characteristic curve analysis revealed different cut-off values for embryo transfer days (57 mIU/mL for day 3 embryo transfer CI: 0.59-0.79 and 87 mIU/mL for day 5 embryo transfer, CI: 0.74-0.86). Subgroup analysis of clinical pregnancies revealed a significant difference between ongoing pregnancies and early fetal losses regarding duration of infertility (81.3±54.4 vs. 100.2±62.2 months), serum oestradiol on hCG day (2667.4±1276.4 vs. 2094.6±1260.5 pg/mL), number of transferred embryos (1.9±0.8 vs. 1.5±0.7) and the prevalence of diminished ovarian reserve as an indication (2.3% vs 12.2%).

CONCLUSION

Beta human chorionic gonadotropin levels on day 12 following embryo transfer provide an important parameter for the prediction of clinical pregnancy; however, other stimulation parameters are indicated in the prediction of ongoing pregnancies.

Serum human chorionic gonadotropin measured 7 days following day 3 embryo transfer might predict pregnancy outcome in IVF

This prospective study investigated the predictive value of pregnancy outcomes with serum human chorionic gonadotropin (hCG) 7 days after day 3 embryo transfer (D3 ET), and whether estradiol (E2) and progesterone (P) improved the diagnostic efficiency. The study comprised 280 in vitro fertilization and embryo transfer (IVF-ET) cycles. Serum samples were obtained 7 days after D3 ET to measure hCG, E2, and P concentrations. Statistical analyses were conducted to evaluate the predictive value for pregnancy outcomes. We found significant differences in hCG level between pregnancy and non-pregnancy, viable and non-viable pregnancy, biochemical and viable pregnancy, as well as singleton and multiple pregnancy. An hCG cutoff value of 2.5 mIU/mL is predictive of pregnancy with a positive predictive value (PPV) of 95.9% and a negative predictive value (NPV) of 92.4%. An hCG value of 10.8 mIU/mL is predictive of a multiple pregnancy with an NPV of 98.1%. The area under the hCG curve between pregnancy and non-pregnancy was not improved by adding E2, P, or combined E2/P. Our results suggest a predictive value of pregnancy outcome with serum hCG drawn 7 days after D3 ET in IVF, and the diagnostic accuracy is not improved by adding measurements of E2/P.

Serum hCG-β levels of postovulatory day 12 and 14 with the sequential application of hCG-β fold change significantly increased predictability of pregnancy outcome after IVF-ET cycle

PURPOSE

To investigate hCG-β level on postovulatory day (POD) 12 and its fold increase as predictors for pregnancy outcome after in vitro fertilization (IVF) cycles.

METHODS

A retrospective cohort study was performed in total 1408 fresh and 598 frozen cycles between November 2008 and October 2011, which resulted in biochemical pregnancy, early pregnancy loss, or live birth of singleton pregnancy. The serum hCG-β levels of POD 12 and 14 were compared among biochemical pregnancy, early pregnancy loss, and live birth groups. The cutoff values of POD 12 and 14 hCG-β levels and the degree of hCG-β increase from POD 12 to 14 were determined for each pregnancy outcome.

RESULTS

POD 12 and 14 hCG-β levels stratified based on pregnancy outcomes were significantly different among the biochemical pregnancy, early pregnancy loss, and live birth in both fresh and frozen cycles. Serum hCG-β levels of POD 12 and 14 and the fold increase of hCG-β levels from POD 12 to 14 significantly predict pregnancy outcomes after fresh and frozen cycles. Among these, the cutoff value of POD 14 hCG-β had the highest sensitivity and positive predictive value (PPV). In fresh cycles, the cutoff values of POD 12 and 14 serum hCG-β levels for clinical pregnancies were 30.2 mIU/mL (sensitivity 81.3 %, specificity 79.6 %, and PPV 92.3 %) and 70.5 mIU/mL (sensitivity 88.4 %, specificity 85.2 %, and PPV 94.7 %). In pregnancies with POD 12 serum hCG-β levels ≥30.2 mIU/mL, the cutoff level of increase of hCG-β for clinical pregnancy was 2.56 (sensitivity 73.6 %, specificity 72.4 %, and PPV 97.8 %). Sequential application of cutoff values such as POD 12 hCG-β and fold increase of hCG-β improved predictability of pregnancy outcome as compared with that of POD 12 hCG-β alone. The cutoff values of POD 12 and 14 serum hCG-β levels for live birth were 40.5 mIU/mL (sensitivity 75.2 %, specificity 72.6 %, PPV 78.9 %) and 104.5 mIU/mL (sensitivity 80.3 %, specificity 74.1 %, PPV 80.8 %). In the frozen cycles, the cutoff values of POD 12 and 14 serum hCG-β level for clinical pregnancy were 31.5 IU/L (sensitivity 80.4 %, specificity 71.1 % and PPV 90 %) and 43.5 mIU/mL (sensitivity 72.6 %, specificity 71.7 %, PPV 77.2 %). In pregnancies with POD 12 serum hCG-β level ≥31.5 mIU/mL, the cutoff value for fold increase of hCG-β was 2.38 for clinical pregnancy (sensitivity 81.6 %, specificity 71.4 % and PPV 87.9 %). The cutoff values of POD 12 and 14 for live birth were 43.5 mIU/mL (sensitivity 72.6 %, specificity 71.7 %, PPV 77.2 %) and 101.6 mIU/mL (sensitivity 79.6 %, specificity 71.1 %, PPV 78.4 %). Sequential application of cutoff values for POD 12 hCG-β level and fold increase of hCG-β significantly increased PPV for live birth but not clinical pregnancy in frozen cycles.

CONCLUSIONS

Early prediction of pregnancy outcome by using POD 12 and 14 cutoff levels and sequential application of cutoff value of fold increase could provide appropriate reference to health care providers to initiate earlier management of high-risk pregnancies and precise follow-up of abnormal pregnancies.

Risk Factors and Early Predictors for Heterotopic Pregnancy after In Vitro Fertilization

This study investigated the risk factors and early predictors for heterotopic pregnancy (HP) after in vitro fertilization and embryo transfer (IVF-ET). From January 2008 to January 2013, 41 cases of HP and 72 cases of intrauterine twin pregnancy after IVF-ET were recruited and retrospectively analyzed. Compared with intrauterine twin pregnancy group, the HP group had a lower basal luteinizing hormone (LH) level (P = 0.005) and more cases had a history of hydrosalpinx (P = 0.008). After 14 days of IVF-ET, the serum β-HCG (β-human chorionic gonadotropin), E2 (Estradiol) and P (Progesterone) levels were lower in HP group (P<0.001, respectively). Moreover, vaginal bleeding and abdominal pain were the significant features of HP before diagnosis (P<0.001, respectively). Further by logistic regression, serum β-hCG, P levels on the 14th day after ET, and vaginal bleeding were identified as the independent factors of HP. These results indicate that when two or more embryos transferred in IVF procedure, β-hCG, P levels on the 14th day after ET, and vaginal bleeding could be taken as predictors for HP.

Human chorionic gonadotropin levels are equally predictive for pregnancy outcome after fresh and vitrified-warmed blastocyst transfer

PURPOSE

The aim of the present study was to evaluate if the live birth predictive values of β-hCG levels differ in fresh and vitrified-warmed blastocyst transfer cycles.

METHODS

In the retrospectively designed study, 775 cycles with positive β-hCG values 13 days after fresh blastocyst transfer (fresh ET; n = 568) or vitrified-warmed blastocyst transfer (FET; n = 207) were selected for analysis. Average β-hCG levels stratified according to pregnancy outcome (biochemical pregnancy, spontaneous abortion, ectopic pregnancy, and singleton or twin birth) were compared between fresh ET and FET cycles. To determine the optimal sensitivity and specificity of β-hCG levels for live birth prediction, a ROC curve was constructed. Fisher's exact test was used to compare the positive predictive values (PPV).

RESULTS

Average β-hCG levels stratified according to pregnancy outcome were not statistically different between fresh ET and FET cycles. In fresh ET and in FET group, the β-hCG levels were significantly higher in pregnancies resulting in live birth compared to non-viable pregnancies (1,035 vs. 462 IU/L, p < 0.001 and 968 vs. 411 IU/L, p < 0.001). Optimal cut-off level for live birth prediction was 495 IU/L (sensitivity 83.0 %, specificity 71.8 %) after ET and 527 IU/L (sensitivity 80.0 % and specificity 76.6 %) after FET. The PPV for live birth rate in the groups after ET and FET were 90.6 % and 84.9 % respectively, without statistically significant difference (p > 0.05).

CONCLUSION

Beta-hCG levels after fresh and vitrified-warmed blastocyst transfer are equally predictive for pregnancy outcome. Clinicians can be encouraged to interpret β-hCG results in the same manner.

Does blastomere biopsy in preimplantation genetic diagnosis affect early serum β-hCG levels?

Objective

To determine whether the serum β-human chorionic gonadotropin (hCG) profile following preimplantation genetic diagnosis (PGD) is lower than that of intracytoplasmic sperm injection (ICSI) cycles.

Methods

A total of 129 PGD cycles and 1,161 age-matched ICSI cycles, which resulted in pregnancy (serum β-hCG≥5 mIU/mL) on post-ovulation day (POD) 12 were included. We compared the mean serum β-hCG levels on POD 12, 14, 21, and 28, doubling time of serum hCG, and created a cut-off value for predicting a singleton pregnancy in each group.

Results

The mean serum β-hCG concentration of the PGD group was significantly lower than that of the control group on POD 12, 14, and 21. The doubling time of serum β-hCG at each time interval showed no significant difference. The cut-off-value of serum β-hCG for predicting a single viable pregnancy was 32.5 mIU/mL on POD 12 and 113.5 mIU/mL on POD 14 for the PGD group, which was lower than that for the control group.

Conclusion

Blastomere biopsy may decrease the β-hCG-producing activity of the trophoblasts, especially in early pregnancy. Setting a lower cut-off value of serum β-hCG for predicting pregnancy outcomes in PGD may be needed.

Early Maternal Serum β-human Chorionic Gonadotropin Measurements After ICSI in the Prediction of Long-term Pregnancy Outcomes: A Retrospective Cohort Analysis

Background

Initial low maternal serum β-human chorionic gonadotropin (β-hCG) is a good predictor of early pregnancy demise. Our objective was to determine its predictive value in determining the long-term outcome in ICSI pregnancies.

Methods

A retrospective cohort study was designed at the Saudi Center for Assisted Reproduction. Two hundred and sixty-one women with ICSI pregnancies were followed up from initial β-hCG level determination till the end of pregnancy. Accuracy of early β-hCG in predicting the occurrence of a live-birth, ongoing pregnancy, late miscarriage, ectopic pregnancy and early miscarriage following ICSI was measured.

Results

β-hCG levels were significantly different in pregnancies that reached the stage of an ongoing pregnancy and live-birth as compared to early pregnancy loss. The ROC curves demonstrated a high sensitivity for identifying patients with ectopic pregnancies and early miscarriage (100% and 93.33% respectively). The remaining results ranged from a sensitivity of 69% to 79% and specificity of 62% to 75%.

Conclusions

In ICSI pregnancies, a single early β-hCG may help to identify pregnancies that will reach full-term and delivery.

Keywords

ICSI; Human chorionic gonadotropin; Outcome; Pregnancy

Double measurements of serum HCG concentration and its ratio may predict IVF outcome

Serum human chorionic gonadotrophin (HCG) concentration is nearly always used to predict pregnancy but there is little data on the clinical utility of the ratio of HCG(21)/HCG(14) combined with double measurement of serum HCG. A total of 1762 cycles were retrospectively analysed for serum HCG concentration and ratio of HCG(21)/HCG(14) on days 14 and 21 after embryo transfer to determine whether the ratio combined with concentration is the optimal predictor of pregnancy. The medians of HCG concentration on days 14 and 21 combined with the ratio of HCG(21)/HCG(14) were calculated for non-viable, viable and heterotopic pregnancies. HCG concentrations of 290IU/l on day 14 and 2970IU/l on day 21 were regarded as the cut-off values to predict viable pregnancy, and values of 630 and 12,000IU/l, respectively, were regarded as the cut-off values to predict multiple pregnancy. The ratio of HCG(21)/HCG(14) in the viable pregnancy group was significantly higher than that in the non-viable pregnancy group (15.86 versus 5.27, P<0.0001). For heterotopic pregnancy, the ratio of HCG(21)/HCG(14) was 11.93. It was concluded that HCG concentration on days 14 and 21 combined with the ratio of HCG(21)/HCG(14) provides a useful predictor of pregnancy outcome. A ratio >15 may predict viable pregnancy.

Proliferation of uterine natural killer cells is induced by human chorionic gonadotropin and mediated via the mannose receptor

The endometrial lining of the human uterus contains a population of phenotypically distinct (CD56(bright), CD16(dim)), tissue-specific, natural killer [uterine natural killer (uNK)] cells that play a key role in the establishment of a successful pregnancy. An increase in the number of endometrial uNK cells occurs when the conceptus implants, and there is a further increase during the early stages of placentation. Here, we describe studies that have identified human chorionic gonadotrophin (hCG), a glycoprotein synthesized by the preimplantation conceptus, as a novel regulator of uNK cell proliferation. The impact of hCG on uNK cells was mediated via the mannose receptor (CD206) rather than by the classical hCG/LH receptor that was not expressed. The mannose receptor and hCG were colocalized on the surface of uNK cells, and proliferation did not occur if cells were incubated with deglycosylated hCG or intact hCG in the presence of excess d-Mannose. These novel observations provide new insight into the endocrine-immune dialogue that exists between the conceptus and immune cells within the receptive endometrium, and have implications for the role of uNK cell-trophoblast interactions and pregnancy outcome.

Early serum β-human chorionic gonadotropin in pregnancies after in vitro fertilization: contribution of treatment variables and prediction of long-term pregnancy outcome

OBJECTIVE

Low initial serum beta hCG is a good predictor of early pregnancy failure. We sought to determine the contribution of treatment variables and the predictive value of early serum beta hCG after IVF on long-term pregnancy outcome.

DESIGN

A retrospective case-control study.

SETTING

An academic IVF unit.

PATIENT(S)

Five hundred thirty-three IVF cycles performed between 1999 and 2004, which resulted in a positive serum beta hCG level (> 10 mIU/mL) on day 13 after embryo transfer (ET).

INTERVENTION(S)

The study group included 281 pregnancies with initial beta hCG < or = 150 mIU/mL on day 13 after ET. Randomly selected 252 IVF cycles with initial beta hCG > 150 mIU/mL comprised the control group. Characteristics of the patients and the treatment protocols were analyzed using logistic regression, Pearson's chi-square, and Fisher's exact test.

MAIN OUTCOME MEASURE(S)

Primary pregnancy outcome was defined as favorable when a fetal pulse was detected, testifying to a viable gestation. Unfavorable outcome referred to chemical or ectopic pregnancies, as well as spontaneous abortions. Additionally, the two groups were followed throughout gestation. Secondary pregnancy outcome was based on the following parameters: gestational age at delivery, method of delivery, and birth weight.

RESULT(S)

Poor primary pregnancy outcome was encountered in 64.8% of the study group and in 22.2% of the control group. Predictors of unfavorable primary pregnancy outcome were older age, use of a short protocol, and shorter than anticipated crown-rump length. No difference was found in the secondary pregnancy outcome between the groups. Preterm labor was more prevalent in the study group, but the difference did not reach statistical significance.

CONCLUSION(S)

Pregnancy viability can be predicted by measuring serum beta hCG as early as on day 13 after ET. Older age, use of a short protocol, and shorter than anticipated crown-rump length are associated with early pregnancy loss. Of those who reach delivery, no significant adverse outcome is anticipated in IVF pregnancies with low initial serum beta hCG.

Highly specific and sensitive rise in Days 14–17 pro-αC inhibin with clinical pregnancy after frozen embryo transfer with ovulatory cycles

BACKGROUND

Pro-alphaC inhibins are luteal derived analytes peaking in the maternal serum as early as Day 16 after conception. We set out to verify a previous post hoc analysis which suggested that pro-alphaC levels measured this early are extremely sensitive in predicting clinical pregnancy success after unstimulated IVF with ovulatory cycles.

METHODS

Prospective observational study of 246 women undergoing frozen embryo transfer with ovulatory cycles. Serum pro-alphaC and beta-HCG levels at 14-17 days after conception were measured by enzyme-linked immunosorbent assay and grouped according to whether a clinical pregnancy occurred (demonstrable cardiac activity at > or =6 weeks' gestation).

RESULTS

Of 34 (13.8%) women who achieved a clinical pregnancy, median (25th-75th centile) Days 14-17 pro-alphaC levels were 995 pg/ml (758-1463), 6- to 7-fold higher than levels observed in the remainder who did not fall pregnant (112.8 pg/ml (104-121); P < 0.0001). At a fixed 95% specificity, pro-alphaC was 100% sensitive in predicting clinical pregnancy. The best specificities achieved at 100% sensitivity were; 94.8% for pro-alphaC, 96.7% for beta-HCG and 98.1% when both analytes were combined.

CONCLUSIONS

Clinical pregnancy is always associated with a release of luteal derived pro-alphaC 14-17 days after conception. Pro-alphaC may play a possible biological role and be a useful clinical biomarker of luteal health.

Low endometrial volume may predict early pregnancy loss in women undergoing in vitro fertilization

PURPOSE

To evaluate the role of 3-D US measurement of the endometrium during early IVF-pregnancy and before the appearance of gestational sac in the prediction of pregnancies outcome.

METHODS

60 pregnant women following IVF treatment were included in the study. The women underwent transvaginal 3D US measurements of endometrial volume and thickness on day 15-17 post ET. Patients were followed and classified according to pregnancy outcome into 2 further groups. The group with early pregnancy loss and the group with ongoing pregnancy.

RESULTS

While no differences were observed between those who miscarried and those who did not in gestational age, endometrial thickness or volume, spontaneous early pregnancy loss was significantly higher in patients with endometrial volume <2 mL as compared to those with endometrial volume >2 mL.

CONCLUSIONS

3-D US measurement of endometrial volume of less than 2 mL during early IVF pregnancy and prior to the appearance of gestational sac is a powerful predictor of pregnancy loss.

Subclinical pregnancy losses among women undergoing in-vitro fertilization with ICSI

BACKGROUND

The purpose of this study is to asses the frequency of subclinical pregnancy loss (SPL) among women undergoing controlled ovarian hyperstimulation (COH) and in-vitro fertilization with ICSI.

METHODS

The study was retrospectively conducted in a private IVF center. SPL was defined by a temporary rise in serum beta hCG, along with the absence of signs of intra- and extra-uterine pregnancy by transvaginal ultrasonography. Overall 5273 COH and ICSI cycles with embryo transfer (ET) were segregated according to serum E(2) levels percentiles (-24th, 25th, 74th, and 75th), women age and the type of spermatozoa for assisted fertilization (ejaculated and surgically retrieved). Those groups were assessed for SPL rates.

RESULTS

Among the 3125 (59.25) conception cycles, 305 (9.7%) were diagnosed as SPL. There was no difference in SPL rate among E(2) percentile groups. Women older than 35 years of age had significantly higher rate of SPL compared to younger women. There was also no difference in SPL rate among pregnancies in whom surgically retrieved spermatozoa used or ejaculated spermatozoa used for assisted fertilization.

CONCLUSION

Our results demonstrated that SPL rate was not influenced by the levels of E(2) during COH or the origin of spermatozoa used for assisted fertilization. However, maternal age was found to be detrimental for SPL.

Optimizing hCG cut-off values: a single determination on day 14 or 15 is sufficient for a reliable prediction of pregnancy outcome

OBJECTIVE

Optimizing the cut-off level for a single serum hCG determination around day 15 after oocyte retrieval or ovulation.

STUDY DESIGN

Retrospective data analysis.

RESULTS

204 hCG samples >5 IU/L between March and October 1999 taken on day 14, 15 or 16 after oocyte retrieval in 204 patients undergoing IVF or ICSI were analyzed. ROC-curves and optimal cut-off levels to discriminate between viable and non-viable pregnancies were calculated for each day separately. Cut-off levels were found at 76, 142 and 223 IU/L for day 14, 15 and 16, respectively, and were verified by 487 hCG samples >5 IU/L taken between January 2000 and June 2004.

CONCLUSIONS

A single serum hCG determination on day 14 or 15 is sufficient to discriminate viable pregnancies accurately from non-viable pregnancies.

Association Between Low Day 16 hCG and Miscarriage After Proven Cardiac Activity

OBJECTIVE

To investigate an association between low human chorionic gonadotrophin (hCG) levels at the end of the first week of implantation and later clinical miscarriage occurring after ultrasound confirmation of a live pregnancy.

METHODS

This was an observational retrospective study of 1,054 women who underwent in vitro fertilization and achieved an ultrasound-confirmed live singleton pregnancy with cardiac activity. The incidence of miscarriage diagnosed at 8-19 weeks +6 days of gestation was estimated in these 3 subgroups according to their hCG concentrations at day 16 after conception: less than the 25th, 25th-75th, and more than the 75th percentiles.

RESULTS

The overall incidence of miscarriage was 11.1% (117/1,054), and the median gestational age at diagnosis was 10 weeks and 4 days. The median (95% confidence interval) day 16 hCG level in the miscarriage group was 182 mIU/mL (157-211), significantly lower than the median level in those who had an ongoing pregnancy (223 mIU/mL [213-233], P < .003). There was an increasing risk of miscarriage associated with decreased hCG levels (8.0% at > 75th percentile; 9.9% at 25th-75th percentiles; 16.7% at < 25th percentile; P = .003).

CONCLUSION

Low hCG levels in very early pregnancy are associated with an increased risk of miscarriage occurring after the clinical recognition of pregnancy. The mechanisms underlying late first-trimester and second-trimester miscarriages may have begun as early as the first week of implantation.

LEVEL OF EVIDENCE

III.

Effects of culture medium on HCG concentrations and their value in predicting successful IVF outcome

The hypothesis was tested that the medium used to culture embryos affects the concentration of human chorionic gonadotrophin (HCG) early in pregnancy. The value of these concentrations in predicting successful outcome was also assessed for each medium studied. Patients undergoing IVF between January 1998 and December 2004 and having a day 3 embryo transfer were stratified into one of four groups according to the medium in which their embryos were cultured (P1, IVF500, G1.2, and G1.3). Using receiver operating characteristic (ROC) curve analysis, cut-off values for serum HCG concentrations on day 15 after embryo transfer were calculated for optimal discrimination between cycles resulting in implantation failure and success for each medium. Cut-off points were chosen to maximize sensitivity and specificity. For viable singleton pregnancies, mean HCG concentrations were greater for G1.3 and lower for IVF500 compared with the other media. Discriminatory HCG cut-off concentrations for predicting implantation success were lowest for IVF500, intermediate for P1 and G1.2 and highest for G1.3. The data support the hypothesis that the medium used to culture embryos significantly affects the concentrations of HCG early in pregnancy. Furthermore, when using HCG cut-off concentrations to assess pregnancy outcome, medium type should be taken into consideration.

Serum oestradiol and β-HCG measurements after day 3 or 5 embryo transfers in interpreting pregnancy outcome

The aim of this study was to assess the clinical value of serum oestradiol concentration 8 days after embryo transfer (D8E2) and beta-human chorionic gonadotrophin (HCG-beta) concentration 12 days after embryo transfer (D12HCG-beta) in the prediction of pregnancy and the outcome of pregnancy following assisted reproduction, taking into account the day of transfer, which was either day 3 (D3) or day 5 (D5). The objective was to improve patient counselling by giving quantitative and reliable predictive information instead of non-specific uncertainties. A total of 2035 embryo transfer cycles performed between January 2003 and June 2005 were analysed retrospectively. Biochemical pregnancy, ectopic pregnancy and first-trimester abortions were classified as non-viable pregnancies; pregnancies beyond 12 weeks gestation were classified as ongoing pregnancies (OP). Significantly higher D8E2 and D12HCG-beta were obtained in D5 transfers compared with D3 transfers with regard to pregnancy and OP (P<or=0.001). For D3 embryo transfers, the cut-off value of D8E2 in predicting OP was 130 pg/ml (sensitivity 80%, specificity 72%), compared with 98 mIU/ml (sensitivity 89%, specificity 69%) for D12HCG-beta. For D5 embryo transfers, the values were 179 pg/ml (sensitivity 79%, specificity 84%) and 257 mIU/ml (sensitivity 78%, specificity 81%) respectively. It appears that serum post-embryo transfer D8E2 and D12HCG-beta concentrations provided clear information regarding pregnancy and the outcome of pregnancy following IVF-embryo transfer.

Doubling time of urine human chorionic gonadotropin after assisted reproductive technology

In the present study, we measured urinary hCG after assisted reproductive technology to accurately calculate normal doubling time (DT) of hCG, and we compared DT values with prognosis of pregnancy. We clarified the correlation between normal DT values, calculated from urinary hCG levels, and viable and nonviable pregnancies.

Serum CA-125 levels in the second week after embryo transfer predict clinical pregnancy

OBJECTIVE

To correlate CA-125 concentrations in serum samples collected for routine hCG measurements 11 +/- 2 days after embryo transfer in relation to pregnancy and its outcome.

DESIGN

Retrospective study.

SETTING

University-based in vitro fertilization (IVF) program.

PATIENT(S)

One hundred and eighty-two consecutive pregnancies conceived after IVF or intracytoplasmic sperm injection, and 41 control cycles without pregnancy from the same patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Analysis of correlation between CA-125 concentrations and hCG and inhibin A levels. Predictive accuracy of these markers was compared by receiver-operating characteristic (ROC) analysis.

RESULT(S)

The CA-125 levels were statistically significantly higher in pregnant than in nonpregnant patients. Within pregnant cycles, CA-125 concentrations correlated positively with levels of hCG and inhibin A. The CA-125 levels were statistically significantly lower in preclinical abortions than in clinical pregnancies. No statistically significant difference was observed between early pregnancy losses and ongoing pregnancies or singleton and multiple pregnancies, respectively. The predictive accuracy of CA-125 measurements was statistically significantly lower than that achieved with hCG or inhibin A.

CONCLUSION(S)

Although CA-125 levels seem to be predictive of clinical pregnancy, they are not predictive of its outcome. Higher CA-125 concentrations may reflect higher endometrial receptivity but do not predict the number or viability of implanted embryos.

Serum hormones for predicting pregnancy outcome after assisted reproductive technology

Serum human chorionic gonadotrophin (HCG) in the second and third week after embryo transfer has been used for prediction of pregnancy outcome after assisted reproduction. There are few data on the clinical utility of HCG, progesterone and oestradiol, measured by contemporary immunoassay, in the fourth week after embryo transfer and later. Moreover, large inter-method differences have been described between automated immunoassays, making method-specific cut-off values mandatory. The main aim of this study was to determine assay-specific optimal cut-off values for serum HCG, progesterone and oestradiol for prediction of clinical pregnancy outcome in singleton pregnancies after assisted reproductive techniques, at days 11, 18 and 25 and at week 6 after embryo transfer. A retrospective study was performed on frozen serum samples of 67 singleton pregnancies after assisted reproduction techniques. HCG, oestradiol and progesterone were determined with the automated (random access) VIDAS immunoanalyser. Receiver operating characteristic curve analysis was performed to determine optimal cut-off values. Predictive values were calculated based on the prevalence of non-viable pregnancy after assisted reproduction. It was concluded that measurement of HCG by VIDAS at days 18 and 25, and at week 6 after embryo transfer yields high positive (70.5-100%) and negative (87.2-94.4%) predictive values for clinical pregnancy outcome.

Early hormonal markers of pregnancy outcome after in vitro fertilization and embryo transfer

PURPOSE

To investigate the relative power of HCG, estradiol, and progesterone determinations in the prediction of pregnancy outcome after IVF. These prognostic hormonal factors were studied as single and combined predictors.

METHODS

Serum concentrations of beta-HCG, progesterone, and estradiol were measured 12-13 days after embryo transfer (study point 1) and 7 days later (study point 2) in a series of 20 consecutive infertile patients having a first-trimester spontaneous clinical abortion after an IVF-embryo transfer cycle. As a control group (n = 60), the next three IVF-embryo transfer cycles resulting in an ongoing pregnancy after each miscarried IVF cycle in our assisted reproduction program was used. The discrimination attained between the two study groups (ongoing pregnancies and miscarriages) was evaluated by logistic regression and receiver operating characteristic (ROC) curve analysis.

RESULTS

Mean hormone concentrations at study points 1 and 2 were higher in the ongoing pregnancy than in the abortion group. Regarding pregnancy outcome the percentage increment of HCG serum levels (> or = 1321%), with an accuracy (predictive value of pregnancy outcome) of 81.2% (sensitivity 98%, specificity 50%), had the best prognostic reliability but no significant differences were found when this parameter was compared with the predictive value of HCG concentration (> or = 72 IU/l) at study point 1 (diagnostic accuracy 80.5%; sensitivity 70%; specificity 80%). When ROC analysis was used, the best predictor of ongoing pregnancy according to the AUC(ROC) was HCG concentration at study point 2 but again no significant differences were found when this parameter was compared with the predictive value of HCG serum levels at study point 1. A multiple marker strategy did not help distinguish viable from nonviable pregnancies.

CONCLUSION

A single, early (days 12-13 after embryo transfer) HCG quantitative serum measurement in IVF cycles not only is diagnostic but also has good predictive value for pregnancy outcome.

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.

Use of serum inhibin A and human chorionic gonadotropin measurements to predict the outcome of in vitro fertilization pregnancies

OBJECTIVE

To assess the clinical value of maternal serum inhibin A measurements in early pregnancy in the prediction of outcome of IVF pregnancies and to compare the predictive accuracy of inhibin A concentrations with serum hCG concentrations.

DESIGN

Retrospective study.University-based IVF program.

PATIENT(S)

One hundred fifty IVF pregnancies of 150 couples were studied during a 4-year period.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The association between pregnancy outcome and age, number of collected oocytes, number of transferred embryos, and serum hCG and inhibin A concentrations in early pregnancy was studied with logistic regression. Predictive accuracy of inhibin A and hCG concentrations was calculated by receiver-operating characteristic (ROC) analysis.

RESULT(S)

Lower serum concentrations of inhibin A and hCG were associated with increased odds for preclinical abortion and early pregnancy loss, whereas higher inhibin A and hCG concentrations were observed in multiple ongoing pregnancies. Inhibin A measurements were superior to hCG in the prediction of preclinical abortions; no significant difference was observed between the predictive value of hCG, inhibin A, or their combination in differentiating between ongoing pregnancies and early pregnancy losses. The discriminative potential of inhibin A for prognosticating multiple ongoing pregnancies was lower than that of hCG.

CONCLUSION(S)

Although serum inhibin A concentrations are more accurate than hCG levels for predicting preclinical abortion after IVF, they had no advantage in forecasting ongoing or multiple ongoing pregnancies, suggesting that routine assessment of serum inhibin A concentrations during follow-up of IVF pregnancies is unjustified.

Serum human chorionic gonadotropin measurements may predict pregnancy outcome and multiple gestation after in vitro fertilization

OBJECTIVE

To predict pregnancy outcome and multiple gestation using a common parameter by which hCG values are made comparable independently of the day of blood sampling.

DESIGN

Retrospective study.

SETTING

University-based IVF program.

PATIENTS

One hundred twenty IVF pregnancies conceived between November, 1995 and August, 1999.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Early pregnancy loss (preclinical and first trimester abortions, ectopic pregnancies) or ongoing pregnancies (singleton and multiple deliveries, second trimester abortions). Day 11 hCG levels were calculated assuming an exponential increase of hCG values in early pregnancy. Receiver-operating characteristic analysis was used to determine cut-off levels with the best sensitivity and specificity for the prediction of pregnancy outcome.

RESULTS

Serum hCG levels in the group of early pregnancy loss were significantly lower than in ongoing pregnancies. A cut-off level of 50 IU/L predicts pregnancy outcome with a sensitivity of 75% and a specificity of 81%, while an hCG value >135 IU/L predicts a multiple ongoing pregnancy with a sensitivity of 80% and a specificity of 88%.

CONCLUSION

After IVF, early pregnancy loss or multiple gestation may be predicted with high sensitivity and specificity by using cut-off values of serum hCG derived from two measurements independently of the day of blood sampling.

Serum HCG 12 days after embryo transfer in predicting pregnancy outcome

BACKGROUND

Assisted reproduction treatment (ART) entails a risk of ectopic pregnancy and early pregnancy loss. Serum HCG has been found to be predictive of pregnancy outcome. Our aim was to assess the clinical value of a single early HCG assay in ART pregnancies taking into account the aetiology and treatment of infertility.

METHODS

During 1994-1999, we studied 774 embryo transfer cycles resulting in pregnancy defined as a serum HCG concentration of > or =5 IU/l on day 12 following embryo transfer. The treatment included IVF in 518, ICSI in 119, and frozen embryo transfer in 137 cycles. Serum HCG concentrations were measured by fluoroimmunometric assay. Pregnancies were classified as viable (live fetus at > or =22 weeks gestation) or non-viable (biochemical pregnancy, miscarriage, ectopic pregnancy and molar pregnancy). Data on the outcomes were retrospectively retrieved from the records.

RESULTS

The median HCG concentration was 126 IU/l in viable pregnancies and 31 IU/l in non-viable pregnancies (P < 0.0001). The median HCG concentration was 115 IU/l in singleton pregnancies and 201 IU/l in multiple pregnancies (P < 0.0001). Male factor infertility was associated with viable pregnancies (P = 0.004) and tubal factor with non-viable pregnancies (P = 0.003); the lowest HCG level (88 IU/l) was observed in subjects with both male factor infertility and ICSI treatment (P = 0.001). An HCG value of 76 IU/l emerged as the most suitable cut-off point to predict viable pregnancy. Probabilities of each type of outcome related to the HCG level are given.

CONCLUSIONS

A single HCG reading on day 12 after embryo transfer helps to plan the subsequent follow-up. Male factor infertility and ICSI are associated with relatively low HCG values in viable pregnancies.

Endocrinology of the peri-implantation period

Current research suggests that the appearance of endometrial integrins and pinopode appearance signal the opening of the receptive phase of the endometrium. These integrins may be activated by the interleukin-1 system (IL-1). IL-1beta, expressed by the blastocyst, induces vascular endothelial growth factor (VEGF) which, in turn, promotes angiogenesis and integrin expression in endometrial cells. The IL-1 system also triggers the expression of gamma interferon (IFN-gamma) from T lymphocytes. Decidual natural killer (NK) lymphocytes interact with invading trophoblast to generate leukaemia inhibitory factor (LIF). LIF induces uPA and gelatinase, enzymes which play a crucial role in trophoblastic invasion. Progesterone is a potent inhibitor of LIF, while oestrogen is a potent inducer. Oestrogen in serum reflects follicular IL-1beta level and correlates with the outcome of embryo transfer after in vitro fertilization (IVF). Progesterone induces nitric oxide (NO) synthesis in the decidua, and NO promotes local vasodilatation and uterine quiescenceMeasurement of placental protein 14 (PP14, glycodelin-A) in serum may be of value as a screening test for implantation potential. However, human chorionic gonadotrophin (hCG) remains the most reliable predictor of successful implantation and pregnancy viability. An ovulation + 14 hCG level < 50 IU/l is often predictive of a non-viable outcome, while an ovulation + 21 hCG of < 200 IU/l always indicates a non-viable pregnancy. hCG secretion by invading trophoblast appears to be negatively modulated by endothelin-1 (ET-1) and prostaglandin F(2alpha)(PGF2alpha), while tissue growth factors and collagenases are positive modulators of hCG expression.ProalphaC, an inhibin pro-monomer, may have some value in monitoring corpus luteum function. Inhibin A, activin A and follistatin all rises throughout pregnancy and peak at 36 weeks of gestation. Relaxin is another ovarian hormone that may have a role in predicting implantation. Relaxin induces placental protein 14 (PP14, glycodelin-A) expression in a receptive endometrium, and measurement of serum PP14 may be of value as a screening test for implantation potential.