A prospective controlled study of in-vitro fertilization, gamete intra-fallopian transfer and intrauterine insemination combined with superovulation

Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis

OBJECTIVE

To evaluate whether the presence or severity of endometriosis affects the outcome of assisted reproductive techniques (ART).

METHODS

In this systematic review, all studies comparing the outcome of ART in women with and those without endometriosis, or at different stages of the disease, were considered eligible. We used either risk ratio (RR) or mean difference (MD) and their 95%CIs for comparisons. The primary outcome was live birth; the secondary outcome was clinical pregnancy. Miscarriage and the number of oocytes retrieved were examined as additional outcomes.

RESULTS

We included 92 studies in the review and 78 in the meta-analysis: 20,167 women with endometriosis were compared with 121,931 women without endometriosis, and 1703 women with Stage-III/IV endometriosis were compared with 2227 women with Stage-I/II endometriosis. The following results were observed for the comparison of women with endometriosis vs women without endometriosis: live birth, RR = 0.99 (95%CI, 0.92-1.06); clinical pregnancy, RR = 0.95 (95%CI, 0.89-1.02); miscarriage, RR = 1.31 (95%CI, 1.07-1.59); number of oocytes retrieved, MD = -1.56 (95%CI, -2.05 to -1.08). The following results were observed for the comparison of women with Stage-III/IV vs Stage-I/II endometriosis: live birth, RR = 0.94 (95%CI, 0.80-1.11); clinical pregnancy, RR = 0.90 (95%CI, 0.82-1.00); miscarriage, RR = 0.99 (95%CI, 0.73-1.36); number of oocytes retrieved, MD = -1.03 (95%CI, -1.67 to -0.39).

CONCLUSIONS

Women with endometriosis undergoing ART have practically the same chance of achieving clinical pregnancy and live birth as do women with other causes of infertility. No relevant difference was observed in the chance of achieving clinical pregnancy and live birth following ART when comparing Stage-III/IV with Stage-I/II endometriosis. The quality of the evidence for the additional examined outcomes was very low, not allowing meaningful conclusions to be drawn.

In vitro fertilization (IVF): a review of 3 decades of clinical innovation and technological advancement

In vitro fertilization, popularly referred to as IVF, has captured the attention of the public since its sensational introduction in 1978. Today assisted reproductive technology is available throughout most of the civilized world, and the practice is largely different from that used during the early days. Refinements in laboratory technology and clinical practice have allowed IVF to evolve into a medical procedure that is efficient, safe, readily accessible, and relatively affordable. More than 2 million IVF children have been born to date, and it is likely that continued enhancements will widen its appeal and applicability.

Implantation Rate Remains Unaffected in Women with Endometriosis Compared to Tubal Factor Infertility

Purpose

To reconsider the implantation and delivery rates which occurred six years later in women with endometriosis from the Yale IVF Programme.

Methods

Five hundred and ninety-seven consecutive IVF and ICSI treatment cycles were analyzed retrospectively. Patients with endometriosis (n=130; 258 cycles) were compared with an age-matched control group with tubal infertility (n=104; 206 cycles) and also with a group with male infertility (n=59; 133 cycles). Data from the endometriosis group were analyzed further in minimal-mild (144 cycles) and moderate-severe (114 cycles) subgroups. All the patients underwent laparoscopy prior to IVF treatment.

Results

Fewer oocytes were retrieved and similar fertilization (59% vs. 61%), implantation (12.3% vs. 16%), and delivery (23.7% vs. 26.3%) rates were found in patients with endometriosis compared to tubal infertility. A trend towards reduced pregnancy rate per transfer (17.5%) in the male infertility vs. endometriosis or tubal infertility groups (34% and 37.8% respectively) was observed. The number of embryos transferred in each group was comparable. Analysis of first cycles only across all groups revealed that the implantation rate did not have any statistically significant differences in the endometriosis versus the tubal or male infertility groups. Within the endometriosis group, the implantation, pregnancy, and delivery rates were similar in subgroups.

Conclusions

We conclude that in patients with endometriosis, implantation, pregnancy, and delivery rates are similar with tubal factor infertility, and higher compared to male infertility. Our results suggest that embryo quality and uterine receptivity remain unaffected in women with endometriosis.

The non-human primate model of endometriosis: research and implications for fecundity

The development of an animal model of endometriosis is crucial for the investigation of disease pathogenesis and therapeutic intervention. These models will enhance our ability to evaluate the causes for the subfertility associated with disease and provide a first-line validation of treatment modulators. Currently rodents and non-human primate models have been developed, but each model has their limitations. The aim of this manuscript is to summarize the current findings and theories on the development of endometriosis and disease progression and the effectiveness of therapeutic targets using the experimental induced model of endometriosis in the baboon (Papio anubis).

Oviductal cells and early conception

The ability to bypass the oviduct by fertilizing human oocytes in vitro and then transferring the ensuing embryos into the uterine environment to produce pregnancies that can be carried to term (assisted reproductive technology, ART) has made the real functional significance of the fallopian tube come under debate. The question has been raised as to whether the oviduct is a simple conduit, providing for the transport of gametes and embryos, or whether it has any functional relevance to early conception. In the field of ART, some reports claim that transfer of embryos either to the uterus or to the oviduct yield similar results, while a greater amount of evidence confirms that tubal transfers are associated with higher pregnancy and take home baby rates, suggesting that unknown factors in the oviduct favour fertilization and embryo viability. This review attempts to provide some answers to questions about the role of oviductal cells in vivo during early conception and in vitro in the field of ART.

Distributive justice and infertility treatment in Canada

An exploration of distributive justice in Canadian infertility treatment requires the integration of ethical, clinical, and economic principles. In 1971, American philosopher John Rawls proposed a theoretical model for fair decision-making in which "rational" and "self-interested" citizens are behind a "veil of ignorance" with respect to both their own position and the position of other decision-makers. Rawls proposed that these self-interested decision-makers, fearing that they are among the least advantaged persons who could be affected by the decision, will agree only upon rules that encode equality of opportunity and that bestow the greatest benefit on the least advantaged citizens. Regarding health policy decision-making, Rawls' model is best illustrated by Canadian philosopher Warren Bourgeois in his panel of "volunteers." These rational and self-interested volunteers receive an amnestic drug that renders them unaware of their health, social, and financial position, but they know that they are representative of diverse spheres of citizens whose well-being will be affected by their decision. After describing fair decision-making, Bourgeois considers the lack of a distributive justice imperative in Canada's Assisted Human Reproduction Act, in contrast to legislation in European nations and Australia, summarizes the economic and clinical considerations that must be provided to the decision-makers behind the "veil of ignorance" for fair decisions to occur, and considers altruism in relation to equality of access. He concludes by noting that among countries with legislation governing assisted reproduction Canada is alone in having legislation that is void of distributive justice in providing access to clinically appropriate infertility care.

The Estrogen Early Response Gene FOS Is Altered in a Baboon Model of Endometriosis1

Endometriosis, the presence of a functional endometrium outside of the uterine cavity, is associated with infertility. In our simulated model of pregnancy in baboons with experimental endometriosis, hCG infusion fails to induce expression of the immunoregulatory protein glycodelin. To test the hypothesis that the development of endometriosis is associated with an aberrant endometrial immunological environment, we examined the expression of a series of immunoregulatory genes in endometrium from baboons with and without endometriosis. Six months following intraperitoneal inoculation with menstrual endometrium, eutopic endometrium was surgically collected between Days 9 and 11 postovulation. Control endometrium was similarly collected from disease-free animals. Total RNA was extracted, and biotinylated cDNA probes were hybridized to the SuperArray GEArray Q series Th1/Th2/Th3 cDNA array, representing 96 genes. Gene expression levels were determined using ScanAlyze and GEArray Analyzer software. Seven genes were upregulated, including JUND, FOS, CCL11, NFKB1 and others, in the endometrium from baboons with endometriosis compared with the endometrium from disease-free animals; one gene, IL1R1, was downregulated. Quantitative RT-PCR confirmed upregulation of FOS and CCL11 in endometriotic eutopic endometrium. Immunohistochemical analysis revealed altered levels and distribution of FOS protein in the eutopic endometrium of baboons with induced endometriosis. These data suggest that in an induced model of endometriosis an aberrant eutopic immunological environment results in a decreased apoptotic potential and in rapid alterations in endometrial gene expression. We propose that the reduced fecundity associated with endometriosis has a multifold etiology in spontaneous and induced disease.

Homologous intrauterine insemination in controlled ovarian hyperstimulation cycles: a comparison among three different regimens

OBJECTIVE

The objective was to assess the efficacy of double intrauterine insemination (IUI) over a single periovulatory IUI in patients undergoing controlled ovarian hyperstimulation with low-dose recombinant follicle stimulating hormone (rFSH) combined with human chorionic gonadotropin (HCG).

STUDY DESIGN

Ninety-four infertile women were randomly assigned to three groups; in group A (38 patients, 47 cycles) a single IUI was performed 36 h after HCG administration combined with timed intercourse the day of HCG administration; within group B (43 patients, 48 cycles) IUI alone was performed 36 h after HCG administration; in group C (39 patients, 43 cycles) a double IUI 12 and 36 h after HCG administration was performed.

RESULTS

The mean age and the causes of infertility were similar between the three groups. The number of follicles greater than 15 mm on the day of HCG administration and the overall dose of rFSH required per cycle was not significantly different among the groups. The pregnancy rate (PR) per cycle and per patient was 14.9% and 18.4% in group A, 10.4% and 11.6% in group B, 20.9% and 23.1% in group C, respectively. There was no statistically significant difference in PR among the three groups.

CONCLUSION

In rFSH/HCG cycles, two IUIs performed 12 and 36 h after HCG administration do not significantly improve pregnancy rates over a single insemination performed 36 h after HCG administration combined with or without timed intercourse the day of HCG administration.

Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis

BACKGROUND

Women with endometriosis who are treated with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) have a lower pregnancy rate compared to women with tubal factor infertility. It has been suggested that the administration of gonadotrophin releasing hormone (GnRH) agonists for a few months prior to IVF or ICSI increases the pregnancy rate.

OBJECTIVES

To determine the effectiveness of administering GnRH agonists for three to six months prior to IVF or ICSI in women with endometriosis.

SEARCH STRATEGY

We used computer searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the National Research Register (NRR) and the MDSG Specialised Register of controlled trials. We handsearched proceedings of annual meetings of the American Society for Reproductive Medicine (ASRM) and the European Society for Human Reproduction and Embryology (ESHRE). We reviewed lists of references in original research and review articles. We contacted experts in various countries to identify unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials using any GnRH agonist prior to IVF or ICSI to treat women with any degree of endometriosis diagnosed by laparoscopy or laparotomy

DATA COLLECTION AND ANALYSIS

Two independent review authors abstracted data (HNS and JGV). We sent e-mails to investigators to seek additional information. We assessed the validity of each study using the methods suggested in the Cochrane Handbook. The data were checked by the third review author (SD) and any disagreement was resolved by arbitration with the fourth review author (AA). We generated 2 x 2 tables for principal outcome measures. The Peto-modified Mantel-Haenszel technique was used to calculate odds ratios (OR) and assess statistical heterogeneity between studies.

MAIN RESULTS

Three randomised controlled trials (with 165 women) were included. The live birth rate per woman was significantly higher in women receiving the GnRH agonist compared to the control group (OR 9.19, 95% CI 1.08 to 78.22). However, this was based on one trial reporting "viable pregnancy" only. The clinical pregnancy rate per woman was also significantly higher (three studies: OR 4.28, 95% CI 2.00 to 9.15). The information on miscarriage rates came from two trials with high heterogeneity and, therefore, results of the meta-analysis were doubtful. The included studies provided insufficient data to investigate the effects of administration of GnRH agonists on multiple or ectopic pregnancies, fetal abnormalities or other complications.

AUTHORS' CONCLUSIONS

The administration of GnRH agonists for a period of three to six months prior to IVF or ICSI in women with endometriosis increases the odds of clinical pregnancy by fourfold. Data regarding adverse effects of this therapy on the mother or fetus are not available at present.

A baboon model for endometriosis: implications for fertility

Endometriosis is one of the most common causes of chronic pelvic pain and infertility in women in the reproductive age group. Although the existence of this disease has been known for over 100 years our current knowledge of its pathogenesis and the pathophysiology of its related infertility remains unclear. Several reasons contribute to our lack of knowledge, the most critical being the difficulty in carrying out objective long-term studies in women. Thus, we and others have developed a model of this disease in the non-human primate, the baboon (Papio anubis). Intraperitoneal inoculation of autologous menstrual endometrium results in the development of endometriotic lesions with gross morphological characteristics similar to those seen in the human. Multiple factors have been implicated in endometriosis-associated infertility. We have described aberrant levels of factors involved in multiple pathways important in the establishment of pregnancy, in the endometrium of baboons induced with endometriosis. Specifically, we have observed dysregulation of proteins involved in invasion, angiogenesis, methylation, cell growth, immunomodulation, and steroid hormone action. These data suggest that, in an induced model of endometriosis in the baboon, an increased angiogenic capacity, decreased apoptotic potential, progesterone resistance, estrogen hyper-responsiveness, and an inability to respond appropriately to embryonic signals contribute to the reduced fecundity associated with this disease.

Gamete intra-fallopian transfer or intrauterine insemination after controlled ovarian hyperstimulation for treatment of infertility due to endometriosis

We compared the effectiveness of gamete intra-Fallopian transfer (GIFT) and intrauterine insemination (IUI) after controlled ovarian hyperstimulation (COH) in the treatment of infertility due to endometriosis. This was a retrospective study carried out at a tertiary teaching medical center. A total of 127 consecutive patients with endometriosis were treated with GIFT or IUI after COH between June 1990 and December 1998. Patients were divided into two groups. Group 1 (n = 97) included patients with stages 1 and 2 endometriosis, and group 2 (n = 30) included patients with stages 3 and 4 endometriosis. Laparoscopic conservative surgery for endometriosis was performed prior to IUI for patients in both group 1 and group 2. In group 1, 55 patients underwent 95 cycles of IUI after COH and 42 patients underwent 57 cycles of GIFT. In group 2, 14 patients underwent 16 cycles of IUI after COH, while 16 patients underwent 22 cycles of GIFT. The stimulation protocol for both GIFT and IUI was mid-luteal pituitary down-regulation with a gonadotropin releasing hormone agonist (GnRH-a) followed by gonadotropins. In group 1, the pregnancy rates (GIFT = 50.9%, IUI = 29.4%) and the delivery rates (GIFT = 28.1%, IUI = 14.7%) per cycle were significantly higher in GIFT compared to IUI (p = 0.009 and p = 0.05, respectively). There was no significant differences in the pregnancy rate (GIFT 69%, IUI 50.9%, respectively) or the delivery rate (GIFT 38.1%, IUI 25.5%) per patient. In group 2, there was no significant difference in the pregnancy rate (GIFT 54.5%, IUI 31.3%) or the delivery rate (GIFT 40.9%, IUI 12.5%) per cycle, but the difference in the pregnancy rate (GIFT 75%, IUI 35.7%) and the delivery rate (GIFT 56.3%, IUI 14.3%) per patient was significantly higher in GIFT compared to IUI (p = 0.04 and p = 0.02, respectively). We conclude that, when the same stimulation protocol is used in the early stages of endometriosis, a few cycles of IUI can achieve similar results to GIFT, and therefore should be used first. In advanced stages of endometriosis GIFT appears to be more effective.

How does endometriosis affect infertility?

Prospective and retrospective clinical trials suggest a decreased oocyte and embryo quality in women with endometriosis. Based on these observations, the authors described an altered intrafollicular milieu in endometriosis, which explains the bad quality oocytes and the resulting embryos with lower capacity to implant. Whether these changes affect the oocytes or are the consequence of genomic alterations manifested by biochemical and chromosomal differences in healthy women is an unresolved issue. If the effects of endometriosis on follicular development are nongenomic in origin, modulation of the process of folliculogenesis may be sufficient to treat the disease and cure infertility associated with endometriosis. A genomic defect needs specific genetic therapy, which currently is not available.

Pre-ovulatory granulosa cells of infertile women with endometriosis are less sensitive to luteinizing hormone

PROBLEM

Reduced fertilization rates in women with minor endometriosis may be the result of direct effects on the ovary or to primary dysfunction within the hypothalamic-pituitary-ovarian axis. This controlled study was designed to examine the steroidogenic potential of luteinized granulosa cells in women with minor endometriosis.

METHOD OF STUDY

Granulosa cells were harvested at oocyte recovery and incubated for 3 hr in increasing concentrations of luteinizing hormone (LH). The dissociation constant for added concentrations of LH was computed (as Km LH) and the results were compared between women with endometriosis and controls.

RESULTS

Women with minor endometriosis had a higher dissociation constant than women with tubal damage [Km 0.98 (0.58-9.24) versus 0.33 (0.28-0.72) ng/mL, P = 0.019], indicating reduced sensitivity to LH.

CONCLUSIONS

In women with endometriosis, granulosa cells were less sensitive to LH stimulation. This provides further evidence for primary ovarian dysfunction as a significant contributory cause of the associated subfertility.

Effect of endometriosis on in vitro fertilization

OBJECTIVE

To investigate the IVF outcome for patients with endometriosis.

DESIGN

Meta-analysis.

SETTING

Academic research center.

PATIENT(S)

A MEDLINE search and review of the literature were performed. Patients were classified by level of endometriosis, and controls were classified according to the indication for IVF.

INTERVENTION(S)

Bivariate analysis and multivariate logistic regression was used to estimate overall effect and control for confounding.

MAIN OUTCOME MEASURE(S)

Pregnancy rates, fertilization rate, implantation rates, and numbers of oocytes retrieved.

RESULT(S)

Twenty-two published studies were included in the overall analysis. The chance of achieving pregnancy was significantly lower for endometriosis patients (odds ratio, 0.56; 95% confidence interval, 0.44-0.70) when compared with tubal factor controls. Multivariate analysis also demonstrated a decrease in fertilization and implantation rates, and a significant decrease in the number of oocytes retrieved for endometriosis patients. Pregnancy rates for women with severe endometriosis were significantly lower than for women with mild disease (odds ratio, 0.60; 95% confidence interval, 0.42-0.87).

CONCLUSION(S)

Patients with endometriosis-associated infertility undergoing IVF respond with significantly decreased levels of all markers of reproductive process, resulting in a pregnancy rate that is almost one half that of women with other indications for IVF. These data suggest that the effect of endometriosis is not exclusively on the receptivity of the endometrium but also on the development of the oocyte and embryo.

Endometriosis and infertility: the debate continues

A causal relationship between minor endometriosis and infertility or subfertility has not yet been demonstrated, although a significant association is shown by prevalence studies. This article critically reviews the evidence for pituitary-ovarian dysfunction as a cause for subfertility in women with minor endometriosis. The lack of fertile controls with endometriosis presents a methodological problem. Group comparison in studies using tubal infertility cases as controls has demonstrated impaired follicular growth, reduced circulating oestradiol concentrations during the preovulatory phase and oestradiol and progesterone during the early luteal phase, and disturbed luteinizing hormone (LH) surge patterns. LH concentration in preovulatory follicular fluid is also reduced, and granulosa cells collected at the same time have impaired steroidogenic capacity in vitro. However, these findings are not consistent in published studies. Significantly lower oocyte fertilization rates (49%) are found compared with controls (69%), even after maximum stimulation with exogenous follicle-stimulating hormone and human chorionic gonadotrophin (52% versus 69%). The implantation rate is also lower (11% versus 13%). An inherent disorder of follicular function seems likely, and LH surge impairment is probably a secondary effect. Impairment of oocyte fertilization would thus contribute substantially to the natural subfertility associated with endometriosis, but in vitro fertilization is still successful as excess numbers of oocytes are available.

Natural cycle IVF in unexplained, endometriosis-associated and tubal factor infertility

BACKGROUND

To elucidate possible differences between unexplained and minimal peritoneal endometriosis-associated infertility, we studied their outcome in natural cycle IVF (NIVF).

METHODS

A prospective cohort study was carried out on unexplained (33 couples), minimal peritoneal endometriosis-associated (30 couples) and tubal factor (24 couples) infertility in 223 NIVF cycles, using human chorionic gonadotrophin (HCG) for ovulation induction.

RESULTS

During the first NIVF attempt, follicular and luteal phase oestradiol, FSH, LH and progesterone concentrations, as well as endometrial thickness and follicular diameter were similar among the three groups. Periovulatory follicular growth monitored from day of HCG administration to oocyte aspiration was significantly lowered in unexplained infertility compared with minimal endometriosis-associated and tubal factor infertility. The fertilization rate, clinical pregnancy rate per initiated cycle, per successful oocyte retrieval and per embryo transfer, in minimal endometriosis (80.0, 10.4, 16.0 and 23.5% respectively) were similar to that in tubal factor infertility patients (68.6, 5.8, 11.4 and 16.0%) but significantly higher (P < 0.05) than that of the unexplained infertility group (62.2, 2.6, 5.4 and 8.7%).

CONCLUSIONS

The significant reduction in follicular periovulatory growth, fertilization and pregnancy rates in unexplained infertility compared with minimal peritoneal endometriosis patients may be explained by sub-optimal follicular development with possibly reduced oocyte quality, intrinsic embryo quality factors or by impaired implantation. From a clinical point of view, NIVF is less suited to unexplained infertility treatment, but might represent an interesting treatment option for minimal peritoneal endometriosis-associated infertility.

Endometrial quality in infertile women with endometriosis

Several analyses in our infertility (IVF) and oocyte donation programs were carried out to gain clinical knowledge of the factors involved in the etiology of endometriosis-associated infertility. We first compared the IVF outcomes in women with tubal infertility and endometriosis. The results indicated that patients with endometriosis had a poorer IVF outcome in terms of reduced pregnancy rate per cycle, per transfer, and reduced implantation rate per embryo replaced. We then evaluated embryo development in vitro in women with and without endometriosis who underwent IVF and embryo replacement 72 hours after oocyte retrieval. We observed that compared to controls, patients with endometriosis had a significantly reduced number of blastomeres per embryo as well as an increased incidence of arrested embryos in vitro. In subsequent studies we compared fertility parameters in patients receiving donor oocytes. We noted that when donor oocytes came from patients without known endometriosis, embryo development and implantation rates were similar in patients with and without endometriosis. However, when the results of oocyte donation were classified according to the nature of the oocytes donated, patients who received embryos derived from oocytes from women with endometriotic ovaries showed a significantly reduced implantation rate compared to the controls. Taken together, these observations suggest that IVF in patients with endometriosis may be related to alterations within the oocyte, which, in turn, result in embryos of lower quality with a reduced ability to implant.

The presence and extent of endometriosis do not effect clinical pregnancy and implantation rates in patients undergoing intracytoplasmic sperm injection

OBJECTIVE

To assess the impact of endometriosis on the outcome of intracytoplasmic sperm injection (ICSI) outcome.

STUDY DESIGN

Retrospective case-control study which enrolled 1280 consecutive cycles of 834 couples of ICSI with ejaculated sperm. Among them, 973 cycles of 632 couples had resulted in embryo transfer (ET). The presence of endometriosis was noted in 110 consecutive cycles of 45 patients among which 78 cycles of 44 patients had resulted in ET. Data from endometriosis group were analyzed in subgroups of minimal-mild (49 ET cycles of 25 patients) and moderate-severe (29 ET cycles of 19 patients). The controls consisted of 1170 consecutive cycles of age-matched 771 couples. Of the controls, 588 couples had 895 cycles of ET. Main outcome measures were implantation and clinical pregnancy rates.

RESULTS

There were no differences in cycle and ET cancellation rates between control and endometriosis groups. The number of oocytes retrieved, fertilization and cleavage rates and the number and quality of embryos developed and transferred were similar among the groups. The implantation and clinical pregnancy rates were also comparable.

CONCLUSION

The presence and extent of endometriosis do not affect implantation and clinical pregnancy rates in patients undergoing ICSI.

Secretion of inhibin B during ovarian stimulation is decreased in infertile women with endometriosis

OBJECTIVE(S)

To determine the levels and pattern of inhibin B secretion during ovarian stimulation in patients with endometriosis and to evaluate the correlation between inhibin B levels and variables of follicular and oocyte development.

DESIGN

Retrospective cohort study.

SETTING

IVF center.

PATIENT(S)

Women with endometriosis (n = 20) and tubal factor (n = 10) as the only cause of infertility.

INTERVENTION(S)

Inhibin B levels were measured during gonadotropin stimulation on day 1, days 8-11, day of hCG administration, and oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Patterns and levels of inhibin B secretion were compared in the two groups. Other variables analyzed were age, days of gonadotropin stimulation and total ampules used, oocytes retrieved, and the fertilization and pregnancy rate.

RESULT(S)

Inhibin B levels and number of oocytes retrieved were significantly lower in patients with endometriosis than in the control group. Two patterns of inhibin B secretion were noted: It peaked in the midfollicular phase or on the day of hCG administration. In contrast, E2 levels peaked on the day of hCG administration. Inhibin B in the midfollicular phase in both groups correlated positively with number of oocytes retrieved. In addition, E2 and inhibin B levels in the midfollicular phase correlated positively.

CONCLUSION(S)

Decreased inhibin B secretion in patients with endometriosis suggests impaired granulosa cell function. Inhibin B may serve as an alternate marker to assess follicular development or to predict the number of oocytes retrieved.

The follicular endocrine environment in stimulated cycles of women with endometriosis: steroid levels and embryo quality

OBJECTIVE

To assess the endocrine milieu in follicles of stimulated cycles comparing women with and without endometriosis. Steroids were measured in follicular fluid (FF) and in in vitro culture of granulosa-luteal cells, and this status was related to the quality of the embryos obtained after IVF.

DESIGN

Case-control study.

SETTING

IVF program at the Instituto Valenciano de Infertilidad.

PATIENT(S)

Twenty-four women with laparoscopically documented endometriosis and 26 controls undergoing IVF.

INTERVENTION(S)

Individual follicular aspiration, oocyte isolation, FF storage, and preparation of luteinized granulosa cells for culture; oocyte insemination and embryo cleavage in standard IVF.

MAIN OUTCOME MEASURE(S)

Serum (day of ovum pickup) and FF measurements of estradiol, progesterone, testosterone, and androstenedione. Secretion of progesterone was measured in the cell-conditioned medium. Results were compared between patients with endometriosis and controls, as well as between oocytes that yielded embryos of different quality.

RESULT(S)

Levels of progesterone in the FF increased with the severity of the disease, whereas testosterone accumulation in the FF decreased with the severity of the disease. An increase in progesterone accumulation in vitro was observed in basal and hCG-induced granulosa cell cultures. No difference was observed in terms of embryo quality, and no steroid marker was able to identify follicles with oocytes that displayed embryos of good or bad quality under the inverted microscope.

CONCLUSION(S)

The data show differences in the steroidogenesis of follicles from stimulated women with and without endometriosis. These changes indicate good endocrine health but are not predictive of embryo quality.

Ovarian dysfunction in endometriosis-associated and unexplained infertility

PURPOSE

The impact of endometriosis and unexplained infertility on follicular function and fertilization of oocytes in cycles totally unperturbed by exogenous gonadotrophins, when compared with controls with tubal damage, were examined.

METHODS

In natural cycles, without any exogenous gonadotropins, endocrine and ultrasonographic studies of follicular maturation in 18 women with minor endometriosis (41 cycles), 15 women with unexplained infertility (31 cycles), and 34 women with tubal damage (88 cycles) were performed.

RESULTS

The endometriosis group had a significantly longer follicular phase (median: 15, 13, and 13 days). Both endometriosis and unexplained infertility had significantly reduced LH concentrations in follicular fluid compared with tubal damage (median: 12.1, 11.5, and 15.9 IU/L, respectively). Endometriosis was associated with a significantly reduced fertilization rate compared with unexplained infertility or tubal damage (46, 65, and 69%, respectively).

CONCLUSIONS

These data show continuing evidence of ovulatory dysfunction leading to reduced fertilization rates in women with minor endometriosis.

Endometriosis is not detrimental to embryo implantation in oocyte recipients

PURPOSE

Our purpose was to determine the effects of endometriosis on implantation and pregnancy rates in ovum recipients.

METHODS

The medical records of 239 consecutive oocyte recipient patients who were treated between January 1, 1991, and June 30, 1995, were analyzed retrospectively. Recipients with endometriosis (group 1; n = 55) were compared to recipients without endometriosis (group II; n = 184). Patients in group I had active endometriotic disease confirmed by laparoscopy and were subdivided into mild (Stages I and II; n = 18) and moderate to severe (Stages III and IV; n = 37) endometriosis.

RESULTS

No difference was found in recipient age, endometrial thickness, donor age, and embryos transferred. The pregnancy rates (28 versus 29%) and implantation rates (12 and 13%) were also comparable between group I and group II, as well as between patients with mild and patients with moderate to severe endometriosis.

CONCLUSIONS

The presence of endometriosis in oocyte recipients does not lower implantation or pregnancy rates. We conclude that the adverse effect of endometriosis on reproductive outcome is not related to implantation but, in fact, is most likely an effect on oocyte or embryo quality.

The influence of endometriosis on the success of gamete intrafallopian transfer (GIFT)

PURPOSE

Our purpose was to evaluate the outcomes of gamete intrafallopian transfer (GIFT) therapy in patients with endometriosis.

METHODS

One hundred eight GIFT cycles performed under the indication of endometriosis were compared to 156 GIFT cycles with indications of other disease entities. A maximum of seven oocytes was transferred into one or both fimbriate ends with prepared spermatozoa. Clinical pregnancy rates and outcomes were evaluated according to Mantel-Haenszel's chi-square test. Multiple logistic regression analysis was performed to determine factors influencing the success on pregnancy in the total treatment cycles.

RESULTS

The anthropological variables, such as age of patients, duration of infertility, and semen grading, were comparable in both groups. The responses to controlled ovarian hyperstimulation (COH) were progressively decreased while increasing the severity of endometriosis conditions such as nonendometriosis, mild-form endometriosis, and advanced-form endometriosis patients. However, there were no significant differences in the clinical pregnancy rates (40.4, 36.7, and 41.7%, respectively), multiple pregnancy rates (34.9, 27.3, and 45.0%, respectively), and early pregnancy loss rates (27.0, 18.2, and 30.0%, respectively). Multivariate statistics of pregnancy rates that adjusted the effects of patients' age, tubal health, presence of active endometriosis and/or endometriomas, number of oocytes transferred, and quality of sperm exhibited no statistical significance between endometriosis and nonendometriosis groups.

CONCLUSIONS

Our data show that patients with records of endometriosis have both a decreased ovarian response to gonadotropin stimulation and a decreased number of retrieved oocytes. Since the number of oocytes needed for the GIFT procedure is limited, pregnancy results for patients in the study group were comparable with those for patients in the control group.

In vitro fertilization, gamete intrafallopian transfer, and superovulation with intrauterine insemination: efficacy and potential health hazards on babies delivered

OBJECTIVE

The purpose of this article was to review the efficacy and potential hazards of assisted conception.

STUDY DESIGN

A review of pertinent scientific articles published in English was done.

RESULTS

There are no adequate prospective, randomized, controlled, or comparative studies of sufficient power on the efficacy of in vitro fertilization, gamete intrafallopian transfer, and superovulation with intrauterine insemination in well-defined infertile couples. In vitro fertilization can overcome tubal sterility. The pregnancy per cycle is 19.8% and delivery per cycle is 16.0% for in vitro fertilization (all indications) and 29.5% and 19.8%, respectively, for gamete intrafallopian transfer. In limited prospective studies, in vitro fertilization, gamete intrafallopian transfer, and superovulation with intrauterine insemination have similar fecundity. Multiple births from in vitro fertilization and gamete intrafallopian transfer are increased, whereas preterm labor and low-birth-weight babies are significantly more common, even in singletons.

CONCLUSION

The efficacy or relative superiority of IVF, gamete intrafallopian transfer, and superovulation with intrauterine insemination in nontubal subfertility remains to be shown by properly designed, prospective, randomized, controlled, or comparative studies. Therefore less invasive and less expensive methods such as expectant management or superovulation with intrauterine insemination should be used before embarking on in vitro fertilization and gamete intrafallopian transfer. Further studies on the outcome of babies delivered after assisted conception are required.

The effect of endometriosis on implantation: results from the Yale University in vitro fertilization and embryo transfer program

OBJECTIVE

To investigate the effect of endometriosis on implantation.

DESIGN

Case-control study from Yale University IVF-ET program.

PATIENTS

Two hundred eighty-four consecutive IVF cycles were analyzed retrospectively. Patients with endometriosis only (n = 35; 89 cycles) were compared with an age-matched control group with tubal infertility (n = 70; 147 cycles) and also to a group with unexplained infertility (n = 15; 48 cycles). Data from the endometriosis group was analyzed further in subgroups of minimal-mild (43 cycles) and moderate-severe (46 cycles).

RESULTS

No difference was found in the number and the quality of oocytes retrieved and fertilization rates between the endometriosis, the tubal infertility, and the unexplained infertility groups. The quality and the number of embryos transferred in each group were comparable. A trend toward reduced pregnancy rate per transfer (14.8%) in the endometriosis versus tubal or unexplained infertility groups (25.7% and 23.3%, respectively) was observed. Implantation rate (gestational sac per transferred embryo) was significantly lower in the endometriosis versus the tubal infertility group (3.9% versus 8.1%; unexplained infertility group, 7.2%). Analysis of first cycles only across all groups revealed that the implantation rate also was significantly lower in the endometriosis versus the tubal infertility group (3.1% versus 9%; unexplained infertility group, 6.7%). Within the endometriosis group, although the pregnancy rate per cycle and per transfer were similar in subgroups, patients with minimal-mild endometriosis had the lowest implantation rate.

CONCLUSION

We conclude that, in patients with endometriosis, implantation rate is low. Abnormal implantation, which may be secondary to endometrial dysfunction or embryotoxic environment, is a factor in endometriosis-associated subfertility.

The effect of endometriosis, its stage and activity, and of autoantibodies on in vitro fertilization and embryo transfer success rates

OBJECTIVES

To analyze IVF cycle parameters, including pregnancy rates (PR), in women with and without endometriosis and to evaluate the effect of the stage and activity of endometriosis and of autoantibodies.

DESIGN

A retrospective analysis of 237 consecutive IVF cycles (193 patients), 119 in women with and 118 without endometriosis. The endometriosis group was further subdivided according to the stage and activity of the disease and autoantibody positivity.

SETTING

Hospital-based and freestanding IVF programs with the same IVF team.

PATIENTS

One hundred ninety-three women of reproductive age undergoing IVF; 84 had prior diagnosis of endometriosis, and 109 had other indications for IVF. Within the endometriosis group, 40 did and 44 did not have evidence of active disease. Autoantibodies were measured in 50 patients.

INTERVENTIONS

The IVF protocol was standard with GnRH agonist administered from the midluteal phase of the preceding cycle. Variables included the method of ET and the use of corticosteroids.

MAIN OUTCOME MEASURES

Number of follicles produced, number of eggs retrieved, fertilization rates, number of embryos transferred, and PR per transfer.

RESULTS

There was no difference between groups in the response to stimulation, number of oocytes retrieved, number fertilized, and number cleaved. The overall PR was 27% per transfer; it was similar in women with and without endometriosis (29% and 25%, respectively). There was also no difference in PR according to the stage or activity of the disease. However, PR in autoantibody-positive and -negative patients were significantly different (22.9% and 45.7%, respectively). Among autoantibody-positive patients treated with corticosteroids, 8 of 10 conceived.

CONCLUSIONS

This study confirms previous reports that IVF success rates are comparable in women with and without endometriosis regardless of the activity and stage of the disease. However, our study also indicates that autoantibodies may affect adversely implantation of embryos and that this effect can be overcome by administration of corticosteroids.

Effectiveness of infertility treatments: choice and comparative analysis

Choice of infertility treatments usually depends on a balance of the chances of conceiving with or without treatment, and with more or less complex and costly treatments, and on other factors such as duration of infertility and the woman's age. Pregnancies often occur independent of treatment and prospective controlled trials are needed. Comparability between reported results requires pregnancy and birth rates to be calculated in a time-specific or cycle-specific way. Cumulative rates are preferable to account for the usual tendency of fecundity to fall progressively. This review focuses on such published data in order to assess the relative effectiveness of treatments, both conventional and assisted conception methods. The main conclusions are: (1) The only treatments that can achieve a normal chance of pregnancy are the ovulation induction methods in cases of oligomenorrhea/amenorrhea, and the assisted conception methods for other female causes and unexplained infertility. (2) Tubal/pelvic infective damage and endometriosis require new severity classifications which are sensitive to functional potential before and after surgery, and in vitro fertilization (IVF) would often be indicated as the primary choice. (3) Duration of unexplained infertility determines the need and therefore benefit of any of the treatments used, of which the assisted conception methods are by far the most effective. (4) Interpretation of reported results of treatments for 'male factor' infertility is critically affected by the diagnostic accuracy of defining sperm dysfunction. (5) In cases of well-defined sperm dysfunction there is little or no therapeutic benefit to the chance of natural conception, nor by intrauterine insemination; there is moderate success by IVF, but no proven benefit over standard IVF by any micromanipulative method except probably intracytoplasmic sperm injection.

Use of follicle-stimulating hormone alone (urofollitropin) to stimulate the ovaries for assisted conception after pituitary desensitization

OBJECTIVE

Analyse outcome of FSH therapy alone after pituitary desensitization for assisted conception to compare with published results of conventional hMG.

DESIGN

Descriptive study of complete series of patients undergoing IVF-ET or GIFT treatment using the chosen drug protocol without exception.

SETTING

University private IVF-ET clinic within a comprehensive fertility service.

PATIENTS

All couples (n = 773), including 10% > or = 40 years old, treated by IVF-ET or GIFT (1,097 cycles started and 1,012 attempted egg recoveries) for mainly tubal pelvic infective damage (36% of cycles), endometriosis (16%), sperm disorders (14%) and prolonged unexplained infertility (34%) during 3 calendar years, 1990 to 1992.

INTERVENTIONS

Ovarian stimulation using FSH alone (urofollitropin, Metrodin; Serono Laboratories Limited, Welwyn Garden City, United Kingdom) after pituitary desensitization using buserelin acetate nasal spray (Suprefact; Hoechst, Hounslow, United Kingdom) from the previous midluteal phase, monitored by ultrasonography and serum E2 measurements, followed by standard IVF-ET or GIFT treatment methods limited to the transfer of no more than three embryos or eggs.

OUTCOME MEASURES

Rates per cycle started of cancellation of egg recovery, failure of egg recovery, clinical pregnancy (ultrasound detection of sac), livebirths, and cumulative pregnancy rates (PR) and birth rates.

RESULTS

In women < 40 years old and men with favorable sperm (77% of couples and 84% of cycles) the cycle cancellation rate of egg recovery was 7%; attempted egg recovery was successful in every case. For IVF-ET the clinical PR per started cycle and the livebirth rate were 27% and 23%, respectively, and for GIFT 39% and 33%, respectively. The four-cycle cumulative PR by either treatment was 77% and livebirth rate 68%. In women > 40 years old, the cycle PR and birth rate were 14% and 8%, respectively. In cases of sperm disorder the rates in women < 40 years old were 17% and 14%, respectively, and > 40 years old were 18% and 0, respectively.

CONCLUSIONS

By comparison with the best worldwide results of assisted conception employing pituitary desensitization, the findings demonstrate that FSH alone to stimulate the ovaries is fully effective and highly successful, and supplementation with LH is not needed.