Relationship of follicle numbers and estradiol levels to multiple implantation in 3,608 intrauterine insemination cycles

OBJECTIVE

To determine the relationship of follicle numbers and estradiol (E(2)) levels to multiple implantations in human menopausal gonadotropin (hMG) and clomiphene citrate (CC) cycles.

DESIGN

Fifteen-year prospective study.

SETTING

Private infertility clinic.

PATIENT(S)

Women who underwent 3608 cycles of husband or donor intrauterine insemination (IUI).

INTERVENTION(S)

Ovulation induction (OI) with CC, hMG, or CC+hMG.

MAIN OUTCOME MEASURE(S)

Pregnancy and multiple implantations.

RESULT(S)

Triplet and higher-order implantations-but not twin implantations-were related to age, E(2) levels, and number of follicles > or = 12 mm and > or = 15 mm, but not number of follicles > or = 18 mm, in hMG and CC+hMG cycles. For patients less than 35 years old, three or more implantations tripled when six or more follicles were > or = 12 mm, in CC, hMG, and CC+hMG cycles, and when E(2) was > or = 1000 pg mL in hMG and CC+hMG cycles. For patients 35 or older, pregnancy rates in hMG and CC+hMG cycles doubled when six or more follicles were > or = 12 mm, or E(2) levels were >1000 pg mL, whereas 3 or more implantations were not significantly increased.

CONCLUSIONS

Withholding hCG or IUI in CC, hMG, and CC+hMG cycles when six or more follicles are > or = 12 mm may reduce triplet and higher-order implantations by 67% without significantly reducing pregnancy rates for patients under 35 years of age.

Comparison of the sperm quality necessary for successful intrauterine insemination with World Health Organization threshold values for normal sperm

OBJECTIVE

To compare World Health Organization threshold values for normal sperm with the initial sperm quality necessary for successful IUI.

DESIGN

Retrospective study.

SETTING

Private fertility clinic.

PATIENT(S)

One thousand eight hundred forty-one couples undergoing 4,056 cycles of IUI.

INTERVENTION(S)

Intrauterine insemination.

MAIN OUTCOME MEASURE(S)

Relation of initial sperm quality to fecundity.

RESULT(S)

Progressive motility and total motile sperm count were the initial sperm characteristics most closely related to pregnancy on discriminant analysis. The per-cycle pregnancy rate averaged 11.1% during the first three IUI cycles. Pregnancy rates were > or = 8.2% per cycle when the initial sperm values were a concentration of > or = 5 X 10(6)/mL, a total count of > or = 10 X 10(6), progressive motility of > or = 30%, or a total motile sperm count of > or = 5 x 10(6). Minimal increases in fecundity occurred when initial values were greater than these threshold levels. The lowest initial values that resulted in pregnancy were a concentration of 2 x 10(6)/mL, a total count of 5 x 10(6). motility of 17%, and a total motile sperm count of 1.6 X 10(6). Pregnancy rates were <3.6% when initial values were between the threshold levels and the lowest levels.

CONCLUSION(S)

The sperm quality that is necessary for successful IUI is lower than World Health Organization threshold values for normal sperm. Intrauterine insemination is effective therapy for male factor infertility when initial sperm motility is > or = 30% and the total motile sperm count is > or = 5 X 10(6). When initial values are lower, IUI has little chance of success.

Doppler ultrasound investigation of uterine and ovarian blood flow in infertility and early pregnancy

This review describes the current use of Doppler ultrasound to examine blood flow in the uterus and ovaries in infertile patients and during early pregnancy. The basics of Doppler ultrasound and the different methods of measuring blood flow are discussed from the viewpoint of the clinician who may be unfamiliar with Doppler physics and terminology. Normal values in the menstrual cycle and the relationship of uterine and ovarian blood flow to infertility and to implantation following in-vitro fertilization are presented. Normal values for uterine blood flow in the first 16 weeks of pregnancy and the effect of sex steroids and ovulation induction on their values are described. The possible relationship of defective uterine blood flow to recurrent abortion is examined. New areas of investigation, such as the effect of standing on blood flow, and the effect of drugs are explored. The findings of this review indicate that Doppler blood flow studies may provide significant information about possible causes of some disorders of infertility and early pregnancy and methods of treatment for the same.

Relationship of clomiphene dose and patient weight to successful treatment

Our objective was to examine the relationship between patient weight and the dose of clomiphene required for pregnancy so as to assess the validity of recommendations that the dose of clomiphene be limited to 100 mg. We retrospectively analysed the weight-dose relationship in 1681 clomiphene pregnancies and the relationship between dose and pregnancy, births, multiple births, number of pre-ovulatory follicles and endometrial thickness in 2841 cycles of clomiphene treatment, 25-250 mg, for 5 days before intrauterine insemination (IUI). Doses of clomiphene >100 mg/day were used before pregnancies in 27.4% of patients who weighed >90 kg and in 14.7% of all pregnancies. In IUI cycles, pregnancies and births, but not multiple births or abortions, were related to dose. An increase in dose from 25 to 100 mg resulted in higher pregnancy and birth rates, and in an increase in the average number of pre-ovulatory follicles > or =12 mm in diameter, from 2.0 to 2.8, with no additional increase at higher doses. Endometrial thickness and cycle day of insemination were not related to dose. We conclude that doses of clomiphene may safely be increased beyond 100 mg, and that doses > or =100 mg are required in significant numbers of patients.

Incidence of spontaneous abortion in clomiphene pregnancies

The purpose of this study was to determine whether the use of clomiphene results in a higher incidence of spontaneous abortion than occurs naturally in subfertile patients. Reproductive outcomes of 1744 clomiphene pregnancies were compared to outcomes of 3245 spontaneous pregnancies in a prospective study. Abortion was classified as clinical if a sac was seen on ultrasound or if it occurred after 6 gestational weeks, and as preclinical if a quantitative human chorionic gonadotrophin (HCG) was > or = 25 mIU and no sac was seen or abortion occurred earlier. The overall incidence of abortion was higher for clomiphene pregnancies (23.7%), compared with spontaneous pregnancies (20.4%) (P < 0.01). Preclinical abortions were increased by clomiphene for all ages (5.8 versus 3.9%, P < 0.01) and for age > or = 30 years (8.0 versus 4.9%, P < 0.001), but not for age < 30 years (3.7 versus 3.0%). Clinical abortions were increased by clomiphene for age < 30 years (15.9 versus 11.2%) (P < 0.01), but not for age > or = 30 years (20.1 versus 22.3%) or all ages (18.0 versus 16.4%). Clinical abortions occurred 22% less often following clomiphene compared with spontaneous pregnancies for patients with luteal insufficiency (18.3 versus 23.6%, P < 0.05). We conclude that the increase in abortion due to clomiphene is small and may be related to different causes for women aged < 30 and > or = 30 years, and also that clomiphene may decrease clinical abortions in patients with luteal insufficiency.

Development, pharmacology and clinical experience with clomiphene citrate

This review describes the development and pharmacology of clomiphene and those specific characteristics of both drug and patients which determine its clinical efficacy. The studies reviewed describe clinical observation of patient characteristics (age, additional infertility diagnosis, semen quality), vaginal ultrasound observations of ovaries (number and size of pre-ovulatory follicles) and endometrial lining (thickness, pattern) in 2841 clomiphene cycles in patients who required intrauterine insemination (IUI) because of poor sperm quality or an unsatisfactory postcoital test. They show that (i) conception in clomiphene cycles is related to the number and size of pre-ovulatory follicles, endometrial thickness, patient age, pelvic adhesions, type of anovulatory disorder and semen quality; (ii) pregnancy rates per clomiphene-IUI cycle are constant through at least six cycles; (iii) multiple births cannot be prevented by withholding human chorionic gonadotrophin or advising against coitus when multiple pre-ovulation follicles are present unless all follicles down to 10-12 mm diameter are counted. We also reviewed pregnancy outcome (number of gestational sacs, babies, preclinical and clinical abortion, ectopic pregnancy and birth sex) in 1744 clomiphene pregnancies from our clinic. We found that (i) preclinical and clinical abortions are increased only slightly by clomiphene use, compared to spontaneous pregnancy; (ii) clinical abortions are decreased in patients with polycystic ovaries and luteal insufficiency who use clomiphene; (iii) conception and preclinical abortions are related to endometrial thickness prior to ovulation; (iv) ectopic pregnancies are not increased by clomiphene and (v) the ratio of male births is not altered by clomiphene, except possibly in timed insemination cycles. These studies repudiate many misconceptions regarding clomiphene. They also show that clinical outcome may be improved by pre-ovulation ultrasound monitoring of ovarian and endometrial response.

Relationship of estradiol and progesterone levels to uterine blood flow during early pregnancy

The purpose of this study was to examine the relationship of uterine blood flow to serum estradiol and progesterone during early pregnancy. Recumbent uterine artery average velocity, diameter, blood flow volume and uterine and spiral artery resistance were measured using vaginal Doppler ultrasound 118 times in 43 patients during gestational (postmenstrual) weeks 5 to 16. Relationships to serum progesterone and estrogen were analyzed before and after week 10, when intervillous circulation begins, by multiple linear regression analysis and analysis of covariance (ANCOVA) to correct for the effect of gestational age. After correction for gestational age, estradiol was negatively related to uterine artery flow volume (p < 0.05), diameter (p < 0.05), pulsatility index (p < 0.05) and resistance index (p < 0.01) for weeks 5-16 and to diameter (p < 0.05) after week 9. Progesterone was positively related to volume (p < 0.05) and velocity (p < 0.01) for weeks 5-16 and to volume (p < 0.05) for weeks 5 to 9. Spiral artery indices of resistance were unrelated to hormone levels. These results indicate that before the 10th gestational week, uterine blood flow volume is related to progesterone, but not estradiol levels, and suggest that high estradiol levels during and after the 10th week may be associated with decreased uterine blood flow volume.

Effect of ovulation induction on uterine blood flow and oestradiol and progesterone concentrations in early pregnancy

To determine if oestradiol and progesterone concentrations are related to uterine blood flow in early pregnancy, we measured these hormones at the time of vaginal Doppler ultrasound before and after the beginning of intervillous circulation in spontaneous pregnancy (group I), after clomiphene citrate administration (group II), and after clomiphene citrate plus human menopausal gonadotrophin (HMG) administration (group III). Despite large increases of oestradiol concentration in group II (60%) and III (300%) and of progesterone in groups II (100%) and III (300%), compared with group I, increases in blood flow were modest during the first 9 weeks of gestation. Uterine artery flow volume increased by 20% in group II and 33% in group III (P < or = 0.02); average velocity increased by 37% in group III (P < or = 0.003) compared with groups I and II; vessel diameter increased by 15% in groups II (P < 0.025) and III (P < 0.001) compared with group I; and the uterine artery resistance index decreased by 3 to 5% in group III (P = 0.004) compared with groups I and II. Serum oestradiol and progesterone concentrations were unrelated to the uterine artery resistance index or volume by an analysis of covariance. We conclude that uterine artery blood flow is significantly increased during early pregnancy following HMG administration, and that the increase is unrelated to increases in oestradiol and progesterone concentrations.

Relationship of uterine blood flow to chorionic sac and embryo growth rates

The embryonic period of development is characterized by marked variability in the rate of embryonic growth and development. Differences in uterine blood flow may explain this variability. We investigated the relationship between uterine artery blood flow volume (VOL), uterine artery pulsatility index (UA-PI), uterine artery resistance index (UA-RI), spiral artery pulsatility index (SA-PI), spiral artery resistance index (SA-RI), chorionic sac diameter (CSD), and crown-rump length (CRL) during 321 first trimester vaginal colour Doppler ultrasound examinations of 94 delivered or continuing pregnancies. After correcting for the confounding effect of gestational age, subject, and serum hormone levels by Analysis of Covariance, CRL was related to UA-PI (P = 0.025) and UA-RI (P < 0.001), but not to VOL, SA-PI, or SA-RI. No relationship was found between CSD and any uterine blood flow variables. Serum oestradiol levels were related to CSD and CRL (P < 0.001). No relationship was found to progesterone, maternal age, parity, or previous abortion. We conclude that differences in uterine blood flow and serum oestradiol explain some of the variability in the rate of embryo growth during the first 12 gestational weeks.

Ultrasonographic features of uterine blood flow during the first 16 weeks of pregnancy

Uterine blood flow volume has been thought to increase in a linear fashion throughout pregnancy, but previous studies in early pregnancy may have not been performed often enough or in sufficient numbers of patients. We measured uterine artery blood flow volume, average velocity, vessel cross-sectional area, resistance index, and spiral artery resistance index with Doppler ultrasound at 1-3 week intervals from gestational (post-menstrual) weeks 5-6 to week 16 in 44 normal, spontaneous, single pregnancies. Uterine artery blood flow volume and velocity increased gradually until the end of week 9, and then rapidly from weeks 10-16. Uterine artery vessel size increased linearly. The uterine artery resistance index was the inverse of volume and velocity, in contrast to the spiral artery resistance index, which decreased linearly. These findings indicate that early pregnancy changes in uterine and spiral artery blood flow occur by different mechanisms, and that when investigating uterine blood flow in early pregnancy, studies need to begin by week 6 and need to be performed at least biweekly.

Effect of standing on non-pregnant uterine blood flow

Uterine artery blood flow measurements made solely in the recumbent position may miss physiological changes that occur while patients are upright. We evaluated the effect of standing on the minute blood flow volume of the ascending uterine artery, the pulsatility index (PI), resistance index (RI) and waveforms and on the PI and RI of the myometrial spiral arteries and waveforms at 3-8 and at 9-14 min standing in 74 non-pregnant women. At 9-14 min, the uterine artery blood flow volume had decreased by an average of 34% and the RI had significantly increased in 70% of subjects. Decreased uterine artery blood flow volume was associated with increased distal resistance and with decreased vessel diameter, possibly due to stretching or kinking of the uterine arteries. Changes in the spiral artery PI paralleled changes in the uterine artery PI at 9-14 min, but were less pronounced. Spiral artery PI and RI were not related to the uterine artery blood flow volume while women were recumbent, although they were significantly related while women were standing. The effects of age, uterine mobility and uterine position on uterine artery or spiral artery blood flow were apparent only while women were standing. We conclude that standing as well as recumbent studies are necessary when uterine and myometrial blood flow are evaluated, and that uterine flow volume per minute should be measured whenever possible.

Relationship of initial chorionic sac diameter to abortion and abortus karyotype based on new growth curves for the 16th to 49th post-ovulation day

In order to determine whether initial chorionic sac diameter is related to subsequent abortion, abortus karyotype, or birth weight and length, chorionic sac diameter was prospectively measured by transvaginal ultrasound in 700 singleton pregnancies before post-ovulation day 31, the latest day cardiac activity becomes detectable in normal pregnancy. Results were compared to values for the 10th to the 90th centiles, determined from 227 measurements of in-vitro fertilization and gamete intra-Fallopian transfer pregnancies. The abortion rate was 23.9% [95% confidence interval (CI) 19.2%, 28.6%] when initial chorionic sac diameter was below the 50th centile, compared to 6.9% (95% CI 4.9%, 9.4%) when equal to or above the 50th centile. Chorionic sac diameter was below the 50th centile in all anembryonic abortions and in 62% of embryonic abortions. Triploidy, trisomy 47 + 16, or trisomy 16 and the presence of satellite bodies on chromosome 22 were the only abortus karyotypes significantly associated with small chorionic sac diameter. Initial chorionic sac diameter was not associated with birth weight or length. We conclude that chorionic sac diameter is decreased in anembryonic and embryonic abortion and that normal pregnancy outcome may be expected in 90-95% of pregnancies in which initial chorionic sac diameter is equal to or above average.

The relationship of initial embryo crown--rump length to pregnancy outcome and abortus karyotype based on new growth curves for the 2-31 mm embryo

The objective of this study was to determine if measurement of initial crown--rump length (CRL) is helpful in predicting low birth weight, newborn length, spontaneous abortions, or abortus karyotype. We measured CRL prospectively in 837 consecutive singleton pregnancies at the time a heart rate was first detectable with transvaginal ultrasonography and compared these measurements to normal values for the 10th through 90th centiles determined from 227 transvaginal ultrasound measurements in in-vitro fertilization and gamete intra-Fallopian transfer pregnancies with known ovulation dates. The relationship of initial CRL to birth weight and length and to abortion and abortus karyotype was analysed after all pregnancies had delivered. Initial CRL measured after the 28th post-ovulation day was predictive of subsequent abortion, but not of low birth weight or length. The abortion rate was 3.3% [95% confidence interval (CI) 1.5%, 5.1%] when initial CRL > or = 50th centile, compared to 19.4% (95% CI 15.4%, 23.4%) when < 50th centile. Initial CRL was < 50th centile in 13 out of 14 trisomic and in eight out of 10 other karyotypically abnormal aborti. These results indicate that initial CRL measured after the 28th post-ovulation day may help to identify pregnancies at increased risk of abortion due to abnormal karyotypes.

Computer analysis of the human embryo growth curve: differences between published ultrasound findings on living embryos in utero and data on fixed specimens

Accurate information on the normal growth rate of the human embryo is fundamental to a better understanding of the embryonic period of pregnancy. Crown-rump length measured previously in utero (N = 227) with vaginal ultrasound in 107 in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) singleton pregnancies was compared to the greatest length of fixed human embryos from the Carnegie collection, of known developmental stage whose postovulatory ages were estimated from menstrual histories. Average crown-rump length in utero was 60% of the greatest length of the fixed specimens prior to postovulation day 33, but were equal after postovulation day 40. The growth rate of in utero embryos and fixed specimens, analyzed by computer using exponential equations, was compared to linear and polynomial equations used in previously published embryo growth tables. The exponential equation, length = exp(a + B/age), fit in utero measurements best, while the equation length = exp[a + b/exp(age)] fit the fixed specimens best. Differences between length in utero and in fixed specimens may be related to distortion of the fixed embryos resulting from the formalin fixation, to ultrasound distortion, to curling of the embryo, or to incorrectly estimated ages of the fixed specimens. Study of human embryos in utero is now practical with vaginal ultrasound.

Relationship of endometrial thickness and pattern to fecundity in ovulation induction cycles: effect of clomiphene citrate alone and with human menopausal gonadotropin

OBJECTIVE

To determine if preovulation endometrial thickness or pattern are related to fecundity and to use of clomiphene citrate (CC) or hMG in IUI.

DESIGN

Prospective ultrasound evaluation the day of hCG after CC alone (n = 197), hMG alone (n = 49), concurrent hMG or sequential CC and hMG (n = 205), and no medications (n = 23).

SETTING

Private fertility clinic.

PATIENTS

Two hundred seventy-one patients undergoing 474 cycles of IUI.

MAIN OUTCOME MEASURES

Endometrial thickness, pattern, per cycle fecundity, and continuing pregnancy.

RESULTS

Endometrial thickness was related to fecundity and continuing pregnancy. No pregnancies occurred when thickness was < 6 mm. The continuing pregnancy rate was 12.6% when thickness was > or = 9 mm, compared with 6.9% when thickness was 6 mm to 8 mm. Endometrial pattern was unrelated to pregnancy. Average endometrial thickness was decreased when hMG and CC were used in combination (7.9 mm) compared with hMG alone (9.4 mm). Endometrial thickness was negatively related to CC dose and positively related to the day of hCG administration by ANOVA.

CONCLUSIONS

Endometrial thickness the day of hCG administration is prognostic of fecundity and continuing pregnancy in cycles of ovulation induction.

Relationship of biochemical pregnancy to pre-ovulatory endometrial thickness and pattern in patients undergoing ovulation induction

In order to assess the relationship between pre-ovulatory endometrial thickness and pattern and biochemical pregnancy, the pregnancy outcome was retrospectively analysed in 81 patients undergoing ovulation induction evaluated by vaginal ultrasound on the day of human chorionic gonadotrophin (HCG) administration or luteinizing hormone (LH) surge. Biochemical pregnancies occurred in 7/32 (21.9%) pregnancies when endometrial thickness was < 9 mm, compared to 0/49 when endometrial thickness was > or = 9 mm on the day of HCG administration or LH surge (P < 0.0025). Clinical abortions occurred in 5/32 (15.6%) pregnancies when endometrial thickness was 6-8 mm, compared to 6/49 (12.2%) when endometrial thickness was 6-8 mm (NS). Endometrial thickness was related to the cycle day of HCG or LH surge (r = 0.37, P < 0.001) but was unrelated to oestradiol level on the day of HCG administration or LH surge (r = 0.12). Biochemical pregnancies were related to endometrial pattern (r = -0.22, P = 0.02) but were unrelated to maternal age or previous abortions. Clinical abortions were related to age (r = 0.26, P = 0.01) and to previous abortion (r = 0.25, P = 0.013) but were unrelated to endometrial pattern. Neither biochemical pregnancy nor clinical abortion was related to oestradiol or LH levels on the day of HCG administration or LH surge. These findings suggest that the majority of biochemical pregnancies do not result from karyotypically abnormal embryos, as do clinical abortions.

Ultrasound evidence for variability in the size and development of normal human embryos before the tenth post-insemination week after assisted reproductive technologies

Differences in human chorionic gonadotrophin (HCG), average chorionic sac diameter, embryo/fetus crown-rump length and biparietal diameter were determined in 107 singleton pregnancies delivered after 34 weeks, whose post-insemination age was precisely known as a result of in-vitro fertilization (n = 28) or gamete intra-Fallopian transfer (n = 79). Crown-rump lengths were interpreted in relation to the developmental stage of the embryo. A 7-fold to 10-fold difference in HCG levels was observed on post-insemination days 13-16. A 2-fold to 3-fold difference occurred in average chorionic sac diameter on days 25-36. A 2-fold difference occurred in crown-rump length on seven of 10 days prior to day 44. Biparietal diameter differed by no more than 42% from day 57-68 and 20% after day 68. Chorionic sac diameter, crown-rump length, and biparietal diameter were also related to newborn weight. The results suggest firstly that marked differences occur in the rate of early human development, secondly, that the differences occur prior to day 27 when observable cardiac activity begins, and thirdly, that the differences are minimized after day 68 when the embryonic period of development is completed.

Sequential clomiphene citrate and human menopausal gonadotrophin for ovulation induction: comparison to clomiphene citrate alone and human menopausal gonadotrophin alone

The need for frequent injections and monitoring, the possibility of multiple gestations, and the higher cost compared to clomiphene citrate, prevents many clinicians from using human menopausal gonadotrophin (HMG) for ovulation induction. A sequential medication regimen, in which HMG is taken after clomiphene, overcomes these problems. We retrospectively compared per cycle fecundity and birth rates in 119 cycles of clomiphene-HMG, 524 cycles of clomiphene alone, 57 cycles of HMG alone, and 79 cycles of concurrent HMG and clomiphene in patients receiving intra-uterine insemination (IUI), who were free of endometriosis or tubal disease. Per cycle fecundity for clomiphene-HMG was 22% [95% confidence interval (CI) 12-34%], double that of clomiphene alone (11%) (95% CI 8-14%) (P < 0.01), and equal to HMG alone (18%) (95% CI 7-29%) or HMG and clomiphene together (19%) (95% CI 10-28%). The multiple birth rate for clomiphene-HMG (7/21) equalled that for HMG alone (3/12) and HMG and clomiphene together (3/8). The average number of ampoules of HMG required [follicle stimulating hormone (FSH) 75 mIU, luteinizing hormone (LH) 75 mIU] was decreased by 65% from 24.5 +/- 1.0 for HMG or HMG and clomiphene together to 8.6 +/- 0.3 for clomiphene-HMG (P < 0.001). Per cycle fecundity was identical when one, two or three ampoules of HMG per day were administered after clomiphene. We conclude that ovulation induction with sequential clomiphene-HMG results in fecundity double that of clomiphene alone and equal to HMG alone or concurrent with clomiphene, thereby reducing the requirement for HMG.

Relationship of first-trimester subchorionic bleeding detected by color Doppler ultrasound to subchorionic fluid, clinical bleeding, and pregnancy outcome

We analyzed retrospectively the incidence of subchorionic fluid and embryonic death in 2116 consecutive patients evaluated with abdominal ultrasound and 783 patients evaluated with vaginal ultrasound. These women were examined during the first 12 postmenstrual weeks and had conceived as a result of infertility treatment. In addition, we analyzed the relationship of subchorionic bleeding to subchorionic fluid in 230 patients evaluated with color Doppler ultrasound and the relationship of subchorionic bleeding to clinical bleeding, precipitating factors, pregnancy outcome, and the karyotypes of abortuses. In single gestational sac pregnancies, subchorionic fluid was found equally often in women scanned with vaginal or color Doppler ultrasound, and less often with abdominal ultrasound (P less than .0001). Embryonic death was increased only in patients with large amounts of subchorionic fluid observed on abdominal ultrasound. Color Doppler ultrasound revealed subchorionic bleeding in 87 of 235 ultrasound scans (37%) and in 48 of 102 patients (47%) when subchorionic fluid was present. Subchorionic bleeding was associated with moderate or large amounts of subchorionic fluid (P = .041), with precipitating events (P less than .0001), and with clinical bleeding (P = .001). It was occult in ten of 48 patients (21%). Embryonic death occurred equally often in women with no fluid and in those with subchorionic fluid, with and without subchorionic bleeding. Abortuses were karyotypically abnormal in an equal proportion of cases with subchorionic bleeding, subchorionic fluid, and no fluid. These findings indicate that subchorionic fluid and subchorionic bleeding are common findings in early pregnancy and are not associated with embryonic death unless they are accompanied by clinical bleeding.

Incidence and significance of unequal gestational sac diameter or embryo crown-rump length in twin pregnancy

The incidence of differences in gestational sac diameter and crown-rump length, measured at the time of the first ultrasound, in which at least one gestational sac or crown-rump length could be visualized, were analysed retrospectively in 260 twin pregnancies in which one or both fetuses were delivered at term. The difference in gestational sac diameter averaged 1.2 +/- 0.1 mm for pregnancies which ended in twin births, compared to 2.0 +/- 0.3 mm when pregnancy ended in single births (P less than 0.02). The difference in crown-rump length averaged 2.4 +/- 0.6 mm for pregnancies which ended in a single birth, compared to 0.9 +/- 0.1 mm for twin births (P = 0.02). Disparities of greater than or equal to 3 mm in gestational sac diameter (P less than 0.05) or crown-rump length (P less than 0.001) were associated with an embryo loss rate greater than or equal to 50%. The disparity in gestational sac diameter (P less than 0.04) and crown-rump length (P less than 0.01) was smaller in pregnancies resulting from assisted reproductive technologies, compared with pregnancies resulting from coitus or insemination. Differences in gestational sac diameter and crown-rump length in early pregnancy were unrelated to differences in birth weight, length or sex.

Relationship of small gestational sac-crown-rump length differences to abortion and abortus karyotypes

We retrospectively reviewed ultrasound findings in 539 infertility patients to evaluate the incidence of small gestational sac syndrome and its association with abortion, karyotype of the abortus, and known abortion factors. Small gestational sac syndrome (gestational sac diameter minus crown-rump length less than 5 mm) occurred in 1.9% of pregnancies scanned with vaginal ultrasound 37-65 days after the first day of the last menstrual period. The rate of fetal death was 80.0% when the gestational sac diameter-crown-rump length difference was less than 5 mm, 26.5% when the difference was 5-7.9 mm (P less than .002 compared with less than 5 mm), and 10.6% when the difference was 8 mm or more (P less than .0001 compared with less than 5 mm). Karyotypes were normal in all eight fetuses when the gestational sac diameter-crown-rump length difference was less than 5 mm (P less than .03). Small gestational sac syndrome was present before fetal death in 10.7% of all cases, and in 24% in which the karyotype was normal. Of the factors analyzed--maternal age, previous abortions, low hCG or progesterone levels, and use of ovulation induction medications--only maternal age was significantly different (P = .011) in patients with small sac syndrome. We conclude that small gestational sac syndrome is an infrequent but important complication of early pregnancy, which occurs more often in karyotypically normal than in abnormal fetuses.

Endometrial pattern and thickness associated with pregnancy outcome after assisted reproduction technologies

The endometrial pattern and thickness was analysed prospectively on the day of administration of human chorionic gonadotrophin (HCG) in 200 in-vitro fertilization (IVF), gamete intra-Fallopian transfer (GIFT) and tubal embryo transfer (TET) cycles. Increasing maturity of the endometrial pattern was positively correlated with oestradiol levels (r = 0.20; P = 0.005), number of mature eggs (r = 0.13; P less than 0.05) and the number of top quality embryos (r = 0.40; P less than 0.001). The endometrial thickness was positively correlated with the number of follicles greater than or equal to 15 mm (r = 0.15; P less than 0.02) and the cycle day on which HCG was administered (r = 0.14; P less than 0.03). It was unaffected by the dose of human menopausal gonadotrophin and was negatively correlated with the use of clomiphene citrate (r = 0.40; P less than 0.001). Fecundity was increased for IVF when the endometrial thickness was greater than or equal to 9 mm (P less than 0.05) and for GIFT and TET when a Type C triple-line endometrial pattern was present (P less than 0.05). Biochemical pregnancies for the combined methods increased from 2.5% of all pregnancies when the endometrial thickness was 9-13 mm, to 27.8% when the thickness was less than 9 mm or greater than 13 mm (P less than 0.01). Biochemical pregnancies occurred in 67% of IVF pregnancies when the endometrial thickness was greater than or equal to 3 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship of follicle number and other factors to fecundability and multiple pregnancy in clomiphene citrate-induced intrauterine insemination cycles

OBJECTIVE

To determine characteristics associated with pregnancy and multiple gestation after clomiphene citrate (CC)-intrauterine insemination (IUI).

DESIGN

Prospective study of all patients undergoing CC-IUI between January 1, 1983 and December 31, 1989.

SETTING

Private fertility clinic.

PATIENTS

Eight hundred forty-nine patients undergoing 1,974 cycles of CC-IUI.

MAIN OUTCOME MEASURES

Relationship between number and size of preovulatory follicles, age, additional infertility diagnosis, medication, and initial semen quality to fecundity, birth, and multiple gestation.

RESULTS

Uncorrected, per cycle fecundity was 7.2%. The number of follicles greater than or equal to 12 mm (r = 0.055, P less than 0.05) was and the number greater than or equal to 15, 18, and 21 mm was not correlated with fecundity. Endometriosis with (P = 0.013) or without (P less than 0.0005) tubal adhesions and tubal adhesions alone (P = 0.005), decreased fecundability by 50%. Initial semen quality did not affect fecundity, unless semen concentration was less than 5 x 10(6)/mL or motility was less than 20%. Multiple pregnancy was not associated with the dose of CC, use of human chorionic gonadotropin, or number of follicles.

CONCLUSIONS

Multiple pregnancy was unrelated to follicle numbers or to CC dose. The highest birth rates after CC-IUI occurred when initial sperm concentration was greater than or equal to 5 x 10(6)/mL, motility was greater than or equal to 20%, and no endometriosis or adhesions were present.

Relationship of follicle number, serum estradiol, and other factors to birth rate and multiparity in human menopausal gonadotropin-induced intrauterine insemination cycles

OBJECTIVE

To determine the characteristics associated with pregnancy and multiple gestation after human menopausal gonadotropin intrauterine insemination (hMG-IUI).

DESIGN

Prospective study of all patients undergoing hMG-IUI between January 1, 1984 and December 31, 1989.

SETTING

University affiliated private clinic.

PATIENTS

Four hundred twenty-four infertility patients undergoing 779 cycles of hMG-IUI.

MAIN OUTCOME MEASURES

The relationship between estradiol (E2), number and size of follicles, age, and initial semen quality on pregnancy and multiple gestations in hMG-IUI cycles.

RESULTS

The number of follicles greater than or equal to 12 mm was correlated with births and predicted all multiple births (r = 0.140, P less than 0.001). The corrected birth rate was 25.8% for age less than 35 and 14.0% for age greater than or equal to 35 when four or more follicles were greater than or equal to 12 mm. The uncorrected clinical pregnancy rate (PR) and birth rate were 12.8% and 10.5%, respectively. Decreased births were associated with tubal adhesions alone (P less than 0.03) or with endometriosis (P less than 0.002), more than four cycles of treatment (P = 0.01), initial sperm count less than 5 x 10(6) per mL (P less than 0.01), initial sperm motility less than 30% (P less than 0.002), and age greater than or equal to 35 (P less than 0.01). Estradiol was correlated with birth rate (r = 0.160, P less than 0.001), which increased from 3.6% when E2 was less than 500 pg/mL to 19.6% when E2 was greater than or equal to 2,500 pg/mL.

CONCLUSIONS

The outcome of hMG-IUI is related to the number of follicles greater than or equal to 12 mm, to E2, and to age. Optimal PRs from hMG-IUI require mild ovarian hyperstimulation.

The probability of multiple births when multiple gestational sacs or viable embryos are diagnosed at first trimester ultrasound

The live birth outcome when multiple gestational sacs were diagnosed at first trimester ultrasound was reviewed in 227 twin, 43 triplet and five quadruplet pregnancies. When two gestational sacs were present, the probability of delivering twins was 63% for maternal age less than 30 and 52% for maternal age greater than or equal to 30. With three gestational sacs, the probability of a triplet birth was 45% for maternal age less than 30 and 18% for maternal age greater than or equal to 30. When two viable embryos were present, the probability of a twin birth was 90% for maternal age less than 30 and 84% for maternal age greater than or equal to 30. With three viable embryos, the probability of a triplet birth was 90% for maternal age less than 30 and 44% for maternal age greater than or equal to 30. Two gestations resulting from ovulation induction with clomiphene citrate were more likely to result in twin delivery at term, compared to spontaneous twin gestations (P = 0.012). These findings may be useful in the treatment and management of patients when multiple gestations are diagnosed early in pregnancy.

Fertilization of human oocytes by microinjection of human sperm aspirated from the caput epididymidis of an individual with obstructive azoospermia

Aspiration of spermatozoa from the caput region of the epididymis was performed, due to obstructive azoospermia. When all inseminated oocytes failed to fertilize in vitro, immotile spermatozoa were microinjected into the perivitelline space to achieve fertilization. Of six oocytes microinjected, one exhibited two normal pronuclei and two polar bodies and was subsequently transferred to a fallopian tube of the wife. One oocyte arrested at syngamy, while two additional oocytes cleaved to four cells each. The remaining two were damaged during microinjection. Although the patient did not conceive, this report provides evidence that (1) spermatozoal motility is not required for successful pronuclear formation when microinjection is performed, and such immotile sperm are not necessarily "dead," and (2) this further corroborates that caput epididymal spermatozoa can participate in the subzonal events of fertilization and that, in the human, exposure of spermatozoa to the distal epididymal milieu may not be a requisite to achieve fertilizing capacity.

The occurrence of ectopic pregnancy with and without clomiphene citrate use in assisted and nonassisted reproductive technology

An eleven-year review of treatment records of patients who became pregnant as a result of infertility treatment (n = 3692) was conducted. All records were examined to determine whether clomiphene citrate (CC) was used in the cycle of conception and whether or not an ectopic pregnancy occurred. Data were additionally analyzed for the incidence of ectopic pregnancy with and without assisted reproductive technology (ART). The incidence of ectopic pregnancy was similar between CC (3.4%) and non-CC (3.4%) treatment groups receiving non-ART treatment. For non-ART treatments, tubal disease and severe endometriosis resulted in an increase in ectopic pregnancies independent of CC use. The incidence of ectopic pregnancy in patients receiving CC + human menopausal gonadotropin (hMG) for in vitro fertilization (5.4%) and gamete intrafallopian transfer (3.1%) was similar compared to ART treatments with hMG alone. The incidence of ectopic pregnancy was more closely associated with infertility diagnosis rather than CC use.

Pregnancies established by gamete intrafallopian transfer and pronuclear-stage transfer in patients with premature ovarian failure using donated oocytes and low-dose oral micronized estradiol and progesterone

This report describes both gamete intrafallopian transfer (GIFT) and pronuclear-stage transfer (PROST) of donated oocytes to patients with premature ovarian failure (POF), using micronized oral progesterone (P4) and low-dose micronized estradiol (E2) for endometrial preparation and maintenance. Patient A, with POF of 15 years' duration, received four donated oocytes for GIFT and subsequently delivered a normal, term, female infant. Patient B was diagnosed as POF 3 years ago. She received four donated oocytes, which were subsequently fertilized in vitro with husband's sperm. The following day, four pronuclear-stage embryos were transferred to her fallopian tubes. She recently delivered twin, healthy female infants. These procedures, along with exogenous hormonal development of the endometrium, provide a simplified means to establish and maintain pregnancy in POF patients. Both patients were maintained on low-dose micronized E2 prior to their procedure, Patient A on 3 mg E2 per day cyclically and Patient B on 0.5 mg E2 continuously. Micronized oral P4 was used to maintain pregnancy.

Outcome in 242 in vitro fertilization-embryo replacement or gamete intrafallopian transfer-induced pregnancies

Two centers combined data on 152 in vitro fertilization embryo replacement and 90 gamete intrafallopian transfer generated pregnancies. The outcomes of the pregnancies with respect to abortion, ectopic gestation, and multiple gestation were evaluated independently by method and by center. Only with multiple gestation by center was a difference seen. Variables examined included estradiol levels, luteal phase support, maternal age, and prior reproductive history, and the number of eggs or embryos replaced.