Assisted reproductive technology in the United States: 2001 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology registry

OBJECTIVE

To summarize the procedures and outcomes of assisted reproductive technologies (ART) that were initiated in the United States in 2001.

DESIGN

Data were collected electronically using the Society for Assisted Reproductive Technology (SART) Clinic Outcome Reporting System software and submitted to the American Society for Reproductive Medicine/SART Registry.

PARTICIPANT(S)

Three hundred eighty-five clinics submitted data on procedures performed in 2001. Data were collated after November 2002 [corrected] so that the outcomes of all pregnancies would be known.

MAIN OUTCOME MEASURE(S)

Incidence of clinical pregnancy, ectopic pregnancy, abortion, stillbirth, and delivery.

RESULT(S)

Programs reported initiating 108,130 cycles of ART treatment. Of these, 79,042 cycles involved IVF (with and without micromanipulation), with a delivery rate per retrieval of 31.6%; 340 were cycles of gamete intrafallopian transfer, with a delivery rate per retrieval of 21.9%; 661 were cycles of zygote intrafallopian transfer, with a delivery rate per retrieval of 31.0%. The following additional ART procedures were also initiated: 8,147 fresh donor oocyte cycles, with a delivery rate per transfer of 47.3%; 14,509 frozen ET procedures, with a delivery rate per transfer of 23.5%; 3,187 frozen ETs employing donated oocytes or embryos, with a delivery rate per transfer of 27.4%; and 1,366 cycles using a host uterus, with a delivery rate per transfer of 38.7%. In addition, 112 cycles were reported as combinations of more than one treatment type, 8 cycles as research, and 85 as embryo banking. As a result of all procedures, 29,585 deliveries were reported, resulting in 41,168 neonates.

CONCLUSION(S)

In 2001, there were more programs reporting ART treatment and a significant increase in reported cycles compared with 2000.

A prospective study of the effects of female and male marijuana use on in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT) outcomes

OBJECTIVE

This study was undertaken to examine whether marijuana use affects in vitro fertilization and gamete intrafallopian transfer (IVF/GIFT).

STUDY DESIGN

Prospective study of 221 IVF/GIFT couples.

RESULTS

Amount of lifetime heavy marijuana use adversely affected IVF/GIFT. Women smoking more than 90 times in their lifetime had 27% fewer oocytes retrieved (P = .03) and 1 fewer embryo transferred (P < .05). Women smoking marijuana more than 10 times in their lifetime had infants 17% (P = .01) smaller at birth. If men smoked marijuana 11 to 90 times in their lifetime, there was a 15% decrease in infant birth weight (P = .03); if this increased to more than 90 times, there was a 23% decrease (P = .01). Timing also played a role. Women smoking marijuana 1 year before IVF/GIFT had 25% fewer oocytes retrieved (P = .03), whereas couples had 28% (P = .04) fewer oocytes fertilized. Women and men who smoked in the past 15 years, had 12% (P = .04) and 16% (P = .03) smaller infants, respectively.

CONCLUSION

Both timing and amount of marijuana use negatively affected IVF/GIFT.

Ethnic background and in vitro fertilization outcomes

OBJECTIVE

To compare IVF outcomes among women of different ethnic backgrounds.

METHOD

This was a retrospective cohort study. Between August 1994 and March 1998, the first IVF cycles of 1039 white, 43 African American, 18 Hispanic, and 35 Asian women were examined.

RESULT

Ages and day 3 FSH levels did not differ significantly among patients. African Americans weighed more than other ethnic groups and were also more likely to have tubal factor infertility than whites. IVF cycle characteristics did not vary among the ethnic groups with the exception that African Americans had a higher level of estradiol on day of HCG than whites. Pregnancy outcomes did not differ among the ethnic groups. The percentage of ectopic pregnancies, spontaneous abortions, and successful live births was similar among the groups.

CONCLUSION

Our data showed no significant difference in pregnancy outcomes with IVF among the ethnic groups.

Pregnancy complications, obstetric risks, and neonatal outcome in singleton and twin pregnancies after GIFT and IVF

PURPOSE

In vitro fertilization (IVF) and to a lower extent gamete intra-fallopian transfer (GIFT) have become routine infertility treatments in industrialized countries. Our purpose is to compare the obstetric and neonatal characteristics of singleton and twin pregnancies after GIFT and IVF with those conceived spontaneously.

METHODS

This case-control study was conducted in a tertiary care medical center. The 322 singleton and 78 twin pregnancies after GIFT or IVF from 1991 through 1996 were evaluated and compared with each other, and with a control group that conceived spontaneously and matched for parity, maternal and gestational age. Statistical significance of differences was assessed by chi(2) test or two-tailed Fisher exact test. Continuous variables were compared by the paired t-test.

RESULTS

Pregnancy-induced hypertension (PIH) and vaginal bleeding were significantly more frequent maternal complications in the GIFT/IVF singleton groups compared to controls. In twin pregnancies the rate of cesarean sections, vaginal bleeding and preterm labor were more common after GIFT/IVF but did not reach statistical significance. Assisted reproduction was associated with low birth weight only in twin pregnancies when controlled for confounding variables, however perinatal outcome was comparable. There was no significant difference in the outcome measures between GIFT and IVF pregnancies.

CONCLUSION

After controlling for parity, maternal and gestational age, singleton pregnancies conceived by GIFT/IVF are at increased obstetrical risk, however the perinatal outcome is comparable despite a lower average birth weight.

Assisted reproductive technology in the United States: 1999 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry

OBJECTIVE

To summarize the procedures and outcomes of ART initiated in the United States in 1999.

DESIGN

Data were collected electronically by using the SART Clinical Outcome Reporting System software and submitted to the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry.

PARTICIPANT(S)

Three hundred sixty programs submitted data on procedures performed in 1999. Data were collated after November 2000 so that the outcome of all pregnancies established would be known.

MAIN OUTCOME MEASURE(S)

Incidence of clinical pregnancy, ectopic pregnancy, abortion, stillbirth, and delivery.

RESULT(S)

Programs reported initiating 88,077 cycles of ART treatment. Of these, 63,639 cycles involved IVF (with and without micromanipulation), with a delivery rate per retrieval of 29.4%; 838 were cycles of gamete intrafallopian transfer, with a delivery rate per retrieval of 27.9%; 945 were cycles of zygote intrafallopian transfer, with a delivery rate per retrieval of 29.8%. The following additional ART procedures were also initiated: 6,509 fresh donor oocyte cycles, with a delivery rate per transfer of 41.8%; 12,005 frozen embryo transfer procedures, with a delivery rate per transfer of 18.6%; 2,488 frozen embryo transfers using donated oocytes or embryos, with a delivery rate per transfer of 23.6%, and 821 cycles using a host uterus, with a delivery rate per transfer of 33.6%. In addition, 398 cycles were reported as combinations of more than one treatment type, 18 cycles as research, and 416 as embryo banking. As a result of all procedures, 21,904 deliveries were reported, resulting in 30,967 neonates.

CONCLUSION(S)

In 1999, more programs reported ART treatment and reported cycles increased significantly (7.5%) compared to 1998. In comparable cycle types, the overall success rate (deliveries per retrieval) increased by 0.4%, which represents an increase of 1.2% compared to the success rate for 1998.

A minimally monitored assisted reproduction stimulation protocol reduces cost without compromising success

OBJECTIVE

To determine if a fixed-dose stimulation protocol with monitoring limited to a single ultrasound can provide acceptable outcomes in assisted reproduction technologies (ART) procedures in appropriately selected patients.

DESIGN

Prospective study of all minimally monitored ART cycles from 1996 through 1998.

SETTING

University ART program.

PATIENTS

Eligibility included Institutional Review Board consent, age 18-37, basal FSH < or = 10, normal semen parameters, and regular menses. IVF (n = 81) and GIFT (n = 14).

INTERVENTIONS

A single ultrasound was performed after 8 or 9 days of stimulation in a fixed-schedule long luteal phase leuprolide protocol. No hormone levels were obtained. Human chorionic gonadotropin was administered when at least 2 follicles were projected to reach 18 mm.

MAIN OUTCOME MEASURES

Pregnancy, delivery, and implantation rates.

RESULTS

The clinical pregnancy rates were 51% for IVF and 36% for GIFT. Delivery rates were 42% for IVF and 29% for GIFT. The implantation rates for IVF were 23% and 17% for GIFT. No patient was admitted for ovarian hyperstimulation.

CONCLUSIONS

We were able to achieve satisfactory pregnancy and delivery rates in properly selected patients with a minimal monitoring protocol, limited to a single ultrasound near the end of a fixed-stimulation regimen. The reduced time commitment and cost led to a very high patient acceptance of this approach.

A one-year experience with a capitated health care plan for infertility

OBJECTIVE

To report on a one-year experience participating in a capitated healthcare plan for infertility.

DESIGN

Prospective study.

SETTING

University population.

PATIENT(S)

Reproductive-age women 15 to 50 years.

INTERVENTION(S)

The first-generation Lewin infertility algorithm and CATHI software were used to negotiate infertility services under a capitated arrangement for $0.50 per member per month. The following reports our experience for the fiscal year 1997.

MAIN OUTCOME MEASURE(S)

Infertility services rendered, pregnancy rate, cost of services, collection rates.

RESULT(S)

Five thousand forty-six women representing 39,689 member months generated 39 new and 198 return visits. Thirty-two percent of the patients required three visits or less; six patients generated 22% of the visits. Fifty-one percent listed infertility as one of their chief complaints; 31% had mixed diagnoses. Eight (7.6%) patients required surgery, 11 (10.5%) patients underwent either IVF or GIFT cycles. Total charges submitted were $176,636; the amount assigned to specialty care was $135,277, and to IVF/GIFT, $33,433. Total capitated payments, including copayments, was $126,256 under the reproductive medicine agreement and $32,891 under the infertility rider. This resulted in a 71% gross collections rate.

CONCLUSION(S)

This study indicates that entering into a capitated health care plan to provide an infertility benefit can produce a successful result.

[The influence of infertility treatment and assisted reproduction techniques on multiple pregnancy rates]

It has to be remembered that pregnancies resulting from assisted reproductive technologies are more complicated that spontaneous pregnancies. There are higher rates of spontaneous abortions, ectopic, and multiple pregnancies. This work summarizes the latest year's experiences from the best world's clinics with multifetal pregnancy incidence in assisted reproductive technologies programs.

Anaesthesia for assisted conception: a survey of UK practice

A telephone survey was undertaken of all UK centres (total 70) licensed for performing in vitro fertilization (IVF) and gamete intra-fallopian transfer (GIFT) by the Human Fertilisation and Embryology Authority (HFEA). The survey was carried out during the months of November and December 1997. Thirty-seven (52.1%) centres were in the NHS sector and 33 (47.8%) in the private sector. A response was available from 60 (84%) centres. A standard questionnaire was used which requested information about the procedures carried out, anaesthetic technique and pharmacological agents used. Forty-seven centres carried out IVF, two centres GIFT and 11 centres both. Out of 58 centres carrying out IVF, sedation was used in 28, general anaesthesia in 17, sedation combined with regional anaesthesia in seven and regional anaesthesia in one. Five centres gave a choice. Out of 22 centres using general anaesthesia for IVF, 12 used inhalational agents (isoflurane eight, enflurane four, sevoflurane two), eight used total intravenous anaesthesia (TIVA) with propofol and two centres inhalational agents or TIVA. Propofol was the induction agent in all but two centres. For IVF under sedation, 18 centres used midazolam, five used diazepam, three used opioids, one used entonox and the remaining ones a combination. When sedation was combined with regional anaesthesia, four centres used midazolam, two used propofol, one used midazolam with propofol, one used opioids and one used entonox. The regional technique in the 11 centres was either paracervical block with lignocaine (eight) or subarachnoid block with bupivacaine (three). Systemic analgesia was secured with fentanyl (22), pethidine (16), alfentanil (15), diclofenac (14), piroxicam (two), ketorolac (one) and ibuprofen (one). Five centres did not use any opioids; 40 centres did not use any nonsteroidal agents (NSAIDs). Out of the 13 centres that carried out GIFT, 12 used general anaesthesia while the thirteenth gave the patient a choice between general or regional anaesthesia. 11 centres used inhalational agents (isoflurane nine, enflurane two) while two used TIVA with propofol; propofol was the induction agent used in six centres while thiopentone was used in five. The range of analgesics was wide--fentanyl in six centres, alfentanil in three, morphine in two, diclofenac in five and ketorolac in one. Two centres did not use any opioids and seven centres did not use an NSAID. The only agreement at present appears to be that halothane is an unwise choice for IVF. No other technique has yet been proven to be either advantageous or detrimental.

Age-related pregnancy rates in GIFT patients

OBJECTIVE

Fecundity and fertility decline with increasing age beginning as early as age 30 and decrease more precipitously after age 40. The purpose of this study was to determine if pregnancy rates of patients attempting gamete intrafallopian transfer (GIFT) are lower for women between the ages of 35 and 40.

METHODS

A retrospective chart review was performed to assess the age-specific pregnancy rates for patients in our GIFT program. We report the results of GIFT at Walter Reed Army Medical Center and the National Naval Medical Center during the period from July 1, 1994, to July 1, 1995.

RESULTS

Fifty-six women aged 21 to 39 underwent one to three cycles of gamete intrafallopian transfer. The 72 tubal transfers performed resulted in 25 pregnancies (34.7% pregnancy rate per transfer).

CONCLUSIONS

In this series, pregnancy rates did not differ significantly in women older than 35 years versus women younger than 35 years. The number of eggs collected decreased significantly with increasing age but was not significantly different between pregnant and nonpregnant patients. Previous reports demonstrate a clear decline in fertility and poor pregnancy rates with assisted reproductive technology in older women. We did not find age-related differences in pregnancy rates among women younger than 40 years undergoing GIFT during the period studied.

The influence of advanced age on the outcome of assisted reproduction

PURPOSE

Our purpose was to determine the influence of age on the outcome of assisted reproduction, with particular interest in women aged 40 years or older.

METHODS

A retrospective review of the 779 patients enrolled in the Royal Hospital for Women Fertility Group fertility program between 1987 and 1994 was performed. The results for women aged 40 years or older were compared with those for women between 36 and 39 years and those younger than 36 years. The main outcome measures were pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response.

RESULTS

Compared with those in younger women, pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response to controlled ovarian stimulation were significantly worse in women aged 40 years or older.

CONCLUSIONS

The outcome of assisted reproduction in women of 40 years of age or older was extremely poor. Compared with those in younger women, pregnancy outcome and ovarian response to controlled ovarian stimulation were significantly worse in women of 40 years or more.

Assisted reproductive technology in the United States and Canada: 1995 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry

OBJECTIVE

To summarize the procedures and outcomes of assisted reproductive technology (ART) initiated in the United States and Canada in 1995.

DESIGN

Data were collected in the Society for Assisted Reproductive Technology database program and cycle reporting forms and were submitted to the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry.

PARTICIPANT(S)

Two hundred eighty-one programs submitted data on procedures performed in 1995. Data were collected after November 1996 so that outcome of all pregnancies established would be known.

MAIN OUTCOME MEASURE(S)

Procedural outcomes measured included clinical pregnancy, ectopic pregnancy, abortion, stillbirth, delivery, and congenital abnormality.

RESULT(S)

Programs reported initiating 59,142 cycles of ART treatment, including frozen embryo and donor oocyte cycles. Of these, 41,087 cycles initiated were IVF (with and without micromanipulation) with 22.5% deliveries per retrieval; 3,741 were cycles of gamete intrafallopian transfer with 27.0% deliveries per retrieval; 1,078 were cycles of zygote intrafallopian transfer with 27.9% deliveries per retrieval. In addition to these cycles initiated in 1995, 8,453 frozen embryo thaw procedures were reported, either as separate procedures or in combination with other ART procedures with 15.2% deliveries per transfer, 3,555 donor oocyte cycles were initiated with an overall success of 36.0% deliveries per transfer, 1,028 cryopreserved embryo thaw procedures from donated oocyte procedures with an overall success of 16.8% deliveries per transfer, and 200 ART treatment cycles in which a host uterus was used were initiated with an overall success of 34.9% deliveries per ET. As a result of all procedures, a total of 11,631 deliveries were reported, resulting in 16,520 neonates.

CONCLUSION(S)

In 1995, there were more programs reporting ART treatment and a significant (19.3%) increase in reported cycles. In comparable cycle types, overall average success rates (deliveries per transfer) exhibited a 0.6% increase or a 2.5% increase over the rates in the 1994 reported summaries.

Secondary donation of frozen embryos is more common after pregnancy initiation with donated eggs than after in vitro fertilization-embryo transfer and gamete intrafallopian transfer

OBJECTIVE

To determine the availability of donated cryopreserved embryos.

DESIGN

Retrospective review.

SETTING

Community hospital-based donor oocyte program.

PATIENT(S)

Eighty-nine consecutive infertile couples and women who had 94 sets of embryos cryopreserved after pregnancy initiation with unfertilized donated eggs between January 1, 1991 and December 31, 1996.

INTERVENTION(S)

Cryopreservation of fertilized ova or cleaving embryos.

MAIN OUTCOME MEASURE(S)

Disposition of frozen embryos as of June 1, 1997.

RESULT(S)

Of the 94 sets of frozen embryos, 52 (55.3%) were thawed into the original recipient. At an average of 30 months since the treatment cycle, 26 (27.7%) sets of embryos remain in storage. Of the 16 sets of embryos not thawed for transfer, 11 sets (11.7%) were donated and 5 sets (5.3%) were destroyed. The fraction of spare embryos donated was much higher after pregnancy initiation with unfertilized donated eggs than after IVF-ET and GIFT (68.8% versus 19.1%, respectively).

CONCLUSION(S)

Couples and women who did not use their frozen embryos after pregnancy initiation with unfertilized donated eggs were twice as likely to donate them as to have them destroyed. Secondary donation of cryopreserved embryos was much more common after pregnancy initiation with unfertilized donated eggs than after standard IVF-ET and GIFT.

Treatment of endometriosis-associated infertility

The choice of treatment options for endometriosis-associated infertility has been both controversial and complex, largely because of lack of data. In the last 10 years, better data from numerous studies with improved design support laparoscopic ablation and/or resection of lesions as the most successful for both minimal/mild and moderate/severe/extensive disease. Laparotomy should be performed when necessary. Observation alone is sometimes indicated in young women with minimal/mild disease. Hormonal suppression has no identifiable role, except perhaps for severe/extensive disease, before IVF or GIFT. Ovarian stimulation with clomiphene or gonadotropins and concomitant intrauterine insemination is indicated for minimal/mild disease. IVF and GIFT are often best for those who have failed other treatments, have advanced age, prolonged infertility, and/or multiple-factor infertility.

Success rates with gamete intrafallopian transfer and in vitro fertilization in women of advanced maternal age

OBJECTIVE

To evaluate the effect of maternal age on outcomes for IVF and GIFT in women 40 to 45 years of age.

DESIGN

Retrospective.

SETTING

Boston IVF, a free-standing university-affiliated IVF and GIFT unit.

PATIENTS

A total of 2,931 cycles of IVF and 1,826 cycles of GIFT were analyzed in women undergoing assisted reproductive technologies (IVF or GIFT) using autologous eggs.

INTERVENTIONS

Medical records of patient outcomes were reviewed.

RESULTS

For patients undergoing IVF, the cancellation rate for initiated cycles showed significant differences in women aged 25 to 39 (38.3%), women aged 40 to 43 (49.5%), and women aged 44 to 45 years (69.5%). A significantly lower delivery rate per stimulation and delivery rate per retrieval was found in women aged 40 to 43 years when compared with women aged 25 to 39 years. No deliveries occurred in 59 cycles in women aged 44 to 45 years, thereby representing a significant difference when compared with both women aged 25 to 39 years and women aged 40 to 43 years. For patients undergoing GIFT, the cancellation rate for initiated cycles was significantly higher in women aged 40 to 43 (25.0%) and 44 to 45 years (31.0%) when compared with women aged 25 to 39 years (15.1%). A significantly lower delivery rate per stimulation and delivery rate per retrieval was found in women aged 40 to 43 and 44 to 45 years when compared with women aged 25 to 39 years.

CONCLUSIONS

Success rates for IVF and GIFT decline significantly in women > 40 years old. Women aged > or = 44 years are unlikely to benefit from the use of IVF and GIFT.

In vitro fertilisation and gamete intrafallopian transfer: an integrative analysis of research, 1987-1992

OBJECTIVE

To provide a statistically integrated analysis and review of all published outcome studies of in vitro fertilisation (IVF) and gamete intrafallopian transfer (GIFT) occurring in English language journals between 1987 and 1992; to provide information regarding outcome of assisted reproduction not otherwise available from national registers; and to assess correspondence of these outcomes with outcome data presented in the national registers of the Fertility Societies of Australia and the United States.

DESIGN

Computer literature review and manual search of major infertility journals to identify all papers reporting clinical pregnancy rates for IVF and GIFT. A secondary analysis of three factors, including 1. treatment (IVF vs GIFT), 2. stimulation protocol [combinations using clomiphene citrate (CC), combinations using gonadotrophin agonists (GnRHa), and combinations using neither clomiphene citrate nor gonadotrophin agonists, (designated by the symbols and acronyms approximately CC approximately GnRHa throughout this article)], and 3. cause of infertility, assessed their impact upon three clinical pregnancy rates: 1. cycles commenced, 2. cycles reaching retrieval and 3. cycles reaching oocyte/embryo transfer, via a series of one-way analyses of variance with either planned contrasts or post hoc comparisons.

SUBJECTS

The unit of observation was the published study. Data were obtained from 31 journals and 216 papers, containing 509 samples and 39,754 per cycles commenced. Data from the national registers of the Fertility Societies of Australia and the United States were used for comparison of literature-based outcomes, where appropriate.

RESULTS

The concordance between the outcomes reported in the national registers of Australia and the United States and the amalgamated literature-based data was such that cautious confidence was placed in the results of the subsequent analyses of the literature-based data which provided information not otherwise available. GIFT resulted in significantly more clinical pregnancies than IVF for each stage of the treatment cycle. Differences in pregnancy rates between IVF and GIFT were 8.6% more pregnancies for GIFT for cycles commenced, 14.2% for cycles reaching retrieval, and 7.5% for cycles reaching oocyte or embryo transfer. Stimulation protocols using gonadotrophin agonists (GnRHa) resulted in more clinical pregnancies than protocols using clomiphene citrate for each stage of the treatment cycle: from commencement (10.22%), to retrieval (8.36%), and to transfer (9.36%). Interaction effects indicated that GIFT-GnRHa combinations were superior to IVF-clomiphene citrate combinations for all rates. For cycles reaching retrieval and transfer, GIFT-GnRHa resulted in significantly more clinical pregnancies than IVF-GnRHa. GIFT-clomiphene citrate was better than IVF-clomiphene citrate and IVF-GnRHa was better than IVF-clomiphene citrate. Women with endometriosis (Stages I or II) achieved higher rates of clinical pregnancy than participants with other causes of infertility.

CONCLUSIONS

Significantly higher pregnancy rates for GIFT and GnRHa were demonstrated in this study. It was argued that since the differences in clinical pregnancy rates were smaller between IVF and GIFT when a GnRHa protocol was employed, the apparent superiority of GIFT may in fact be due, at least in part, to GnRHa. This question needs further prospective investigation. Women with endometriosis (Stage I or II) achieved higher pregnancy rates than those with other causes of infertility. Overall, this study provides confirmation that well-held clinical conclusions have a true basis in the published literature and that the published literature reflects population data reported in national registers. Further prospective research is needed to clarify the unique probabilities of a live birth for individual couples.

Singleton and twin confinements associated with infertility treatments

A cross-sectional sample of 150 singleton and 159 twin confinements delivered in Western Australia in 1991 were randomly sampled in 1993; 63% of the women responded to a postal questionnaire. Thirteen percent of respondents with singletons and 26% of those with twins reported having problems conceiving at some stage in their life. Six percent of those who had singleton confinements and 22% of those women who had twin confinements sought fertility advice prior to the conception of the index pregnancy. One percent (95% CI 0.03%, 5.5%) of women with singletons received infertility treatment compared with 17% (95% CI 10.4%, 26.3%) of those with twins. Overall 82.7% (95% CI 75.2%, 90.1%) of twin confinements followed spontaneous conception, 11.2% (95% CI 5.7%, 19.2%) followed ovarian stimulation treatment alone and 6.1% (95% CI 2.3%, 12.9%) followed IVF or GIFT procedures. The probability of a spontaneous twin confinement was 1 in 95. It was concluded that nearly twice as many twin pregnancies were associated with ovarian stimulation treatment given alone than with IVF and GIFT combined. The routinely collected data about assisted twin conceptions provide an incomplete picture with regard to the role of different infertility treatment modalities.

Appraisal of gamete intrafallopian transfer

OBJECTIVE

To collect results of gamete intrafallopian transfer on a large scale in order to compare treatment indications, results, and factors which influence the success rates; to evaluate whether gamete intrafallopian transfer is well-established and what the real place of this procedure is among other assisted reproduction techniques.

DESIGN

Data relating to gamete intrafallopian transfer were collected from World Reports, national registries of different countries and meta-analysis of medical publications during the years 1986-1991.

SUBJECT

Official registries reported 47,200 treatment cycles and 18,759 treatment cycles were analysed from ten medical publications.

RESULTS

The procedure accounts for 13.5% of all assisted reproduction techniques but its popularity varies significantly among countries. The same indications for gamete intrafallopian transfer are followed by all countries, but great differences exist with regard to the proportional share of each etiology. Also, the share has changed considerably over the years. TREATMENT OUTCOME: 10,667 clinical pregnancies were reported which represent 24% of treatment cycles and 29% of ovum pick-up. The live birth rate was 23.3%; abortion rate, 22%; and ectopic pregnancy rate, 5.5%. The stillbirth rate was 2.3% and the malformation rate was 2.8%, not confined to specific organs or systems. There were 19.5% twins, 4.6% triplets and 0.3% quadruplets or more. The number of transferred oocytes influenced pregnancy rates: 28% for transfer of four oocytes and only 10% following transfer of one oocyte. The cause of infertility might influence the results and the poorest results are obtained for male factor infertility. In most cases correlation of success rates reported by leading units through medical publications closely resembles the overall national registries results. Indications for this treatment were broadened over the years, but its role among other assisted reproduction technologies is not agreed upon, especially for male factor and unexplained infertility.

CONCLUSIONS

Gamete intrafallopian transfer carries an overall higher pregnancy rate than in vitro fertilization. Quality control by professional or public associations should be established and more research employed over indications for treatment and results in order to establish when GIFT is the treatment of choice and when other modes of treatment should be preferred.

Transcervical tubal transfer of gametes and embryos

The benefit of intrafallopian transfer techniques is still disputable in assisted reproductive techniques. On this background, alternatives to laparoscopic transfer procedures are in development. Current transcervical intrafallopian transfers of gametes and embryos are lacking success and reproducibility of results. New developments in catheter techniques and optical systems are offering new concepts for more successful transcervical approaches and preparing the basis for truly prospective studies.

GIFT, ZIFT, and related techniques

This review focuses on the theoretical backgrounds for tubal gamete and zygote/embryo transfer, as well as the clinical results of gamete intrafallopian transfer (GIFT), which are compared with other non-fertilization procedures in infertile women with patent fallopian tubes. While GIFT and zygote intrafallopian transfer (ZIFT) probably result in a more synchronized entry of embryos into the uterine cavity, prospective, randomized studies have not shown these methods to be preferable to conventional in-vitro fertilization and embryo transfer. Nevertheless, co-culture with various cell types seems to yield more viable embryos with a high rate of implantation. The promising results with co-culture do not seem to be a cell- or species-specific phenomenon. This non-specific positive or negative conditioning effect of co-culture on embryo quality indicates that more optimal culture media for in-vitro fertilization can probably be devised. The requirements of laparoscopy and general anesthesia with GIFT have prompted the development of simpler methods based on fertilization in vivo. Various methods of artificial insemination combined with controlled ovarian hyperstimulation yield comparable results with GIFT in unexplained infertility. In endometriosis, GIFT seems to give better results compared with insemination techniques. Less invasive transcervical gamete and embryo transfer techniques have now been established, obviating the need for operating theater facilities.

Gamete intrafallopian transfer. An overview

Gamete intrafallopian transfer involves a direct transfer of both human gametes, sperm and oocytes, into the fallopian tube. Since the first report of a successful pregnancy following the use of this technique by Asch et al in 1984, its role in the treatment of infertile women with patent tubes has been established. Recent data demonstrate a 34.4% clinical pregnancy rate, with the highest pregnancy rate achieved in infertile women due to endometriosis or unexplained infertility.

The likelihood of pregnancy with IVF and GIFT in Australia and New Zealand

OBJECTIVE

To determine the likelihood of pregnancy for couples entering the New Reproductive Technology (NRT) programs in Australia and New Zealand, by combining the data from nearly all the practising units.

DESIGN

All units practising in-vitro fertilisation (IVF) and/or gamete intrafallopian transfer (GIFT) were contacted and asked to provide data on patients treated and pregnancy rates. These figures were then combined to produce life tables to determine the likelihood of pregnancy with repeated attempts.

SETTING

IVF/GIFT units in five States of Australia, the Australian Capital Territory and New Zealand. Eighteen of the 22 units provided data to be analysed.

PATIENTS

Data were available for analysis on 18,089 cycles of IVF resulting in 3034 clinical pregnancies, and 6308 cycles of GIFT resulting in 1724 clinical pregnancies.

MAIN OUTCOME MEASURES

This was either "clinical pregnancy" (the presence of products of conception on ultrasound examination), or "viable pregnancy" (a pregnancy developing to at least 20 weeks of gestation).

RESULTS

After four attempts at IVF, half the couples achieved a pregnancy, whereas four attempts at GIFT resulted in two-thirds of the couples achieving pregnancy.

CONCLUSION

Both IVF and GIFT are effective and successful options for infertile or subfertile couples. New Reproductive Technology should be readily available in every advanced clinic dealing with subfertile couples in the 1990s.

Heterotopic pregnancy associated with gamete intra-fallopian transfer

Recent reports in the literature have focused on the increased risk of heterotopic pregnancy after the transfer of multiple concepti or oocytes. In an international collaborative patient registry between 1985 and 1989, 601 clinical pregnancies resulted from 2092 gamete intra-Fallopian transfer (GIFT) retrieval cycles. Five of the pregnancies were heterotopic (0.83%). After surgical intervention, all five cases of combined gestation resulted in live birth from intrauterine pregnancies. Routine vaginal ultrasonographic examination of the adnexa in patients who conceive after GIFT may help early diagnosis of heterotopic pregnancy. If the diagnosis is made early, conservative treatment may preserve the future fecundity of the patient and more intrauterine pregnancies may be salvaged.

The efficiency and efficacy of IVF and GIFT

Data relating to the rate of clinical pregnancy obtained with in-vitro fertilization--embryo transfer (IVF-ET) and gamete intra-Fallopian transfer (GIFT) are available for Australia, UK, USA and France. For IVF-ET the value is not affected by the indication but is affected by the age of the woman. The rate of spontaneous abortion, at approximately 20-25% also increases with age and is an important consideration in view of the increased age of patients undergoing IVF-ET. A take-home baby rate of 30% is obtained from an estimated 70% of clinical pregnancies leading to live births and an estimate of 42.8% pregnancies after three attempts. The greater number of oocytes transferred with GIFT may be associated with the increased frequency of multiple pregnancies.

Alternatives to IVF: the outcome of 1071 first GIFT procedures

Gamete intra-Fallopian transfer (GIFT) is the most important treatment method for infertile couples that has been developed since in-vitro fertilization and embryo transfer (IVF/ET) became available. Analysis of the data of 1071 first GIFT procedures is presented and the predominant factors affecting success are discussed. An overall pregnancy rate of 33.6% was achieved in this group of patients who were unselected in relation to age, number of oocytes transferred, quality of sperm and response to ovulation induction. The success of GIFT is dependent upon the number and quality of oocytes transferred and upon the quality of the sperm. Pregnancy occurred in 21.4% of patients receiving up to four oocytes compared with 40.3% in whom five or more were transferred. Multiple pregnancy rates however were 17.3% in the first group and 32.3% in the second group. Age is a major factor influencing the chances of success with patients less than 30 years of age achieving a 40.2% pregnancy rate reducing to 19.2% in the over 40 group. Conversely the spontaneous abortion rate increased from 23.4% in the under 30 group to 48.6% in those over 40 years of age. No pregnancies were achieved when sperm motility was less than 20% in the original specimen, whereas pregnancy rates of up to 20% resulted when sperm density was below 10 million. The overall results of this study show comparable success rates for different causes of infertility and that there is a definite association between the outcome of treatment and the number and quality of gametes transferred. A philosophy of flexibility in the treatment of infertile couples is advocated.

Gamete intrafallopian transfer vs superovulation with intrauterine insemination for the treatment of infertility

Superovulation with intrauterine insemination (SO-IUI) has been suggested as an alternative to gamete intrafallopian transfer (GIFT), despite the absence of controlled or comparative trials. We retrospectively analyzed all GIFT and SO-IUI cycles performed concurrently from January 1985 to August of 1987 at a single university center. Pregnancy rates were significantly better for GIFT than SO-IUI (P less than 0.001), with an odds ratio of 3.25 (P = 0.001). Stepwise multiple logistic regression identified factors that correlate with pregnancy: absence of endometriosis (P = 0.05), infertility less than 3 years' duration (P = 0.002), TMS greater than or equal to 30 X 10(6) (P = 0.005), and treatment with GIFT rather than SO-IUI (P = 0.001). These data give a first approximation of the increased efficacy of GIFT versus SO-IUI and provide valuable insight into significant confounding variables to be considered when planning a randomized, prospective trial to evaluate these techniques.

In vitro fertilization/embryo transfer in the United States: 1987 results from the National IVF-ET Registry

This is the second annual report of the U.S. Registry of IVF-ET and related practices. The present report describes the 1987 experiences of 96 U.S. member clinics with respect to treatments and outcomes. During 1987, 14,647 in vitro fertilization (IVF) and/or gamete intrafallopian transfer (GIFT) stimulation cycles were performed; there were 490 frozen embryo and 60 donor oocyte transfers. Ninety percent of the clinics had at least one delivery, and overall, a total of 1858 babies were born. The overall clinical pregnancy rates were 16% for IVF (based on 8725 retrievals), 25% for GIFT (based on 1968 retrievals), and 28% for IVF and GIFT in combination (based on 199 retrievals). The results for each procedure are described in detail.