Elevated basal estradiol levels have no negative prognosis in young women undergoing ART cycles

The objective of this study was to determine the relationship between serum estradiol levels on day 2 of an in vitro fertilization and embryo transfer (IVF-ET) cycle and the chance of pregnancy and implantation rates according to age. Two hundred and forty-eight cycles of IVF-ET in patients treated with gonadotropin-releasing hormone analog (GnRHa, follicle-stimulating hormone (FSH) and human menopausal gonadotropin (hMG) were divided into several groups according to the basal serum concentrations of estradiol (E2):A < 25 pg/ml, B 26-50 pg/ml, C 51-75 pg/ml, D 76-100 pg/ml, E > 100 pg/ml. Furthermore, the patients were subdivided into two subgroups according to age: I younger; and II, older than 35 years. Pregnancy and implantation rates were analyzed for each subgroup according to basal E2 level and age. Statistical analysis was performed using analysis of variance, chi2 and Fisher's test. The number(s) of cycles for each subgroup were 164 and 84 for I and II, respectively. Even though there were no significant differences among groups for the pregnancy rates for individual groups, there was a tendency for a decreased rate with increasing levels of E2 only in women older than 35 years of age. When pregnancy rates of all women with E2 levels above 25 pg/ml were calculated, the differences between those observed in subgroup I (< or = 35 years) and II (> 35 years) was significant: p = 0.02 (38.7% vs. 18.7%, respectively). When implantation rates in the same groups and subgroups were analyzed, we found that again the differences were statistically significant: p = 0.001 (13.1%vs, 4.3% for I and II). The results of the present studies reveal that basal levels of E2 are a marker of poor prognosis for implantation and pregnancy in assisted reproduction (ART) cycles only in patients over the age of 35 years. These data cast doubt on the use of basal levels of E2 to screen women below the age of 35 prior to initiating an ART cycle. In addition, high levels of basal E2 per se may not be deleterious for reproductive efficiency in younger women, since pregnancy and implantation rates did not differ among patients younger than 35 years old (IA to E).

Spontaneous resolution of ectopic pregnancy in a surrogate after oocyte donation and frozen embryo transfer

A case of tubal pregnancy in a young and healthy woman participating in a programme of in-vitro fertilization (IVF) gestational surrogacy is reported. The gestational surrogate was the 30 year old fertile sister of a 25 year old patient affected by stage 1 ovarian cancer. After mandatory oncological consultation, the donor was recommended to prospectively undergo controlled ovarian hyperstimulation cycles for embryo banking before being treated by total hysterectomy. Available embryos were cryopreserved and after adequate endometrial preparation using artificial cycles of hormone replacement therapy, three thawed frozen embryos were transferred to the surrogate. At 17 days following embryo transfer the surrogate was noted to have a negative beta-human chorionic gonadotrophin (HCG) serum concentration. All medication was suspended and a few days later normal menstrual bleeding occurred. After 2 weeks, the beta-HCG concentrations, performed as part of routine follow-up evaluation, were showing signs of trophoblast activity (236 mIU/ml). Taking into account the stable condition of the patient, a decision was made to undertake expectant management. At 43 days after embryo transfer, a complete tubal abortion was apparently seen in the posterior cul-de-sac by ultrasound associated with a subtle and short lasting pelvic pain. We stress that this ectopic gestation was able to maintain prolonged viability in conditions of absent corpus luteum and exogenous steroid supplementation.

Vaginal bleeding and early pregnancy outcome in an infertile population

OBJECTIVE

Our purpose was to determine the prognostic value of vaginal bleeding in early pregnancy outcome as well as to analyze the role of cardiac activity in predicting pregnancy viability in the presence of vaginal bleeding.

STUDY DESIGN

This was a cohort study of pregnancies obtained using either assisted reproductive technology (ART) or routine infertility treatment (RIT). Two hundred twenty-eight pregnant women were divided into two groups based on the presence or absence of vaginal bleeding. Successive measurements of beta-hCG levels were obtained every 2 days, starting on day 14 after ovulation or embryo transfer. All pregnancies underwent weekly transvaginal ultrasound (UTZ) examinations beginning on day 21. The occurrence of vaginal bleeding was monitored weekly.

RESULTS

Seventy of the 228 patients (31%) had bleeding in early pregnancy, resulting in 31 (44%) pregnancy losses. Only 22 pregnancy losses (14%) were observed in 158 patients who did not have bleeding (P < 0.001). The abortion rate for the bleeding versus nonbleeding groups was 35 and 9%, respectively (P < 0.001). Vaginal bleeding was associated with a higher abortion rate in pregnancies following RIT than ART (51 vs 8%; P < 0.001). Fetal cardiac activity was noted by vaginal ultrasound in 189 patients. In this subpopulation, bleeding was also associated with a higher abortion rate than that in the nonbleeding group (17 vs 4%; P < 0.001). However this higher incidence was observed only in pregnancies following RIT, not ART (28 vs 5%; P < 0.001).

CONCLUSIONS

Although bleeding significantly decreased the chance of a normal pregnancy outcome, more than 50% of the pregnancies did progress to term. The presence of cardiac activity in this population as a sign of fetal viability offered a better pregnancy prognosis. However, the predictive value of fetal cardiac activity was reduced in the presence of vaginal bleeding in an infertile population treated with RIT.

Successful pregnancy outcome after cryopreservation of all fresh embryos with subsequent transfer into an unstimulated cycle

OBJECTIVE

To assess the pregnancy outcome of freezing and storing all fresh embryos produced in a stimulated IVF cycle and replacing them in a subsequent nongonadotropin-stimulated cycle.

DESIGN

Retrospective study.

SETTING

University-associated assisted reproductive technology program.

PATIENTS

We studied 36 patients (age range 23 to 44 years) who underwent cryopreservation of all fresh embryos in a controlled ovarian hyperstimulation (COH) cycle because of either the risk of severe ovarian hyperstimulation (24 patients, group 1) or the presence of an endometrial lining < 8 mm in thickness (12 patients, group 2). Five hundred fifty-five embryos were generated for replacement in 63 cycles. All embryos were cryopreserved in 1.5 M propanediol at the pronuclear or two-cell stage, and 264 embryos subsequently were transferred into a hormone replacement cycle (70%) or natural ovulatory cycle (30%). The average number of embryos transferred per patient was 4.2.

RESULTS

Twenty-one clinical pregnancies were achieved, giving a pregnancy rate (PR) of 58.3% per patient (33.3% per cycle). The live birth rate was 50% per patient (28.6% per cycle). The implantation rate was 9.1%. Groups 1 and 2 had a similar PR per patient (58.3%). With 208 cryopreserved embryos remaining and considering the 33.3% PR per cycle, we expect the overall extrapolated PR to be 63.9%.

CONCLUSIONS

This is the first series showing that freezing and storing all fresh embryos produced in a stimulated IVF cycle and replacing them in a subsequent nongonadotropin-stimulated cycle results in successful PRs. These results underlie the importance of a successful cryopreservation program in IVF and could be a possible approach to overcoming the alleged adverse effects of COH on the endometrium, thereby improving the chances of pregnancy when numerous embryos are obtained simultaneously.

Successful fertilization, pregnancy, and birth using epididymal sperm frozen 24 hours after conventional oocyte insemination

OBJECTIVE

To assess if epididymal sperm cryopreserved 24 hours after exposure to oocytes in conventional IVF can be successfully used for intracytoplasmic sperm injection (ICSI) in a subsequent cycle.

DESIGN

Case report.

SETTING

University of California, Irvine, Center for Reproductive Health.

PATIENTS

Two men with obstructive azoospermia requiring microsurgical epididymal sperm aspiration, IVF, and ICSI.

INTERVENTIONS

Freezing of epididymal sperm 24 hours after egg exposure in conventional IVF and subsequent use for assisted fertilization in a new cycle.

MAIN OUTCOME MEASURE

Frozen-thawed epididymal sperm survivability and maintenance of fertilization and pregnancy capacity.

RESULTS

At the time of sperm aspiration procedure (cycle I) a total of 30 oocytes were available for insemination. Of these, 15 were used for conventional IVF resulting in 2 embryos (13%) and 15 were used for ICSI, resulting in 3 embryos (20%). Sperm was cryopreserved 24 hours after conventional IVF and thawed 6 months later in a new cycle. Upon thawing, sperm were still found to be motile and at this time (cycle II) only assisted fertilization was used. Of 27 oocytes injected, 12 (44%) produced normal, cleaving embryos. One singleton pregnancy with the birth of a healthy infant girl was achieved after the tubal transfer of 5 embryos.

CONCLUSION

The birth of a normal, healthy infant girl with epididymal sperm frozen 24 hours after exposure to oocytes in conventional IVF emphasizes the value of freezing any aliquot of epididymal sperm, even if the motility is very low, to avoid additional surgery in the male. From a basic science standpoint, this observation may renew interest in the study of sperm cryopreservation after occurrence of acrosome reaction and hyperactivation.

Intracytoplasmic sperm injection and embryo development of human oocytes cryopreserved using 1,2-propanediol

This study reports the subsequent embryo development of cryopreserved mature human oocytes following insemination or intracytoplasmic sperm injection (ICSI). Metaphase II oocytes were cryopreserved using a slow freezing-rapid thawing procedure employing the cryoprotectant 1,2-propanediol. The study was conducted at two centres. The normal insemination of cryopreserved oocytes was undertaken in one centre, and ICSI of cryopreserved oocytes in the other. Both methods resulted in a 50% normal fertilization rate. A low rate of abnormal fertilization was observed in the inseminated group of oocytes (5%) compared with 21% for the ICSI oocytes; this was not significantly different. Embryo development was assessed daily for 7 days. All normal fertilized cryopreserved oocytes in both groups cleaved on day 2, with a similar appearance to in-vitro fertilization and ICSI embryos. In the normal inseminated oocytes, there was a significant decrease in the number of embryos cleaving on day 3 (33%) compared with the development of ICSI oocytes, with a subsequent gradual reduction over days 4 and 5 (22 and 11% respectively) resulting in one early blastocyst on day 7 (11%). In contrast, all ICSI-generated embryos continued to cleave on day 3, with a gradual reduction over subsequent days (day 4, 86%; day 5, 57%; day 6, 43%; day 7, 29%). By day 7, two of the blastocysts had started to hatch, resulting in a 66% hatching rate of blastocysts formed from ICSI of cryopreserved oocytes. This is the first study to show normal development to the hatching blastocyst stage following ICSI of cryopreserved human oocytes.

Enzymatic amplification of specific deoxyribonucleic acid sequences from single cells: evaluation of a simplified and rapid method for use in preimplantation genetic diagnosis

OBJECTIVE

To develop a simplified polymerase chain reaction (PCR) protocol on single cells for the purpose of preimplantation genetic diagnosis. Also to evaluate a new thermal cycler, RoboCycler 40 (Stratagene, La Jolla, CA), for reducing the time to complete PCR amplification.

DESIGN

PCR amplification without DNA purification or reamplification of a 149 base pair (bp) segment of the human Y chromosome was used as a model. The assay was tested in human fetal cells, single lymphocytes and single human blastomeres.

RESULTS

Amplification of the 149 bp segment using fetal cells was 100% correct. Results on single lymphocytes were concordant in all but one of the 15 male cases. However, 2 of the 25 female cases were identified as male suggesting the occurrence of DNA contamination. Analysis of 61 blastomeres were concordant in 57 cases (93%); results for male blastomeres showed 12% of false negatives. No false positives were detected for female cells. Amplification using the simplified PCR protocol in combination with the RoboCycler was completed in 2 hours.

CONCLUSION

These data show that this PCR assay performed directly, without DNA extraction or purification and without re-amplification is a practical and effective approach for amplification of specific DNA sequences in single cells. Furthermore, the simplified PCR protocol significantly reduced the time to complete DNA amplification. The reduced time is expected to facilitate the management of a routine program for preimplantation genetic diagnosis.

Testosterone and androstenedione in premature ovarian failure pregnancies: evidence for an ovarian source of androgens in early pregnancy

Numerous anecdotal reports but few scientific approaches have suggested an increase in androgens in early pregnancy. In this study we have compared the concentration of serum androgens, testosterone and androstenedione in early pregnancy, starting within the cycle of conception. We have taken the opportunity to study women with premature ovarian failure where pregnancy develops in the virtual absence of ovarian functions. This study demonstrates that the concentration of testosterone (0.29 +/- 0.04 ng/ml) and androstenedione (1.770 +/- 0.136 ng/ml) in these subjects is as low as, if not lower than, non-pregnant women (0.39 +/- 0.02 and 2.170 +/- 0.025 ng/ml), significantly increased in normal pregnancies (1.190 +/- 0.118 and 3.920 +/- 0.297 ng/ml; P < 0.05) and even further increased in human menopausal gonadotrophin-treated cycles (1.990 +/- 0.230 and 8.19 +/- 0.72 ng/ml; P < 0.05). These studies demonstrate that the ovary is a contributor to the circulating concentrations of testosterone and androstenedione starting within the cycle of conception.

Outcome of triplet pregnancies after assisted reproductive techniques: how frequent are the vanishing embryos?

OBJECTIVE

To assess the incidence of spontaneous embryo reduction as well as the obstetric and neonatal outcome of triplet gestations after assisted reproductive techniques (ART).

METHODS

We analyzed the spontaneous outcome of 38 pregnancies in which three gestational sacs were identified with vaginal ultrasound between 21 and 28 days after ART. Weekly follow-up visits were scheduled during the first trimester until referral to a high-risk obstetrician. After delivery, each patient was interviewed individually and, if necessary, the obstetrician was contacted.

RESULTS

The triplets delivery rate was 47.4%, whereas 31.6% delivered twins, 18.4% delivered singletons, and only one patient miscarried all three cases (2.6%). Finding three fetal heart beats was associated with a triplet delivery rate of 69.2%, a twin incidence of 19.2%, and a singleton birth rate of 11.6%. Embryo resorptions were observed mainly during the first 7 weeks of gestation and did not occur beyond the 14th week. The mean gestational age at delivery and neonatal birth weight were significantly lower among triplets (32.8 weeks and 1,740 g versus 35.3 weeks and 2,352 g in twins and 39.1 weeks and 3,122 g for singletons). Triplets had a 100% prematurity and cesarean section rate compared with 67% and 75% in twins and 0% and 43% in singletons, respectively. Hospitalization at the Neonatal Intensive Care Unit was required in 83% of newborn triplets, 29% of twins, and 0% of singletons, with a mean stay of 34 and 21 days for triplets and twins, respectively. One stillbirth and no neonatal deaths were reported, with an overall perinatal mortality rate of 11.9 per 1,000.

CONCLUSIONS

Spontaneously, approximately 50% of triplet pregnancies will experience at least one embryo resorption. The ongoing triplets demand a complex and more expensive perinatal management, a strong argument to consider limiting the number of oocytes-embryos transferred in ART.

The abnormally large follicle during controlled ovarian hyperstimulation: management and outcome of the cycle

OBJECTIVE

To investigate if the presence of an abnormally large follicle during controlled ovarian hyperstimulation (COH) under pituitary suppression has any effect on the outcome of the cycle.

DESIGN

Prospective, observational.

SETTING

The reproductive endocrinology unit of a university hospital.

PATIENTS

One hundred fifty patients undergoing COH for assisted reproductive techniques during a 6-month period (August 1990 to January 1991).

INTERVENTIONS

Transvaginal follicular aspiration and IVF-uterine ET.

RESULTS

A total of 19 cycles had abnormally large follicles identified on day 8 of the stimulation cycle after normal baseline ultrasound. Gonadotropins were continued and hCG injection was indicated when two or more follicles of the main cohort achieved a diameter of 20 to 22 mm. Twenty preovulatory oocytes were retrieved from 22 large follicles. Two were transferred for GIFT and 18 were inseminated in vitro, resulting in a 72.0% fertilization rate. The mean number of oocytes retrieved per patient was 10.9, 71.4% of which were mature with a fertilization rate of 67.7%. All these figures were comparable with the results obtained in the 131 patients of the control group undergoing IVF. No evidence of premature luteinization was observed in the study group, based on plasma P levels (x 0.83 ng/mL [conversion factor to SI unit, 3.180], range 0.31 to 1.40 ng/mL). The clinical pregnancy rate for the group with abnormally large follicles did not differ from the control group (27.8% versus 28.2%, respectively).

CONCLUSIONS

The presence of an abnormally large follicle during COH under pituitary suppression does not affect the outcome of the cycle. Moreover, under these conditions, continuous gonadotropin stimulation of a follicle to diameters considerably larger than the standard ones does not have a detrimental effect on the oocyte contained in it, suggesting that oocyte aging is an independent process from follicular growth once LH surge is prevented.

Increased capillary permeability induced by human follicular fluid: a hypothesis for an ovarian origin of the hyperstimulation syndrome

OBJECTIVE

To examine the effect of follicular fluid (FF) and peritoneal fluid (PF) from patients undergoing assisted reproductive technology procedures on endothelial barrier function. This was determined in vitro by measuring the permeability of filter-grown bovine aortic endothelial cell monolayers to a permeability marker.

DESIGN

Endothelial cells obtained from bovine thoracic arotas were treated with collagenase solution and plated on millicell filters, on which they formed confluent monolayers. Flux rate was determined at 60 minutes by measuring the radioactive tracer (3H mannitol) permeating from the apical to the basolateral part of the filter. Fifty-eight samples of FF and PF, both from stimulated and natural cycles were analyzed and grouped according to the number of eggs retrieved. Follicular fluid and PF samples from natural cycles were used as controls.

RESULTS

There was an augmentation in the permeability rate of both FF and PF from patients undergoing controlled ovarian hyperstimulation (COH) who responded with an increasing number of eggs compared with controls (51% and 39%, respectively). When analyzing samples from patients who responded with a low number of oocytes, no significant increase was observed.

CONCLUSIONS

It is known that in OHSS, the increase in capillary permeability is related to the administration of gonadotropins, and is believed to be mediated by a vasoactive substance of ovarian origin. In this study, FF and PF from patients undergoing COH showed a significant increase in the permeability rate through endothelial cells in vitro. Based on these findings, it could be hypothesized that if the same events took place in vivo, the isolation of this factor from ovarian source could be of significant importance to elucidate the pathogenesis of OHSS.

Presence of thyroid antibodies in early reproductive failure: biochemical versus clinical pregnancies

OBJECTIVE

To evaluate the clinical usefulness of thyroid antibodies in determining early pregnancy outcome.

SETTING

University-based facility at the Center for Reproductive Health, University of California, Irvine.

PATIENTS

Four hundred eighty-seven infertile patients that successfully conceived with assisted reproductive techniques from January 1991 to December 1992.

INTERVENTIONS

An enzyme immunoassay for semiquantification of thyroglobulin (TG) and thyroid peroxidase antibodies used to determine antibody status from stored serum of these patients.

MAIN OUTCOME MEASURE

Thyroid antibody status in early pregnancy.

RESULTS

Of the 487 patients studied, there were 106 women who were antibody positive for anti-TG, antithyroid peroxidase, or both, and 381 who were negative. The overall incidence of positivity was 22%. In the antibody-positive group there was a 32% clinical miscarriage rate in comparison to 16% in the antibody-negative group. This did reach statistical significance. There was no significant difference between the two groups in the incidence of biochemical or ectopic pregnancies. There also was no significant difference between the groups in age, gravidity, or number of prior pregnancy losses.

CONCLUSION

In our patient population, thyroid antibodies proved to be a useful marker for identifying women at risk for clinical miscarriage but they appear not to have an association with biochemical pregnancies.

The use of progestins for programming assisted reproductive cycles and gonadotropin-releasing hormone agonist flare-up protocols in older patients

OBJECTIVES

To determine if the use of norethisterone acetate (NET) in the previous cycle affects the ovarian response to GnRH agonist (GnRH-a) in flare-up protocols and controlled ovarian hyperstimulation in older patients.

DESIGN

Retrospective analysis of the outcome of the assisted reproductive technology (ART) cycle.

PATIENTS

Eighty women > 37 years old undergoing controlled ovarian hyperstimulation (COH) for a ART cycle (GIFT, IVF, zygote intrafallopian transfer). Forty received NET during the luteal phase of the previous cycle for programming the procedure and 40 did not receive NET (control group). Gonadotropin-releasing hormone agonist in follicular phase (flare-up) protocols were administered to all the patients.

MAIN OUTCOME MEASURES

Cycle outcome: amount of gonadotropins used, oocyte production and quality, fertilization, and pregnancy rates. Estradiol, FSH, and LH levels the first 3 days of COH in eight patients.

RESULTS

There were no differences between both groups in the cycle outcome. Estradiol levels during the first 3 days of COH were higher in the patients that did not receive NET in the previous cycle. Follicle-stimulating hormone and LH levels were similar in both groups.

CONCLUSIONS

The administration of NET in the previous cycle in patients > 37 years old does not affect the ovarian response to the combination of follicular phase GnRH-a and gonadotropins for COH.

Use of epididymal sperm for assisted reproduction in men with acquired, irreparable obstructive azoospermia

Microsurgical epididymal sperm aspiration (MESA) and in vitro fertilization (IVF) is primarily offered to men with congenital absence of the vas deferens (CAVD). However, the IVF capacity of these epididymal sperm is low ( < 15%) and unpredictable. In this study, IVF and intracytoplasmic sperm injection (ICSI) results in patients with non-congenital, irreparable obstructive azoospermia were analysed. Thirty-three patients were evaluated for a total of 37 cycles of MESA and IVF. Most had obstruction secondary to failed vasectomy reversal and to epididymal blockage. The overall fertilization rate was 30% with regular IVF and 26% with ICSI, and six clinical pregnancies were obtained. Both rates are significantly higher than the IVF rate previously reported with sperm from men with CAVD (13%, P < 0.00001). In men with non-congenital obstructive azoospermia, a significant difference was found in the average sperm count (56.9 x 10(6) v. 12.3 x 10(6), P < 0.04) and total motile count (16.6 x 10(6) v. 1.6 x 10(6), P < 0.01) respectively for patients who achieved IVF and those who did not. It is concluded that (a) the real IVF capacity of human epididymal sperm is 30%, or 42%, if calculated only for patients who achieved fertilization, (b) this higher rate is an indirect support of the hypothesis that sperm from men with CAVD have intrinsic biochemical defects, related to cystic fibrosis mutations, responsible for their low and unpredictable IVF rate, and (c) MESA and IVF can be offered at the same time or as an alternative to patients requesting vasectomy reversal.

Enzymatic characterization of zona pellucida hardening in human eggs and embryos

PURPOSE

To characterize possible hardening of the human zona pellucida (ZP) and evaluate the effect of culture duration, patient age, and ZP thickness, ZP of unfertilized eggs (experiment 1, n = 367; experiment 2, n = 174) and abnormal embryos (experiment 1, n = 52) were randomly designated for alpha-chymotrypsin treatment after 0, 24, 48, 72, 96, 120 h (experiment 1) and 48 h, 72 h, and 1 week (experiment 2) of in vitro culture in HTF medium supplemented with 0.5% human serum albumin. Mean ZP thickness was predetermined in experiment 2.

METHODS

The dispersion of the ZP glycoproteins was assessed, and the duration of time for complete digestion was recorded as an index of ZP hardness.

RESULTS

In experiment 1, enzyme digestion duration increased (P < 0.05) in the first 24 h in vitro from 18.0 +/- 2.0 to 34.6 +/- 2.5 min, and tended to decrease over the next 4 days in culture (25.2 +/- 1.3, 29.4 +/- 0.9, 27.3 +/- 0.6, 26.6 +/- 1.1, and 20.7 +/- 1.5 min on Day 2-6 ZP, respectively). Zona hardening of fertilized eggs was revealed by a longer (P < 0.01) digestion time (32.2 +/- 1.8 vs 25.8 +/- 0.6 min).

CONCLUSIONS

There were significant patient-to-patient variation (16.4 +/- 0.7 to 39.6 +/- 2.2 min); however, age was not correlated to enzyme digestion duration. In experiment 2 we determined that ZP thickness (range 8.4-21.6 microns; mean 14.6 +/- 0.2 microns) was not correlated (r = 0.09) to the digestion interval (mean 24.3 +/- 0.8 min). Based on our enzymatic ZP digestion measurements, it is apparent that spontaneous zona hardening does occur within 24 h of in vitro culture, similar to levels achieved postfertilization. The data do not support, however, the concept that additional, abnormal hardening of the ZP occurs during extended culturing.

Is there a role for ovarian stimulation and intra-uterine insemination after age 40?

The objective of this study was to determine the conception rate in infertile couples in which the female partner was > or = 40 years old and who had received ovarian stimulation treatment and intra-uterine insemination (IUI). It was a retrospective study of 77 patients who underwent a total of 210 treatment cycles. Protocols for ovulation induction included clomiphene citrate, human menopausal gonadotrophin (HMG) and clomiphene citrate plus HMG. Patients were monitored using transvaginal ultrasound, and two IUI were performed 24 and 48 h after the determination of urinary luteinizing hormone (LH) surge or human chorionic gonadotrophin (HCG) injection. A total of 11 pregnancies were reported, giving a pregnancy rate of 14% per patient and 5% per cycle. Eight spontaneous abortions occurred, giving a pregnancy wastage of 73%. In a previous comparative analysis of 543 patients < 39 years old receiving IUI and identical protocols of ovarian stimulation, 141 pregnancies were achieved, giving a pregnancy rate of 21% per patient and 10% per cycle. The miscarriage rate in that group was 18%. This report compares IUI results for women > or = 40 years with those obtained previously for younger women, and shows the very poor success rate in women > 40 years of age. This information will be important in the proper counselling of this group of patients, as well as indicating that a prompt recommendation for assisted reproductive treatment should be made soon after the failure of a few attempted cycles of ovarian stimulation treatment and IUI.

Oocyte donation in humans: a model to study the effect of age on embryo implantation rate

Although a number of different mechanisms have been suggested to account for the decline of fertility with age, the majority of studies agree that poor oocyte quality and reduced endometrial receptivity are the most important. In fact, the increased incidence of early pregnancy loss and chromosomal abnormalities of oocytes in older women, as well as the ability to reverse decreasing pregnancy rates by using oocyte donation, strongly support the evidence that oocyte ageing is the main factor responsible for decreasing fertility. Conversely, the lack of knowledge of the physiological variables that determine a successful nidation of a human embryo makes the analysis of uterine receptivity much more difficult. In order to evaluate the impact of the age of donors and recipients on pregnancy, implantation and abortion rates, we have retrospectively analysed 258 cycles from our programme of oocyte donation. Results were reviewed according to the following subclasses of age groups: < or = 30, 31-35 and 36-39 years for donors, and < or = 30, 31-35, 36-40, 41-45 and 46-53 years for recipients.(ABSTRACT TRUNCATED AT 250 WORDS)

Relative force of human epididymal sperm

OBJECTIVE

To assess the relative escape force of human epididymal sperm using a laser generated optical trap and compare it with that of human ejaculated sperm.

DESIGN

Evaluation of the relative force generated by epididymal and ejaculated sperm using an 800-nm laser-generated optical trap system (titanium-sapphire, model 899-01; Coherent Innova, Palo Alto, CA).

SETTING

University-based facility at the Beckman Laser Institute and Medical Clinic and Center for Reproductive Health, University of California, Irvine.

INTERVENTIONS

A total of 2,720 sperm from 28 samples were randomly analyzed. Fifteen were ejaculated samples (1,650 sperm) obtained from men with proven fertilization, and 13 were epididymal samples (1,070 sperm) aspirated microsurgically from patients with obstructive azoospermia. An optical trap equipped with the 100x Neofluar objective was used to analyze an average of 100 sperm per patient.

MAIN OUTCOME MEASURES

Determination of mean relative escape force values in milliwatts for epididymal and ejaculated sperm samples.

RESULTS

The mean relative escape force for epididymal sperm was 32.4 mW, significantly lower than ejaculated sperm, which was 85.1 mW. By correlating epididymal sperm relative force with fertilization in vitro at an arbitrary cutoff value of 30 mW, it was found that no fertilization occurred if a sample had < 13% of sperm at that value.

CONCLUSIONS

[1] The average relative escape force of the epididymal sperm was found to be 60% weaker than that of ejaculated sperm. [2] It is demonstrated that the noncontact laser optical trap is a sensitive tool that can evaluate single sperm force as a new physiological parameter.

The predictive value of a single beta human chorionic gonadotropin in pregnancies achieved by assisted reproductive technology

OBJECTIVE

To investigate whether a single serum beta-hCG in pregnancies achieved by assisted reproductive technologies (ART) can accurately predict pregnancy viability and, in viable pregnancies, multiple gestation.

DESIGN

Four hundred sixty-one consecutive successful ART pregnancies were studied retrospectively. Seventy-one of the 461 patients were excluded because their beta-hCG was either drawn on the incorrect day or outside our facility. Three hundred ninety subjects had a serum beta-hCG drawn 14 days after ET or 16 days after gamete transfer. The beta-hCG samples were analyzed by immunoradiometric assay based on the Third International Reference Standard (IRS) (First International Reference Preparation (IRP)). Pregnancy status was followed, at minimum, through the first trimester.

RESULTS

One hundred fifty (38%) of the 390 were found to be nonviable, resulting in spontaneous abortion (n = 38, 10%), ectopic pregnancy (n = 27, 6%), or biochemical pregnancies (n = 85, 22%). A statistically significant difference by the Scheffe F-test was found between the mean beta-hCG value of the nonviable (115 mIU/mL) (conversion factor to SI unit, 1.00) and viable (428 mIU/mL) pregnancies. The positive predictive value of a single beta-hCG > 100 mIU/mL in distinguishing viable from nonviable pregnancies was 0.83 (sensitivity 91%, specificity 71%). Of the 240 viable pregnancies, 74 (32%) were multiple gestations (57 twins, 14 triplets, and 3 quadruplets). The mean beta-hCG of the singleton pregnancies (266 mIU/mL) was significantly different from that of the multiple gestations (792 mIU/mL). The positive predictive value of a single serum beta-hCG < or = 400 mIU/mL in distinguishing singleton from multiple gestations was 0.92 (sensitivity 86%, specificity 82%).

CONCLUSION

A single early serum beta-hCG may be used in ART pregnancies to predict which pregnancies will continue beyond the first trimester and to identify multiple gestations. Early reassuring tests may reduce anxiety.

Comparison between nafarelin and leuprolide acetate for in vitro fertilization: preliminary clinical study

OBJECTIVE

To evaluate the clinical effect of two different biochemical GnRH agonists (GnRH-a), nafarelin acetate and leuprolide acetate (LA), as adjunct to induction of ovulation in patients for IVF.

DESIGN

Twenty-four women were assigned randomly to either nafarelin acetate or LA during IVF cycles.

SETTING

University-affiliated clinics.

PATIENTS

Infertile women undergoing IVF cycles in an academic research environment.

INTERVENTIONS

Intranasal nafarelin at a dosage of 200 micrograms twice daily or LA at a dose of 1 mg/d SC was administered. Blood samples were collected on day 21 of previous cycle, days 2 and 8, and before hCG injection.

MAIN OUTCOME MEASURE

Patient response as indicated by follicular phase serum levels of E2, FSH, and LH.

RESULTS

Hormone profiles on cycle day 2 showed no statistical difference between both GnRH-a groups in FSH levels and a slight statistical difference for E2 levels. Patient response as demonstrated by follicular phase of E2, FSH, and LH measured on cycle day 8 and the day of hCG injection showed no statistically significant difference in both groups. Furthermore, the mean number of follicles, eggs retrieved, egg quality, fertilization rate, and number of embryos transferred and frozen were similar. The cycle cancellation rate and pregnancy rate per stimulation start were also not statistically different between the two groups.

CONCLUSION

The study shows the comparable efficacy of these two drugs in controlled ovarian hyperstimulation (COH) protocols. The easy administration of nafarelin with prompt nasal absorption and the readily achieved blood level made nafarelin an option for use in COH in assisted reproductive technology.

Frozen zygote intrafallopian transfer: a successful approach for transfer of cryopreserved embryos

OBJECTIVE

To assess whether frozen ET to the fallopian tube is a possible alternative for cryopreserved embryos.

DESIGN

Fifty-four patients (mean age 35 years) participated, in which their embryos were cryopreserved in 1.5 M propanediol at the pronuclear or two-cell stage. Each patient then underwent a steroid replacement cycle consisting of oral micronized 17 beta-E2 2 mg on days 2 to 4, 4 mg on days 5 to 7, 6 mg on days 8 to 10, and 8 mg from day 11 on. Serial ultrasounds were performed to evaluate the endometrium until an optimal thickness of > or = 10 mm triple layer was achieved. At this time, 100 mg IM progesterone was initiated and the zygote intrafallopian transfer (ZIFT) procedure was performed on the third day of P administration. The average number of embryos transferred was 4.4.

RESULTS

Twenty-two clinical pregnancies resulted, giving a pregnancy rate of 41%. Eight miscarriages occurred and one ectopic pregnancy resulted, giving a live birth rate of 24%. Implantation rate was 10.8%. The highest chance of pregnancy was seen in patients who never had a previous IVF, GIFT, or ZIFT (61%).

CONCLUSION

This is the first report of a series of frozen ETs to the fallopian tubes. These results indicate that tubal transfer may offer a protective benefit of the tubal environment and avoidance of endometrial trauma, and should be added to our armamentarium of replacing cryopreserved embryos.

Correlation between epididymal length and fertilization rate in men with congenital absence of the vas deferens

OBJECTIVE

To investigate whether the variable length of the epididymides in men with congenital absence of the vas deferens might have a correlation with IVF and pregnancy rate results.

DESIGN

Microsurgical retrieval of epididymal sperm from men with congenital absence of the vas deferens and their use for IVF.

SETTING

Center for Reproductive Health, University of California, Irvine, California.

PATIENTS

One hundred eight men with confirmed diagnosis of congenital absence of the vas deferens enrolled in the microsurgical epididymal sperm aspiration and IVF program.

INTERVENTIONS

Measurement in centimeters of the epididymal length at the time of the sperm aspiration procedure.

MAIN OUTCOME MEASURE

Rates of fertilization and pregnancy according to the epididymal length.

RESULTS

Three groups were identified: group I (n = 29), epididymal length between 0.5 and 1.9 cm; group II (n = 66), length between 2.0 and 4.0 cm; and group III (n = 13), length in excess of 4.0 cm. Although the aspiration site was the proximal caput for each case, patients of group III had the highest fertilization and pregnancy rate (24% and 43%, respectively). Patients with the shortest epididymis (group I) had the worst IVF outcome (fertilization rate 7% and pregnancy rate 7%) whereas in group II the fertilization rate was 13% and the pregnancy rate was 18%.

CONCLUSION

This study demonstrates that epididymal sperm from men with congenital absence of the vas deferens having a longer epididymis have a better IVF rate. A long epididymis can allow [1] the arrival of more frequent waves of fresh sperm whereas in a short epididymis the system is completely congested and occupied by old and senescent sperm, [2] less obstructive damages, and [3] a back flow of biochemical factors produced in the more distal segments that could ultimately enhance the fertilization capacity of proximal epididymal sperm.

Prospective randomized comparison of human chorionic gonadotropin versus intramuscular progesterone for luteal-phase support in assisted reproduction

OBJECTIVE

The purpose of the study was to determine the impact of two forms of luteal-phase supplementation, human chorionic gonadotropin (hCG) and progesterone (P), during gonadotropin releasing hormone agonist (GnRh-a)/controlled ovarian hyperstimulation (COH) cycles.

DESIGN AND PATIENTS

The study was a prospective, randomized evaluation of 77 patients. Group 1 patients (n = 38) received 2000 IU of hCG, injected subcutaneously, on days 3, 6, 9, and 12 after transvaginal aspiration of the oocytes (TVA = day 0). Group 2 patients (n = 39) received 50-mg daily injections of intramuscular (i.m.) P from days 2 to 14 after TVA. Blood tests were performed on days 0, 5, 8, and 12 after TVA.

SETTING

The in vitro fertilization program of a tertiary care institution was the study setting.

MAIN OUTCOME MEASURES

The main outcome measures were (1) pregnancy and implantation rates; (2) serum estradiol (E), P, and hCG levels; and (3) occurrence of side effects.

RESULTS

Clinical pregnancy and implantation rates in group 1 versus group 2 were similar (36.7 vs 35.3 and 12 vs 14%, respectively). Regardless of pregnancy occurrence, on days 8 and 12 after TVA, serum E and P levels were higher in group 1 than group 2 but the resulting E/P ratios were similar. Five of 38 patients (group 1) developed moderate to severe ovarian hyperstimulation syndrome (OHSS) right after the first or second supplementary hCG injection. In these patients, the mean serum E level on the day of hCG trigger injection was about 3250 pg/ml and the number of follicles was between 9 and 17. In 6 of 39 patients (group 2) allergic reactions were observed at the P injection sites.

CONCLUSIONS

Based on our data, hCG administration as a form of luteal supplementation did not translate, in comparison to P, into significant benefits for the patients. At the same time, it significantly increased the risk of ovarian hyperstimulation. We suggest that whenever, during COH cycles, serum E levels are over 2500 pg/ml and the number of follicles exceeds 10, luteal support with hCG should be excluded.

Evidence for a novel adenylyl cyclase in human epididymal sperm

Since cAMP is considered to play a major role in the acquisition of maturation and fertilizing capacity of mammalian sperm, we investigated the expression of cAMP-synthesizing adenylyl cyclase (AC) in sperm retrieved directly from the human epididymis. Particulate fractions were prepared from purified epididymal sperm samples and AC was monitored by the direct conversion of ATP into cAMP. We report that in great contrast to human ejaculated sperm and other mammalian sperm cells, the human epididymal sperm do not express a Mn(2+)-sensitive AC. However, a functional AC was readily detectable in these sperm cells in the presence of saturating concentrations of Ca2+ (50mM) and bicarbonate (HCO3-, 50mM), a combination that causes maximal activation in human ejaculated sperm. Using these conditions, human epididymal sperm AC showed similar capacity to generate cAMP compared to human ejaculated sperm AC. When assays were performed in the presence of Mg2+ and a saturating concentration of GMP-P(NH)P (50 microM), the hydrolysis-resistant GTP analog, and forskolin (100 microM), no activity was detected indicating that the epididymal sperm AC differs from that in somatic cells. These data demonstrate that human epididymal sperm contain an AC that is unique and different from the enzyme system described in somatic cells and other mammalian sperm cells, including human ejaculated sperm.

Pregnancy and implantation rates in normal replacement versus stimulated cycles

The relative importance that endometrial development and embryo quality have on implantation rates achieved with assisted reproductive technology (ART) is the subject of controversy. Ovarian stimulation has been repeatedly mentioned as having a detrimental effect on endometrial receptivity (Paulson et al., 1990, Fertil. Steril., 53, 870-874). We compared pregnancy and implantation rates achieved with ART during stimulated cycles and hormonal replacement cycles, in patients matched for the following criteria: age < 35 years for the patient donating oocytes; transfer of at least two good quality embryos/oocytes and good quality transfer. All transfer cases performed during hormonal replacement cycles were done with donated oocytes. Comparison of results between techniques was not attempted due to potential differences in populations. The pregnancy and implantation rates achieved with each technique during stimulated and hormonal replacement cycles were not statistically different. In contradiction to previous results, our data suggest that differences in uterine receptivity between stimulated and hormonal replacement cycles in the age group studied are not of critical importance in embryo implantation. Good embryo quality appears to be the dominant factor in determining the success of ART.

Cystic fibrosis mutations impair the fertilization rate of epididymal sperm from men with congenital absence of the vas deferens

One of the limiting factors for the successful treatment of male sterility due to congenital absence of the vas deferens (CAVD) is the low (< 20%) and extremely unpredictable rate of in-vitro fertilization of their epididymal spermatozoa. The recent demonstration that CAVD is a mild form of cystic fibrosis (CF) disease, almost exclusively involving the genital tract, has prompted us to investigate the hypothesis of whether there could be an association between particular CF genotype mutations and the in-vitro performance of epididymal sperm. In this study 63 patients with surgically confirmed diagnosis of CAVD undergoing microsurgical epididymal sperm aspiration (MESA) and in-vitro fertilization (IVF) were evaluated. The genetic screening was carried out on DNA extracted from peripheral lymphocytes and amplified by the polymerase chain reaction. A total of 12 mutations in the cystic fibrosis transmembrane regulator gene (CFTR), representing approximately 90% of the total known CF mutations, were tested. The presence or absence of mutations, as well as the type of mutation found, was correlated with the IVF and pregnancy rates. Of the 63 patients examined, 40 (64%) were positive to the CF screening and 23 were negative. In three cases no spermatozoa were found because of rete testis blockage. The difference in fertilization rates between patients testing positive and negative was highly significant (P = 0.000003), 13 versus 23%, respectively. In order to pinpoint which mutation could account for the most deleterious effect on the IVF results, we analysed these by keeping the patients separated by CF mutations.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of intravenous albumin in patients at high risk for severe ovarian hyperstimulation syndrome

Previous experiences in subjects with other forms of third space fluid accumulation have shown that albumin is efficacious in preventing and correcting haemodynamic instability. Using a similar approach in an effort to increase the serum oncotic pressure and to reverse the leakage of fluids from the intravascular space, high risk subjects for severe ovarian hyperstimulation syndrome (SOHS) were treated with albumin. In a recent large study two high risk factors were identified, i.e. the number of oocytes and levels of serum oestradiol. Thirty-six women undergoing assisted reproductive techniques who presented both these factors, received intravenous albumin at a dose of 5% in Ringers lactate in doses of 500 ml during oocyte retrieval and 500 ml immediately thereafter in the recovery room. Daily measurements of urine output, serum and urine electrolytes, weight, abdominal girth, and haematocrit prior to and after oocyte retrieval revealed normal serum and urine electrolyte levels, and no signs of haemoconcentration. No patient in this study developed SOHS, and of course none had to be hospitalized. Vaginal ultrasound performed in the majority of the subjects revealed < or = 100 ml of peritoneal fluid 48-72 h after oocyte retrieval. The only complication from the use of intravenous albumin was the appearance of a 'flu-like condition' (low grade temperature, nausea and muscle pains) developed by 12 women between days 3 and 5 after oocyte collection. Intravenous albumin had thus prevented the development of severe ovarian hyperstimulation syndrome in an assisted reproduction programme.(ABSTRACT TRUNCATED AT 250 WORDS)

Can severe male factor infertility be treated without micromanipulation?

OBJECTIVE

To present data on IVF in severe male factor infertility using modified IVF laboratory methods and to compare them with the reported data of gamete micromanipulation.

DESIGN

Retrospective, not randomized.

SETTING

University of California, Irvine, Center for Reproductive Health.

PATIENTS

Seventy-one patients with severe oligoasthenozoospermia defined as total motile count in the pretreatment sample of < 5 x 10(6). Two groups were identified, group I with total motile count between 1.5 and 5 x 10(6) and group II with total motile count < 1.5 x 10(6).

INTERVENTIONS

Treatment of the semen samples with mini-Percoll and the modification of standard IVF techniques. These modifications include insemination with larger numbers of sperm, the use of culture tubes for insemination of oocytes, and pooling oocytes together in one or more culture tubes.

MAIN OUTCOME MEASURES

Fertilization and pregnancy rates (PRs). Additionally, the number of patients achieving cryopreservation and patients with previous failure to fertilize are specified.

RESULTS

Eighty percent of the patients achieved fertilization with an overall rate of 38% per oocyte. Fifty-three ETs were performed and 23 clinical pregnancies (43% per transfer and 35% per cycle) were achieved. Fifty percent of the patients had excess embryos for cryopreservation. In group I the fertilization rate was 54% with a PR of 56% per transfer and 48% per cycle. In group II the fertilization rate was 25% with a PR per transfer of 32% and 24% per cycle. Of 28 patients who had previous failure of fertilization, 25 fertilized and 8 pregnancies were established.

CONCLUSIONS

These data demonstrate that by the modification of standard laboratory methods for IVF, monospermic fertilization, cleavage, and a high clinical PR can be achieved in cases of severe male factor infertility without having to resort to micromanipulation.

Cumulative pregnancy rate from one gamete intra-fallopian transfer (GIFT) cycle with cryopreservation of embryos: a practical mathematical calculation

We evaluated the cumulative pregnancy rate from one gamete intra-Fallopian transfer (GIFT) cycle plus subsequent cycles in which embryos cryopreserved at the time of the original GIFT cycle were transferred. All patients who had their first GIFT cycle in our centre between January, 1989 and March, 1991 were included. Ovarian stimulation was accomplished with leuprolide acetate (luteal phase protocol) and a combination of follicle stimulating hormone and human menopausal gonadotrophin. GIFT was performed with three to five oocytes. Excess oocytes were inseminated and good quality embryos were cryopreserved at the 2- to 4-cell stage with 1-2 propanediol. When the GIFT cycle did not result in a pregnancy, uterine transfer of cryopreserved embryos was carried out in subsequent unstimulated cycles. A total of 97 patients had GIFT and 46 pregnancies were achieved (47.4%). A total of 51 patients (52.5%) had embryos frozen; of these, 21 were from the non-pregnant group (41.1%) and 30 from the pregnant group (65.2%) (P < 0.05). Up to now, 22 of them have undergone a frozen-thawed embryo transfer cycle, and two of them achieved a pregnancy. Based on these data, patients having a GIFT could theoretically expect a cumulative pregnancy rate of 52.2%.

Effect of a gonadotropin-releasing hormone agonist on luteinizing hormone receptors and steroidogenesis in ovarian cells

OBJECTIVE

To examine the effect of a gonadotropin-releasing hormone agonist (GnRH-a), leuprolide acetate (LA), on human chorionic gonadotropin/luteinizing hormone (LH) receptors content and progesterone (P) and estradiol (E2) production in cultured granulosa or luteal cells.

DESIGN

Prospective.

SETTING

Private Fertility Clinic and National Research Institute.

PATIENTS

Twenty patients undergoing in vitro fertilization or gamete intrafallopian transfer programs.

RESULTS

Human chorionic gonadotropin/LH receptors in human granulosa cells increased after 48 hours of culture, and LA inhibited such effect. Leuprolide acetate, 1 ng/mL, in the cultures produced an increase in P production. On the contrary, LA inhibited E2 production. Additionally, the in vivo effect of LA (2 micrograms/rat per 7 days) was studied in corpus luteum of superovulated rats. Luteal cells from LA-treated rats in culture produced lower P than the controls but showed an increase in aromatase activity. Luteal LH receptors declined after 48 hours of culture with LA.

CONCLUSION

The high doses of gonadotropin necessary to induce ovarian hyperstimulation when GnRH-a is administered could be related with an inhibitory effect of these agonists on LH receptors and aromatase activity.

Improvement of clinical pregnancy rate and implantation rate of in-vitro fertilization-embryo transfer patients by using methylprednisone

A prospective non-randomized study was undertaken to test whether immunosuppression improves implantation and pregnancy rates in an in-vitro fertilization-embryo transfer (IVF-ET) programme in patients with tubal factor infertility. Treatment involved ovarian stimulation, transvaginal oocyte retrieval, IVF-ET, and assessment of short-term administration of large doses of corticosteroids (60 mg of methyl-prednisone x 4 days). When compared to the group that did not receive immunosuppressive doses of methylprednisone (group A; mean age 31.85 +/- 4.09 years), those subjects who were treated (group A2) showed a statistically significant increase in pregnancy (P < 0.01) and take home baby rate (P < 0.01). Similar results were observed in subjects who received corticosteroids in their first IVF-ET attempt (group B; mean age 34.32 +/- 4.98 years). Our results suggest that immunosuppressive doses of corticosteroids administered for a short period of time to patients undergoing IVF-ET could significantly improve the implantation and pregnancy rates. Possible mechanisms of action of corticosteroids are proposed.

Aetiology of congenital absence of vas deferens: genetic study of three generations

Bilateral congenital absence of the vas deferens (CAVD) is a form of male sterility (found in otherwise normal men) of unknown aetiology. Because males with cystic fibrosis (CF) almost invariably have CAVD as well, we investigated the hypothesis that men with isolated CAVD might share a common genetic background with males with CF. Genetic testing for CF was carried out in three generations of subjects: 44 patients with CAVD and their wives, 24 of their parents, and 13 of their offspring generated by microsurgical epididymal sperm aspiration (MESA) and in-vitro fertilization (IVF). DNA extracted from peripheral lymphocytes was amplified by the polymerase chain reaction (PCR) and then analysed for 12 mutations in the cystic fibrosis transmembrane conductance regulatory (CFTR) gene. Among 44 patients tested with CAVD, 26 (59%) were positive for at least one CF mutation, while the carrier frequency for CF mutations in the general population is only 4%. Four patients were found to be compound heterozygotes, three with genotypes Delta F-508/R117H, one with R553X/R117H. Among 24 parents tested, 15 (seven fathers, eight mothers) had sons with CAVD who were positive for CF mutations. Of these, nine (four fathers and five mothers) were found to be carriers for CF mutations. These four fathers, although carriers of CF mutations, were obviously fertile. Of the 13 offspring tested, six (three boys and three girls) had CF positive fathers. Of these, three (two girls and one boy) were found to be carriers for CF mutations. These MESA/IVF children are the first offspring to whom men with CAVD have been able to transmit CF mutations.(ABSTRACT TRUNCATED AT 250 WORDS)

Transvaginal-transmyometrial embryo transfer: the Towako method; experiences of 104 cases

A new technique of ET based on US-guided transmyometrial puncture has been performed in 104 cases. Thirty-eight patients conceived for a clinical PR of 36.5% per attempt. The use of this technique is proposed to overcome problems of difficult transfers because of cervical abnormalities. No serious complications were observed.

An analysis of social and psychological characteristics of women volunteering to become oocyte donors

OBJECTIVES

To design a recruitment program and analysis to determine social and psychological characteristics of women who volunteer to be oocyte donors; to evaluate consistency between clinical interviews and psychological testing; and to determine whether socially and psychologically normal women tend to volunteer.

PARTICIPANTS

Over a 2-year period 95 women were recruited from a middle-class population surrounding the medical center. Candidates were evaluated on the basis of clinical interviews and performance on the Minnesota Multiphasic Personality Inventory. Seventy-three percent were accepted, and 63% donated oocytes.

INTERVENTIONS

Interviews and psychological test evaluation were conducted independently by a clinical sociologist and a clinical psychologist; selections were made in a meeting of the treatment team.

RESULTS

Interview and test data demonstrated consistency and indicated that women who volunteer tend to be socially conventional, outgoing, and free from psychopathology. The typical donor tends to be 26 years old, married with one or two children, holds religious or spiritual beliefs, has 2 years of college, works at least part-time in a white collar job, and is a person with high energy who has additional interests. Incidence of dysfunction in family of origin or family of orientation (abandonment, abuse) is unremarkable. Although motherhood is highly valued by oocyte donor volunteers, in test performance this group does not endorse traditional female role stereotypes.

CONCLUSIONS

We have determined that this recruitment protocol is reliable for screening normal oocyte donors and would recommend its use in programs involved in oocyte donation.

Relationship of epididymal sperm antibodies to their in vitro fertilization capacity in men with congenital absence of the vas deferens

OBJECTIVES

To test, using the immunobead binding technique, for the presence of antisperm antibodies on epididymal sperm, in epididymal fluid, and in serum of men with congenital absence of the vas deferens. To evaluate the in vitro fertilization (IVF) capacity of human epididymal sperm in the presence of antisperm antibodies.

DESIGN

Prospective. At the time of oocyte insemination, sperm from the proximal caput epididymis or vasa efferentia were tested by direct immunobinding technique. The epididymal fluid and serum were tested by indirect immunobinding technique.

SETTING

Center for Reproductive Health, University of California-Irvine.

PATIENTS

Forty-five patients with congenital absence of the vas deferens participating in the microsurgical epididymal sperm aspiration and IVF program.

MAIN OUTCOME MEASURE

Incidence of antisperm antibodies to epididymal sperm and their relationship with IVF results.

RESULTS

Sixteen men (35%) tested positively to the direct immunobead test on epididymal sperm; 7 (16%) were positive in epididymal fluid and 13 (29%) were positive in serum. Five pregnancies (31%) occurred in the positive group of which two were from patients who had sperm binding of 100% for immunoglobulin (Ig)G (all over sperm surface) and 90% (midpiece, tail) and 50% (tail, tiptail), respectively, for IgA. Five pregnancies (18%) were obtained in the negative group. No statistical difference was observed in the overall fertilization rate between the two groups.

CONCLUSION

Human epididymal sperm and epididymal fluid retrieved from men with congenital absence of the vas deferens can react positively to immunobead test. However, the presence of antisperm antibodies do not seem to impair the IVF capacity of epididymal sperm.

Penetration of zona-free hamster oocytes using human sperm aspirated from the epididymis of men with congenital absence of the vas deferens: comparison with human in vitro fertilization

OBJECTIVES

To assess the ability of sperm aspirated from the epididymis of men with congenital absence of the vas deferens to penetrate zona-free hamster oocytes. To directly compare the performance of human epididymal sperm in the zona-free hamster oocyte sperm penetration assay (SPA) with the results of human in vitro fertilization (IVF).

DESIGN

Sperm penetration assay was carried out with epididymal sperm retrieved microsurgically, and with ejaculated sperm obtained from fertile donors (internal controls). For direct comparison, SPA was performed with the same epididymal sperm sample used for IVF.

PATIENTS, PARTICIPANTS

Men with congenital absence of the vas deferens undergoing sperm aspiration as part of their infertility treatment and control donors who provided ejaculated sperm.

RESULTS

Epididymal sperm penetrated SPA with a score of 0% to 30%. The SPA scores for internal controls using ejaculated sperm was 30% to 71%. Linear regression analysis of the association between penetration scores in SPA and fertilization rate in IVF indicated a positive correlation that was highly significative.

CONCLUSIONS

These findings using SPA confirm previous reports on the fertilizing potential of human epididymal sperm and its ability to produce normal pregnancies. The good correlation between SPA and human IVF using epididymal sperm suggest that SPA is an excellent bioassay to test laboratory experimental conditions for improving fertilizing capacity of human epididymal sperm.

Failed oocyte retrieval after lack of human chorionic gonadotropin administration in assisted reproductive technology

OBJECTIVE

To document the absence of oocytes in follicular aspirates in women who, during controlled ovarian stimulation with gonadotropin-releasing hormone agonist (GnRH-a) and menotropins, fail to receive human chorionic gonadotropin (hCG) administration.

DESIGN

Retrospective analysis of clinical laboratory data.

SETTING

Multicentric.

PATIENTS

Five women undergoing controlled ovarian hyperstimulation with GnRH-a and menotropins for programs of assisted reproductive technologies.

RESULTS

The documented absence of an hCG injection produced "empty follicles" at transvaginal guided aspiration, despite numerous follicular lavages and aspiration of peritoneal fluid. The lack of oocytes and granulosa-cumulus complex in the follicular fluid was reverted in other cycles in the same patients when hCG was properly administered.

CONCLUSIONS

(1) This study emphasizes the importance of proper patients' and nurses' instructions for preparation of hCG injections and proper mixture of vehicle and powder before follicular aspiration. (2) In the absence of cumulus-corona-oocyte complex at aspiration, measure serum beta-hCG to ascertain whether hCG injection was administered or not. (3) Routine preoperative beta-hCG levels may be helpful to avoid unnecessary surgeries.

Epididymal sperm in assisted reproductive technology

Infertile men with obstructive azoospermia mainly due to congenital absence of the vas deferens (CAVD) now have the option of trying to father their own progeny. In fact, in the last five years epididymal sperm retrieval microsurgically have been successfully used for in vitro fertilisation of human oocytes. In this report the clinical results of 98 consecutive procedures of microsurgical epididymal sperm aspiration (MESA) combined with in vitro fertilisation (IVF) and tubal embryo transfer (TET) are described. An overall fertilisation rate of 17% and a pregnancy rate of 36% per transfer is reported. Five of the 18 pregnancies resulted in abortion (27%) and 13 were delivered at term. Additionally, extra embryos for freezing and potential use for future attempts were made available for 13 couples. Men with CAVD have also allowed the study of spermatogenesis, immunological response and sperm disposal mechanisms in condition of chronic obstruction.

Ultrastructure of human sperm in men with congenital absence of the vas deferens: clinical implications

OBJECTIVE

To determine the ultrastructural features of epididymal and vasa efferentia sperm in men with congenital absence of the vas deferens.

DESIGN

Prospective.

SETTING

University of California Irvine Center for Reproductive Health.

PATIENTS

Thirteen men with surgical diagnosis of congenital absence of the vas deferens undergoing epididymal and vasa efferentia aspiration for assisted reproductive technology procedures.

RESULTS

The morphological quality and the integrity of the spermatozoa aspirated from the extratesticular segment of the rete testis, the vasa efferentia, and the caput epididymis were always markedly superior to those of sperm aspirated from the corpus and cauda epididymis, where the vast majority, if not all, were degenerating or frankly necrotic. The aspirates obtained from the distal segments of the epididymis also contained large numbers of sperm-laden macrophages; these were instead absent or exceptional in the fluids aspirated from the pre-epididymal portions of the excurrent pathways and from the caput of the epididymis.

CONCLUSIONS

This study demonstrates that the ultrastructural morphology of spermatozoa obtained by aspiration from the rete testis, vasa efferentia, and caput epididymis of individuals with congenital absence of the vas deferens is indistinguishable from that of spermatozoa in the semen.

The role of the laboratory in the handling of epididymal sperm for assisted reproductive technologies

This report describes the historical experience of our laboratory in the handling and processing of epididymal sperm from men with congenital absence of the vas deferens. Three different methods of sperm preparation were used: swim-up or resuspension in the first group of patients treated, mini-Percoll in the second group, and mini-Percoll used in conjunction with pentoxifylline and 2' deoxyadenosine in the third group. Twenty-four percent of cases achieved fertilization in group I, whereas in groups II and III the rate was 59% and 57%, respectively. Fertilization rates in each group were 6.5% in group I, 16% in group II, and 35% in group III. Three pregnancies were obtained in group I, 13 in group II, and 2 in group III. Groups II (21%) and III (63%) were able to have excess embryos to cryopreserve.

Replacement of frozen embryos generated from epididymal spermatozoa: the first two pregnancies

This report describes the first two pregnancies which occurred after cryopreservation, thawing and transfer of embryos generated using epididymal spermatozoa from men with congenital absence of the vas deferens. Of the 32 embryos that were thawed, 24 survived (75%) and were replaced in seven transfer cycles resulting in two (29%) pregnancies successfully delivered. The demonstration that excess embryos obtained with the use of epididymal spermatozoa can be safely frozen/thawed, and that their survival is not different from other embryos generated by in-vitro fertilization, represents a great advantage for the reproductive performance of men with congenital absence of the vas deferens undergoing microsurgical aspiration of epididymal spermatozoa.