Implementing Mycoplasma genitalium testing across a London-based sexual health service: A quality improvement project

Recent national guidelines recommended testing for Mycoplasma genitalium (MG) in clinically-indicated conditions (CIC) including non-gonococcal urethritis (NGU), pelvic inflammatory disease (PID) and epididymo-orchitis. Over five months in 2018 a quality improvement project (QIP) was carried out across three London sexual health clinics with the aim of increasing MG testing rates in CICs. Three Plan-Do-Study-Act (PDSA) cycles were completed: improving IT access, an education event and reminder emails for clinicians who did not test in CIC. To measure testing rates ten patients from each CIC were randomly selected each week and MG testing outcomes were collected. As a balancing measure, we identified the rate of inappropriate MG testing. MG testing rates in patients with NGU increased to 90% following QIP initiation (baseline rate 60%) and this increase was sustained. No increase in MG testing was seen in PID and epididymo-orchitis. Inappropriate MG test rates were high (median of 11%) but remained constant throughout the QIP period. As MG testing is expanding across the UK, we outline a QIP integrating MG testing into a busy multi-site, sexual health service improving testing uptake while not increasing inappropriate testing.

The Development of Gonadotropins for Clinical Use in the Treatment of Infertility

The first commercially available gonadotropin product was a human chorionic gonadotropin (hCG) extract, followed by animal pituitary gonadotropin extracts. These extracts were effective, leading to the introduction of the two-step protocol, which involved ovarian stimulation using animal gonadotropins followed by ovulation triggering using hCG. However, ovarian response to animal gonadotropins was maintained for only a short period of time due to immune recognition. This prompted the development of human pituitary gonadotropins; however, supply problems, the risk for Creutzfeld-Jakob disease, and the advent of recombinant technology eventually led to the withdrawal of human pituitary gonadotropin from the market. Urinary human menopausal gonadotropin (hMG) preparations were also produced, with subsequent improvements in purification techniques enabling development of products with standardized proportions of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) activity. In 1962 the first reported pregnancy following ovulation stimulation with hMG and ovulation induction with hCG was described, and this product was later established as part of the standard protocol for ART. Improvements in immunopurification techniques enabled the removal of LH from hMG preparations; however, unidentified urinary protein contaminants remained a problem. Subsequently, monoclonal FSH antibodies were used to produce a highly purified FSH preparation containing <0.1 IU of LH activity and <5% unidentified urinary proteins, enabling the formulation of smaller injection volumes that could be administered subcutaneously rather than intramuscularly. Ongoing issues with gonadotropins derived from urine donations, including batch-to-batch variability and a finite donor supply, were overcome by the development of recombinant gonadotropin products. The first recombinant human FSH molecules received marketing approvals in 1995 (follitropin alfa) and 1996 (follitropin beta). These had superior purity and a more homogenous glycosylation pattern compared with urinary or pituitary FSH. Subsequently recombinant versions of LH and hCG have been developed, and biosimilar versions of follitropin alfa have received marketing authorization. More recent developments include a recombinant FSH produced using a human cell line, and a long-acting FSH preparation. These state of the art products are administered subcutaneously via pen injection devices.

Multi-centre phase IV trial to investigate the immunogenicity of a new liquid formulation of recombinant human growth hormone in adults with growth hormone deficiency

PURPOSE

To investigate whether a new liquid formulation of recombinant human growth hormone (r-hGH) induces the production of binding antibodies (BAbs) in adults with congenital or adult-onset growth hormone deficiency (GHD).

METHODS

Men or women aged 19-65 years with adult growth hormone deficiency who were r-hGH-naïve or had stopped treatment ≥ 1 month before screening were treated with between 0.15 and 0.30 mg/day r-hGH liquid formulation for 39 weeks. The primary endpoint was the proportion of patients who developed BAbs at any time. Secondary endpoints were the proportion of patients with BAbs who became positive for neutralising antibodies, the effects on biomarkers of r-hGH exposure, safety, and adherence to treatment downloaded from the easypod™ connect software.

RESULTS

Seventy-eight patients (61.5% men) with mean age 44.5 years (range 21-65) started and 68 (87.2%) completed the 39-week treatment period. 82.1% were treatment naïve; all were negative for BAbs to r-hGH at baseline. The median (interquartile range) duration of treatment [273 (267.0-277.0) days] was consistent with patients receiving the required doses, and mean treatment adherence measured using easypod™ connect was 89.3%. The proportion of patients who developed BAbs was 0% (95% confidence interval 0-4.68%) and biomarker profiles were consistent with exposure to r-hGH. 92.3% of patients reported ≥ 1 adverse event during treatment. Most events were mild or moderate and no new safety concerns were detected.

CONCLUSIONS

The low immunogenicity profile of the liquid formulation was consistent with that for the freeze-dried formulation, and no new safety concerns were reported.

The personal burden for caregivers of children with phenylketonuria: A cross-sectional study investigating time burden and costs in the UK

INTRODUCTION

Management of phenylketonuria (PKU) is mainly achieved through strict dietary control that aims to limit the intake of phenylalanine (Phe). Adherence to this diet is burdensome due to the need for specially prepared low-Phe meals and regular monitoring of Phe concentrations. A UK cross-sectional study was conducted to identify the personal time and monetary burden associated with aspects of the PKU lifestyle for caregivers of children (aged < 18 years) living with PKU.

METHODS

Caregivers of pediatric patients with PKU attending one of four specialist metabolic centers in the UK were invited to participate in a questionnaire-based survey that evaluated different aspects of PKU management that could potentially present out-of-pocket costs (OOPCs) or time burden. Medical clinicians/dieticians provided patient information on PKU severity and an assessment of blood Phe control.

RESULTS

The survey was completed by 114 caregivers of 106 children having mild or moderate (n = 45; 39%) or classical (n = 60; 53%) PKU (severity data missing for n = 1), among whom 8 (8%) and 87 (82%) reported poorly controlled and controlled blood Phe status, respectively; Phe control data were missing for 11 children. Dietary management of PKU incurred a median time burden of > 19 h per week. OOPCs were incurred via attendance at PKU events, PKU-related equipment, and extra holiday expenditure. 21% of caregivers reduced their working hours (median 18.5 h/week) to care for their child, with a further 24% leaving their paid jobs completely.

DISCUSSION AND CONCLUSIONS

Dietary management of PKU is associated with a considerable time burden for caregivers of pediatric patients with PKU. A personal financial burden also arises from OOPCs and lost earnings.

Midluteal serum progesterone levels and pregnancy following ovulation induction with human follicle-stimulating hormone: results of a combined-data analysis

OBJECTIVE

This retrospective analysis of combined data (one Phase II and three Phase III clinical trials) of patients with oligo- or anovulatory infertility aimed to evaluate the association between pregnancy and midluteal serum progesterone (P4) level following ovulation induction and hence the indicative value of P4 for ovulation and pregnancy achievement.

STUDY DESIGN

All patients (n = 913) were treated with human follicle-stimulating hormone. Cycles (n = 1,554) with one or two serum P4 levels in the luteal phase (days 5-12) following human chorionic gonadotropin administration and complete data on cycle outcome were included.

RESULTS

Clinical pregnancy was achieved in 295/1,554 (19.0%) cycles; 87.5% of these led to live births (16.6%/cycle). Including and excluding multiple pregnancy data, 88% and 86% of all live births had P4 values >10 ng/mL, respectively. Overall clinical pregnancy rate plateaued at midluteal P4 levels >25 ng/mL but, when multiple pregnancies were excluded, plateaued at 20-25 ng/mL and then decreased. Mean midluteal P4 levels were twice as high in multiple versus singleton pregnancies.

CONCLUSION

A midluteal P4 level >10 ng/mL may represent an appropriate threshold for indication of ovulation resulting in live birth. Multiple pregnancies were associated with higher mean midluteal P4 levels.

Individualizing FSH dose for assisted reproduction using a novel algorithm: the CONSORT study

The CONSORT dosing algorithm individualizes recombinant human FSH (r-hFSH) doses for assisted reproduction technologies, assigning 37.5 IU increments according to patient characteristics: basal FSH, body mass index, age and antral follicle count. A prospective, uncontrolled, international, 18-centre, pilot study of normo-ovulatory women aged 18-34 years inclusive undergoing a long agonist treatment protocol was performed. Follitropin alpha filled-by-mass (GONAL-f) dose was assigned by the algorithm and was intended to be altered only for risk of ovarian hyperstimulation syndrome (OHSS). Primary end-point was number of oocytes retrieved. Dose groups containing >or=5 patients were analysed: 75 IU (n = 48), 112.5 IU (n = 45), 150 IU (n = 34), 187.5 IU (n = 24), 225 IU (n = 10). Cancellations due to inadequate response were higher than expected in the 75 IU group (12/48). Overall, a median of 9.0 oocytes were retrieved (8.5, 8.0, 10.0, 12.0 and 8.0 in the 75, 112.5, 150, 187.5 and 225 IU groups respectively). Clinical pregnancy rates/cycle started were 31.3, 31.1, 35.3, 50.0 and 20.0%, respectively (overall, 34.2%). Two patients had severe OHSS. Use of the CONSORT algorithm achieved an adequate oocyte yield and good pregnancy rates in this preliminary study. Adjustment of the algorithm could reduce cancellation rates.

Recombinant human leukemia inhibitory factor does not improve implantation and pregnancy outcomes after assisted reproductive techniques in women with recurrent unexplained implantation failure

In this randomized, double-blind, placebo-controlled, multicenter study, women (n = 149) with a history of at least two unexplained implantation failures after assisted reproductive techniques received recombinant human leukemia inhibitory factor, 150 microg SC twice daily for 7 days, or placebo. The clinical pregnancy rate after ET was significantly lower in patients receiving recombinant human leukemia inhibitory factor than in those receiving placebo (17.6% vs. 34.0%, respectively).

Predictive factors and a corresponding treatment algorithm for controlled ovarian stimulation in patients treated with recombinant human follicle stimulating hormone (follitropin alfa) during assisted reproduction technology (ART) procedures. An analysis of 1378 patients

BACKGROUND

Identifying parameters that can accurately predict the response to controlled ovarian stimulation (COS) would be of great benefit in assisted reproductive technology (ART) procedures. An analysis was undertaken with the objective of determining whether specific factors could optimally predict a response to stimulation in ART, and to then develop a corresponding treatment algorithm that could be used to calculate the optimal starting dose of recombinant human follicle stimulating hormone (r-hFSH; follitropin alfa) for selected patients.

METHODS

The overall population consisted of 2280 normo-ovulatory ART patients from 11 randomised clinical trials. However, for the final analysis population, only patients less than 35 years of age who received r-hFSH monotherapy (N = 1378) were included.

RESULTS

Backwards stepwise regression modelling indicated that predictive factors for ovarian response included basal FSH, BMI, age and number of follicles < 11 mm at baseline screening. The concordance probability index was 59.5% for this model.

CONCLUSIONS

In the largest data series so far analysed to determine predictive factors of ovarian response, basal FSH, BMI, age and number of follicles < 11 mm at screening were the most important variables in ART patients less than 35 years of age who were treated with r-hFSH monotherapy. Using these four predictive factors, a follitropin alfa starting dose calculator was developed that can be used to select the FSH starting dose required for an optimal response. The relevance of this dose calculator will be evaluated in a prospective clinical trial.

Luteal phase support

Assisted reproductive techniques have become a routine treatment for infertility. The extended use of gonadotrophin-releasing hormone analogues in assisted reproductive techniques has made luteal phase support mandatory, as it has been clearly demonstrated that they alter luteal LH pulsatility. For luteal support, HCG administration, though effective, has a high risk of ovarian hyperstimulation syndrome. Progesterone continues to be the gold standard for supplementation. Vaginal progesterone represents a highly effective alternative to painful intramuscular injections. The vaginal route is mainly characterized by direct delivery of the progesterone to the endometrium, thus producing high levels at the target tissue and a very low incidence of side effects.

Clinical management of functional ovarian cysts: a prospective and randomized study

Most ovarian cysts in women of reproductive age are physiological (functional) and patients have been treated for years with oral contraceptives to obtain the resolution of these cysts. Expectant management has been suggested to have the same effectiveness as hormonal treatment but such suggestions come from studies including all kinds of cysts. The objective of the present study was to assess the resolution of functional ovarian cysts, observed after ovulation induction, with expectant management and hormonal treatment and also to determine the period of time necessary for the resolution of the cysts. For this purpose, 53 patients with ovarian cysts, observed by transvaginal ultrasound within the first 5 days of a cycle after ovulation induction, were randomized to have expectant management (group A) or to receive oral contraception (group B) for one cycle. If the cyst persisted, the patient was followed for another cycle, without any treatment. Within the 50 women who completed the trial, a complete resolution of the cysts was observed in 19/25 (76%) and 18/25 (72%) in groups A and B respectively. On the other hand, all the persistent cysts disappeared after a second cycle without any treatment. In conclusion, expectant management is as effective as oral contraceptives for the resolution of functional ovarian cysts induced by ovarian stimulation. However, studies with a larger number of cases are needed to increase the power of the results and to obtain a firm conclusion.

Prospective randomized trial to evaluate the efficacy of a vaginal ring releasing progesterone for IVF and oocyte donation

A polysyloxane vaginal ring containing 1g of natural progesterone was developed as luteal supplementation for women treated with IVF-embryo transfer and for agonadal women participating in an oocyte donation programme. The ring provides continuous release of progesterone (10-20 nmol/l) for 90 days. The efficacy of this form of progesterone supplementation was evaluated in two multicentre prospective randomized trials. IVF-embryo transfer trial: After oocyte aspiration, 505 women were randomly allocated to progesterone supplementation with vaginal ring or i.m. progesterone (50 mg/day). The clinical pregnancy rate was 36.6% in both groups. Implantation rate was 15.9% in the vaginal ring and 16.0% in i.m. progesterone. Oocyte donation trial: After endometrial proliferation with micronized oestradiol, 153 women were allocated to progesterone replacement with a vaginal ring or i.m. progesterone (100 mg/day). Clinical pregnancy rate was 39.8 and 28.6% respectively. Implantation rate was significantly higher with the vaginal ring compared with i.m. progesterone (19.9 and 11.6% respectively, P = 0.006). The vaginal ring is a novel development which provides continuous release of progesterone for 90 days. In IVF-embryo transfer, its effectiveness is similar to daily i.m. injections. In oocyte donation the ring provides a progestative milieu which improves the implantation rate and eliminates the discomfort of daily i.m. injections.

Preliminary results on the role of embryonic human chorionic gonadotrophin in corpus luteum rescue during early pregnancy and the relationship to abortion and ectopic pregnancy

The precise mechanisms by which corpus luteum (CL) function is modulated during early pregnancy are not known. Evidence in failed pregnancies (ectopic, abortions), shows that factors other than human chorionic gonadotrophin (HCG) could be involved in its regulation. The objective of this study was to investigate the dynamics of beta-HCG, progesterone and oestradiol production in early pregnancy and its relation to embryonic quality and topographic localization. Plasma concentrations of progesterone, oestradiol and beta-HCG were studied between days +12 and +21 after an in-vitro fertilization (IVF) embryo transfer in 11 intrauterine pregnancies, 10 intrauterine abortions and seven tubal pregnancies. Tubal pregnancies and abortions were grouped according to doubling time (DT) of HCG. Results showed that oestradiol concentrations were apparently reduced in both ectopic pregnancies and abortions compared with normal pregnancies. The fall in oestradiol concentrations was seen in ectopic pregnancies with an abnormal DT for HCG and in all abortions. When the ectopic pregnancy had a normal DT, oestradiol and progesterone concentrations were normal. In abortions, the fall in oestradiol and progesterone concentrations was less influenced by the DT of HCG. These findings suggest that corpus luteum function depends on an adequate DT of HCG more than an absolute value, and with normal trophoblastic tissue the site of implantation does not affect CL function.

Comparison of ultrasonography and hysteroscopy in the diagnosis of intrauterine lesions in infertile women

STUDY OBJECTIVE

To compare the effectiveness of transvaginal ultrasound versus hysteroscopy in the diagnosis of benign intrauterine lesions, with histology as the gold standard.

DESIGN

Retrospective study (Canadian Task Force classification II-1).

SETTING

Unit of Reproductive Medicine, Department of Obstetrics and Gynecology of Clinica Las Condes, Santiago, Chile.

PATIENTS

Infertile women who had undergone complete fertility evaluation.

INTERVENTION

Transvaginal ultrasound, hysteroscopy, and histologic evaluation of endometrial samples performed in all 126 women.

MEASUREMENTS AND MAIN RESULTS

The most frequent condition was a normal cavity (59.5%), followed by endometrial polyps (34.9%) and fibromyomas (3.9%). Synechiae and bone metaplasia were extremely rare. Sensitivity of transvaginal ultrasound for the diagnosis of endometrial polyps was 95.6% compared with 89.9% for hysteroscopy (NS). Specificity was 97.4% with transvaginal ultrasound versus 93. 3% with hysteroscopy (NS). Positive and negative predictive values were similar for both methods.

CONCLUSION

Transvaginal ultrasound is as effective as hysteroscopy in diagnosing benign intrauterine lesions. It could be the first clinical diagnostic test in the investigation of the uterine cavity.

Comparison of Ultrasonography and Hysteroscopy in the Diagnosis of Intrauterine Lesions in Infertile Women

Transvaginal ultrasound is a noninvasive diagnostic technique that remains to be proved as accurate as hysteroscopy in the diagnosis of benign intrauterine lesions. We compared its efficacy with that of hysteroscopy in the diagnosis of benign intrauterine pathology in 126 infertile women in whom the diagnosis was confirmed by histologic studies. The women had a complete evaluation with preoperative transvaginal ultrasound, hysteroscopy, and histologic analysis of uterine cavity specimens. Sensivity, specificity, and predictive values were calculated for ultrasound and hysteroscopy considering the histologic study as 100%. Sensivity was 95% and 100%, and specificity 97.4% and 93.7% for transvaginal ultrasound and hysteroscopy, respectively. The positive predictive value for benign intrauterine lesions was 100% for ultrasound and 89.8% for hysteroscopy. The most frequent intrauterine lesions found were polyps and myomas. Transvaginal ultrasound is a valuable method of diagnosing benign intrauterine lesions in infertile women, and is especially important as a noninvasive technique to plan hysteroscopic surgery.

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.

[Follicular and endometrial growth profiles in stimulated cycles with clomiphene citrate]

To study follicular and endometrial growth patterns in Clomiphene Citrate (CC) stimulated cycles, 50 CC cycles of 31 infertile women with patient Fallopian Tubes, were followed, 17 spontaneous conceptional cycles of fertile women were followed as controls. The pattern of follicular growth was similar in both groups until the day before ovulation in which CC cycles showed larger follicular diameters than spontaneous ones; 23.8 +/- 3.1 mm versus 21.6 +/- 2.9 mm (p = 0.013). Follicular rupture occurred on day 16.1 +/- 2.9 in CC cycles, and on day 15.1 +/- 1.85 on spontaneous conceptional ones. This suggests that the follicle, under the influence of CC, has to reach a larger critical mass to produce enough estradiol to revert the hypothalamic blockage produced by the drug, thus permitting the preovulatory LH surge. Endometrium under CC action, was always thinner than in natural cycles. On the day of follicular rupture, the CC cycle's endometrium measured 11.1 +/- 2.02 mm and the natural cycle's endometrium measured 10.6 +/- 1.8 mm (ns). This finding could be attributed to a antiestrogenic effect of CC on the endometrium. It is concluded that cycles under CC action have different follicular and endometrial growth patterns than spontaneous conceptional cycles.

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.

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%.

[Simplified management of an in vitro fertilization program]

The development of in vitro fertilization has accelerated in a dramatic way the understanding on gamete physiology. Results obtained with the technique are easily reproducible and consistent between different centers. It is well known that cumulative pregnancy rates with 5 or 6 cycles can reach up to 60% of couples being pregnant. However, the main limitations to successive attempts have been the cost of the procedure and the surgical transfer of the embryos. In an attempt to overcome this difficulties, efforts has been made to simplify the monitoring of induction of ovulation, use of GnRh analogs and non surgical transfers whenever it is possible. Results presented in 47 of these cycles show non significant differences, with data published elsewhere, on oocyte maturity, fertilization and cleavage rates. Moreover pregnancy rates per aspiration are 28.6% and per transfer 33.3%. We can conclude that ultrasonography alone to monitor ovulation induction as well as uterine transfers do not affect the outcome of the cycle.

Embryo implantation rates in oocyte donation: a prospective comparison of tubal versus uterine transfers

OBJECTIVE

To compare pregnancy and implantation rates in tubal and uterine transfers during a hormonal replacement cycle in an oocyte donation program.

DESIGN

Prospective randomized.

PATIENTS

Forty-two consecutive patients who entered an oocyte donation program.

INTERVENTIONS

Twenty-two patients were assigned for uterine transfer and 20 for tubal embryo transfer (ET).

RESULTS

Twenty-three pregnancies were achieved, 12 (54.5%) after uterine transfers and 11 (57.9%) after tubal transfers. Implantation rates in both groups are not significantly different (17.4% uterine transfers versus 21.5% tubal ETs).

CONCLUSIONS

Our results suggest that in hormonal replacement cycles (uniform endometrial stimulation) there is no advantage in transferring embryos to the fallopian tube. Furthermore, embryo quality and endometrial receptivity appear to be significantly more important than the time of entrance of an embryo to the uterine cavity in determining its chances of implantation.

Embryo implantation rates in stimulated and hormonal replacement cycles: uterine versus tubal transfers

The relative importance that endometrial development and the time of entrance of embryos to the uterine cavity have on their chances of implantation, is controversial. We review pregnancy rate (PR) and implantation rate (IR) on 186 patients selected based on the following criteria: 1) age < or = 35 for patients undergoing ovarian stimulation. 2) transfer of at least two good quality embryos and 3) quality of the transfer: optimum. 131 patients received embryos during a Stimulated Cycle (SC). 67 of them had uterine (UT) and 64 tubal transfers (TT), with PR of 38.8% and 53.1% (N.S.) and IR of 13.9% and 20.9% (p < 0.005) respectively. 55 patients received embryos in a Hormonal Replacement Cycle (HRC). 28 of them had UT and 27 TT. PR were 53.6% and 62.9% (N.S.) and IR 17.0% and 21.6% (N.S.) respectively. Our data suggests that: 1) the delayed entrance of embryos into the uterus and/or their atraumatic transfer into the tubes does not seem to improve their chances of implanting. 2) Endometrial differences between stimulated and hormonal replacement cycles seem not to be of critical importance after 48 to 72 hours after oocyte aspiration. 3) A detrimental effect of the endometrial milieu of stimulated cycles, that express only the first 48 to 72 hours after oocyte aspiration, is suggested.