Blastocyst development and pregnancies after IVF of mature oocytes retrieved from unstimulated patients with PCOS after in-vivo HCG priming.

A major side-effect of controlled ovarian stimulation (COS) in patients with polycystic ovarian syndrome (PCOS) is the risk of ovarian hyperstimulation syndrome (OHSS). In-vitro maturation (IVM) of immature oocytes represents a potential alternative for the fertility treatment of these patients. Two patients at high risk of OHSS were primed with 10,000 IU HCG 36 h before oocyte retrieval. After retrieval, oocyte maturity was evaluated. Oocytes considered to be mature at the time of collection were inseminated by IVF or ICSI, and the resulting embryos were cultured to blastocysts. Transfer of these blastocysts resulted in pregnancy in both patients. Immature oocytes were cultured in YS medium supplemented with 30% human follicular fluid, 1 IU/ml rFSH, 10 IU/ml HCG and 10 ng/ml epidermal growth factor (rhEGF). After in-vitro maturation of the oocytes, ICSI was performed. Two and five expanded blastocysts were obtained after 5 day culture and were cryopreserved. This report indicates that mature oocytes can be collected at the time of retrieval using only in-vivo HCG priming in women with PCOS, and clinical pregnancy can be established by transfer of blastocysts derived from the mature oocytes. This approach opens a potential for a new dimension in the management of patients with PCOS.     

Avoiding multiple pregnancies in ART: consideration of new strategies

To maximize pregnancy rates, physicians who perform IVF, often transfer multiple embryos, which increases the multiple birth risk. Multiple birth infants are at significant risk for a number of adverse outcomes including preterm delivery, low birth weight, congenital malformations, fetal and infant deaths and long term morbidity and disability among survivors. Since the ultimate goal for an IVF treatment is the birth of a healthy infant, an important issue for all kinds of assisted reproductive technologies (ART) must be the reduction or elimination of multiple pregnancies. In this article, different strategies to avoid multiple births in ART are discussed.     

The effect of HCG supplementation after combined GnRH agonist/HMG treatment in an IVF programme

The necessity of luteal-phase supplementation in an IVF programme is of continuing interest. After ovarian stimulation with clomiphene and human menopausal gonadotrophin (HMG), the beneficial effect of supporting the luteal phase has never been scientifically demonstrated. After ovarian stimulation with GnRH agonist/HMG, the luteal phase seems to be inadequate, but in a previous study we did not find evidence to support the need for oral progesterone supplementation. To evaluate the beneficial effect of human chorionic gonadotrophin (HCG) supplementation, we performed a multicentre, double-blind, randomized study with HCG (193 transfers) against placebo (194 transfers). The ongoing pregnancy rate per transfer cycle was significantly better with HCG (18.7 versus 9.3). This is the first truly objective (randomized) study demonstrating the beneficial effect of supporting the luteal phase in an IVF programme.     

Baseline non-fasting serum leptin concentration to body mass index ratio is predictive of IVF outcomes

BACKGROUND: The present study was designed to determine whether circulating leptin concentrations and/or body mass index (BMI) in women undergoing IVF are predictive of outcomes. METHODS: IVF cycle outcomes, e.g. fertilization, embryo development, implantation, pregnancy, were analysed relative to baseline (i.e. day gonadotrophin stimulation was initiated) non-fasting serum leptin concentrations and BMI. RESULTS: Serum leptin concentrations correlated with BMI (r = 0.739, P < 0.0001) as expected. Multiple logistic regression analyses showed correlation between serum leptin and pregnancy success (likelihood ratio = 5.198, P < 0.05), but there was no association between pregnancy and BMI. However, the serum leptin to BMI ratio was more strongly correlated (likelihood ratio = 7.258, P < 0.01) with pregnancy success than was leptin alone. Moreover, women with a low leptin:BMI ratio (< or =0.3) had significantly more superior quality embryos on day 3 post-retrieval (2.5 versus 1.4, P < 0.05, Kruskal-Wallis) and a greater implantation rate (26.7 versus 13.2%, P < 0.025, chi(2)) than women with a high leptin:BMI ratio (> or =0.7). CONCLUSIONS: The leptin:BMI ratio appears to be highly predictive of IVF success. Elevated leptin concentrations, particularly relative to BMI, may negatively impact fertility by assisted reproduction, possibly through direct ovarian actions resulting in impaired oocyte quality and/or early embryo development.     

Maternal serum HCG is higher in the presence of a female fetus as early as week 3 post-fertilization

BACKGROUND: Maternal serum HCG (MSHCG) is higher when the fetus is a female than when it is male. This has been demonstrated in the second and third trimesters of pregnancy, and recently at 10-14 weeks gestation. In this study we assessed whether this gender-related difference can be detected as early as week 3 post-fertilization. METHODS: The IVF setting was chosen because it provides precise dating of gestational age and early sonography for the number of gestational sacs. The study included 347 IVF cycles from 335 patients. Only pregnancies with a single implanted embryo that resulted in a single live birth of known gender were included. MSHCG was measured on days 14-20 post-fertilization, and levels were expressed as gestational age-corrected multiples of the median (MoMs). The log10 MSHCG MoMs were compared according to fetal gender. RESULTS: MSHCG levels were significantly higher (18.5%) in week 3 post-fertilization in the presence of a female fetus (P < 0.0002). CONCLUSION: Because a fetal gender-related difference in MSHCG can be demonstrated as early as week 3 post-fertilization, the difference may be attributed to placental factors and not to the effects of the fetal hypothalamic-hypophyseal-gonadal axis.     

Influence of the duration of the oestradiol rise on the success rate in GnRH analogue/HMG-stimulated IVF cycles

The influence of the duration of the serum oestradiol (E2) rise before human chorionic gonadotrophin (HCG) injection on the outcome of in-vitro fertilization (IVF) cycles was investigated. Two different stimulation protocols were compared. In 218 cycles, the Norfolk protocol for stimulation with human menopausal gonadotrophin (HMG) was used (protocol A). In 235 cycles, pituitary function was suppressed by a single injection of a long-acting GnRH analogue ('Decapeptyl microcapsules') before HMG stimulation was started (protocol B). The overall pregnancy rates were significantly higher with protocol B (22% per puncture, 21% per started cycle) than with protocol A (14% per puncture, 9% per started cycle). For each interval of E2 rise duration (5-11 days), the fertilization rates (per oocyte) and the pregnancy rates (per puncture) were evaluated. There was a clear-cut maximum of the pregnancy rates for 6 and 7 days of E2 rise (21 and 16% respectively) for protocol A. For protocol B, pregnancy rates were generally higher than for protocol A. There was also a maximum of the pregnancy rates for 6 (32%) and 7 (29%) days of E2 rise but this maximum was not as clear-cut as for protocol A. The fertilization rates showed no significant differences for each interval of E2 rise in both groups (between 63 and 89%). Therefore, it is concluded that endometrial maturity, and not the oocyte's ability for fertilization, is the most critical factor for success in IVF cycles.(ABSTRACT TRUNCATED AT 250 WORDS)     

Obstetric outcome of singleton pregnancies after IVF: a matched control study in four Dutch university hospitals

In singleton pregnancies after IVF a high rate of preterm deliveries and an increased rate of small-for-gestational age (SGA) children in comparison to the general parturient population have been reported. However, due to differences between IVF mothers and their peers who conceived naturally, careful selection of the control group is necessary to assess whether IVF pregnancies really carry increased risks of adverse outcome. In our study 307 IVF pregnancies were compared with 307 control pregnancies after elaborate matching for an extensive number of maternal characteristics, as well as for the hospital that provided the obstetric care. Four Dutch university hospitals contributed to the study. In cases with spontaneous onset of labour, gestational age at delivery was 3 days shorter in the IVF group (275 versus 278 days, P = 0.05). The proportion of SGA was higher in the IVF group (16.2 versus 7.9%, P < 0.001). The combination of these two results denotes a distinct difference between IVF and control pregnancies. Placental weight was comparable in both groups.     

Number of embryos for transfer after IVF and ICSI: a Cochrane review

BACKGROUND: The most common complication of IVF is multiple pregnancy, which occurs in 25% of pregnancies following the transfer of two embryos. Single embryo transfer can minimize twin pregnancies but could also lower live birth rates. Our aim was to perform a systematic review of randomized trials to determine the effectiveness of single versus double embryo transfer. METHODS: Cochrane Collaboration review methods were followed. Randomized controlled trials comparing single and double embryo transfers were identified by searching Medline, EMBASE and the Cochrane register of controlled trials. Contents of specialist journals and proceedings from meetings of relevant societies were hand searched. Data were pooled with Rev Man software using the Peto-modified Mantel-Hanzel method. RESULTS: Pooled results from four trials indicate that although double embryo transfer leads to a higher live birth rate per woman [odds ratio (OR) 1.94, 95% confidence interval (CI) 1.47-2.55] in a fresh IVF cycle, comparable results are obtained by subsequent transfer of a frozen embryo (OR 1.19, 95% CI 0.87-1.62). The multiple pregnancy rate is significantly higher (OR 62.83, 95% CI 8.52-463.57) after double embryo transfer. CONCLUSIONS: Single embryo transfer significantly reduces the risk of multiple pregnancy, but also decreases the chance of live birth in a fresh IVF cycle. Subsequent replacement of a single frozen embryo achieves a live birth rate comparable with double embryo transfer.     

Effects of subfertility cause, smoking and body weight on the success rate of IVF

BACKGROUND: We investigated the separate and combined effects of smoking and body mass index (BMI) on the success rate of IVF for couples with different causes of subfertility. METHODS: The success rate of IVF was examined in 8457 women. Detailed information on reproduction and lifestyle factors was combined with medical record data on IVF treatment. All IVF clinics in The Netherlands participated in this study. The main outcome measures were live birth rate per first cycle of IVF differentiated for the major predictive factors. RESULTS: For male subfertility the delivery rate per cycle was significantly lower than unexplained subfertility, OR of 0.70 (95% CI 0.57-0.86); for tubal pathology, the delivery rate was slightly lower, OR = 0.86 (95% CI 0.70-1.01). Smoking was associated with a significantly lower delivery rate was slightly lower; for OR = 0.72 (95% CI 0.61-0.84) and a significantly higher abortion rate compared to non-smoking delivery rates of 21.4% and 16.4%, respectively (P=0.02). Women with a BMI of > or = 27 kg/m2 had a significantly lower delivery rate, with an OR of 0.67 (95% CI 0.48-0.94), compared with normal weight women (BMI > or = 20 and <27 kg/m2). CONCLUSIONS: Both smoking and overweight unfavourably affect the live birth rate after IVF. The devastating impact of smoking on the live birth rate in IVF treatment is comparable with an increase in female age of >10 years from age 20 to 30 years. Subfertile couples may improve the outcome of IVF treatment by lifestyle changes.     

Prevention of twin pregnancies after IVF/ICSI by single embryo transfer. ESHRE Campus Course Report

Twin pregnancies constitute the most serious complication for both mother and children after IVF/ICSI treatment, but transfer of at least two 'best looking' embryos remains the standard policy. This is due to our inability and reluctance to identify both the 'twin prone' patient and the top quality embryo. Some centres now electively transfer a single embryo (eSET) when particular embryo quality and patient criteria are met. Results from several centres were presented during an ESHRE Campus Course, held on May 6(th) 2000. Sound clinical trials are needed to clarify several points of discussion. What is the clinical profile of patients in whom eSET should be considered? Will the overall (ongoing) pregnancy rate of the IVF/ICSI programme decrease if eSET is performed in these patients? What is the twinning rate when eSET is a routine policy? Will the financial gain by avoiding perinatal hospitalization costs of prevented twins be balanced by the likely need to perform a number of extra IVF/ICSI cycles? What will be gained by freezing the extra number of high quality embryos? Should eSET be performed at the 2 pronuclear stage, the early cleaving embryo or the blastocyst stage? Common sense dictates that eSET as a concept should be applied from now onwards.     

Morphological anomalies in the placentae of IVF pregnancies: preliminary report of a multicentric study

Macroscopic characteristics of 100 fetal adnexae from pregnanciesobtained by in-vitro fertilization and embryo transfer (IVF-ET)were compared with data for normal pregnancies taken from theliterature. Material was obtained from 63 singleton, 15 twin,one triplet and one quadruplet pregnancies. The fetal and placentalweights as well as the fetal:placental weight ratio were withinthe normal range for gestational age. Whilst placental morphologywas normal, the insertion of the umbilical cord was frequentlyabnormal. Marginal (15%) and velamentous (14%) insertions ofthe umbilical cord were found more frequently than in a generalobstetrical population (6% and 1% respectively). Excluding placentaefrom multiple pregnancies (which are known to have a higherincidence of abnormal cord insertion) the frequency did notdecrease and remained significantly higher than in a normalpopulation (P<0.01 and P<0.001, for marginal and velamentousinsertion respectively). Abnormal insertion of the cord is ofmajor clinical importance because of its association with vasapraevia and fetal haemorrhage (Benkiser Syndrome). Since thiscondition is thought to be caused by disturbed orientation ofthe blastocyst at implantation it is probably related to theIVF-ET procedure.     

Accumulation of human chorionic gonadotrophin in the serum of patients during in-vitro fertilization treatment cycles with Pergonal

We examined the possible contribution of human chorionic gonadotrophin(HCG) in Pergonal to the serum luteinizing hormone (LH)-likebioactivity in 10 patients (median age32 years, range 28–38)with tubal infertility who were undergoing in-vitro fertilization(IVF), together with 19 controls (median age30 years, range21–43). IVF patients were treated with clomiphene (50mg twice daily) over days 2–6 and Pergonal (150 IU i.m.)daily from day 5 until at least day 10. Serum LH was measuredby fluoro-immunometric assay (I-LH) and in-vitro Leydig cellbioassay (B-LH). Serum HCG was measured by fluoro-immunometricassay. The data were analysed by paired two-tailed t-test, followinglogarithmic transformation. From days 1–5, there was anincrease in serum B-LH (mean, 95% confidence intervals givenin parentheses) from 8.3 (6.8, 10.2) IU/1 to 11.7 (9.8, 13.9)IU/1 [P= 0.004], and in serum I-LH from 4.5 (3.7, 5.4) IU/1to 5.4 (4.6, 6.3) IU/1 [P= 0.002]. From days 5–8, therewas a rise in B-LH to 16.6 (12.6, 21.9) IU/1 [P= 0.023]. Therise in I-LH to 6.3 (5.1, 7.8) IU/1 [P= 0.081] failed to reachsignificance. Furthermore, serum HCG was <<0.75 IU/1 untilafter Pergonal was administered on day 5, then rose to a plateauon day 8 at 1.2(0.8, 1.6) IU/1. Serum HCG in the controls remained<<0.75 IU/1 throughout. We conclude there is a disproportionateincrease in serum B-LH compared to I-LH from days 5–8,corresponding with a rise in serum HCG and the commencementof treatment with Pergonal. The HCG in Pergonal may be contributingto an undesirable rise in serum LH-like bioactivity, which mightreduce the success rate of IVF.     

Early and late presentation of the ovarian hyperstimulation syndrome: two distinct entities with different risk factors

This study was designed to identify clinical predictors forearly and late ovarian hyperstimulation syndrome (OHSS). A retrospectiveanalysis of all 592 in-vitro fertilization (IVF) cycles fromthe programme's inception in 1988 up to March 1993 was performed.Six patients (1.0° of cycles) had moderate or severe OHSSpresenting 3–7 days post-human chorionic gonadotrophin(HCG), and four patients (0.7° of cycles) had severe OHSSpresenting 12–17 days post-HCG. No patient with earlyOHSS went on to develop late OHSS, and no patient with lateOHSS had demonstrated early OHSS. Stepwise logistic regressionshowed that early OHSS was predicted by the number of oocytesretrieved (range 18–46) (P= 0.0001) and the oestradiolconcentration on the day HCG was given (range 12 122–24454 pmol/1) (P = 0.0003). Late OHSS was predicted by the numberof gestational sacs (range 2–3) on ultrasound 4 weeksafter embryo transfer (P = 0.0001) but not by the number ofoocytes or oestradiol. Early OHSS was an acute effect of theHCG administered prior to egg retrieval in women with high oestradioland larger numbers of follicles (range 22–51). Late OHSSwas induced by the rising serum concentration of HCG producedby the early pregnancy, and in this series of cases it was associatedonly with multiple gestation.     

Obstetric outcome of twin pregnancies after in-vitro fertilization: a matched control study in four Dutch university hospitals

In singleton pregnancies after in-vitro fertilization (IVF), increased rates of obstetric and perinatal complications have been reported. Studies that compared IVF twin pregnancies with spontaneously conceived twins have yielded conflicting results. We compared 96 IVF twin pregnancies to 96 controls after elaborate matching. The design of our study precluded matching by zygosity. The monozygosity rate was higher in the control group and this implies that beforehand the risk for a less favourable outcome in the control group was higher than in the IVF group. However, the average birthweight of the IVF children was less than that of children in the control group (P = 0.04). This was not due to more intrauterine growth retardation in the IVF group. The mean gestational age at birth was 5 days shorter in IVF than control pregnancies, and although this difference was not significant it might explain the lower birthweight in the IVF group. The discordance rate in the IVF group was significantly increased. We found no difference in perinatal mortality and morbidity. We conclude that this study provides further evidence for a different outcome of IVF twin pregnancies in comparison with spontaneously conceived twin pregnancies.     

Pregnancy: The increased risk of complication observed in singleton pregnancies resulting from in-vitro fertilization (IVF) does not seem to be related to the IVF method itself

Singleton pregnancies resulting from in-vitro fertilization(IVF) seem to have an increased risk of obstetric and paediatriccomplications. In a retrospective study we compared, duringthe same period, 162 IVF singleton pregnancies with 263 pregnanciesresulting from stimulated cycles (without IVF) and with 5096natural pregnancies. No significant difference was found betweenthe first two groups concerning complications (i.e. prematurity,low birthweight, small-for-gestational-age and perinatal mortality).The results indicate that an adverse outcome is more commonfor pregnancies after ovarian stimulation (with or without IVF)compared to natural pregnancies. Therefore the increased riskdoes not appear to be linked to the IVF method itself but ratherto a common factor in these two populations, i.e. populationcharacteristics, underlying infertile status and/or ovarianstimulation.     

血清孕酮、HCG检测在先兆流产中的临床诊断意义

目的探讨血清孕酮、HCG定量测定在先兆流产中的临床诊断意义。方法采用化学发光法对196例孕期在4～6w的早孕者中进行血清孕酮、HCG值的测定。结果先兆流产组、难免流产组的血清孕酮、HCG值与正常组比较有显著性意义（P〈0．001）；难免流产组血清孕酮、HCG值显著低于先兆流产组（P〈0．05、P〈0．001）。结论测定妊娠4-6w早孕者的血清孕酮、HCG值时预测早期先兆流产有一定的临床诊断意义。     

Maternal serum hCG and alpha-fetoprotein levels in pregnancies conceived after IVF or ICSI with fresh and frozen-thawed embryos

BACKGROUND: Studies have shown that levels of serum markers of Down's syndrome were altered in pregnancies conceived after IVF, though the reason for this remains unknown. METHODS: Second-trimester maternal serum levels of hCG and alpha-fetoprotein (AFP) in pregnancies conceived with fresh and frozen-thawed embryos after assisted reproduction were compared with those conceived spontaneously. RESULTS: There were 203 pregnancies with fresh embryo transfers (130 IVF cases, 73 ICSI cases) and 98 pregnancies with frozen-thawed embryo transfers (61 IVF cases, 37 ICSI cases). The controls consisted of 17 145 spontaneous pregnancies. The median hCG multiples of the median (MoM) was significantly increased to 1.24 in 98 pregnancies conceived after frozen embryo transfer. This elevation was observed only in the IVF-frozen embryo transfer subgroup (P < 0.001), but not in the ICSI-frozen embryo transfer subgroup. The median AFP MoM for 203 pregnancies after fresh embryo transfer was 0.90. Among the subgroups, the median AFP MoM was significantly reduced to 0.90 and 0.86 in IVF-embryo transfer (P = 0.04) and ICSI-embryo transfer (P = 0.001) pregnancies respectively, and significantly raised to 1.20 in the IVF-frozen embryo transfer subgroup. CONCLUSIONS: The degree of alterations in maternal serum hCG and AFP levels varied between fresh and frozen-thawed embryos, and also between the mode of fertilization. Pregnancies resulting from ICSI or frozen embryo transfer should be regarded as distinct entities from those of IVF-embryo transfer.     

Identification of viable embryos in IVF by non-invasive measurement of amino acid turnover

BACKGROUND: IVF is limited by low success rates and an unacceptably high multiple pregnancy rate. These outcomes would be improved significantly if a single embryo of high viability could be replaced in each treatment cycle, but widespread acceptance of such a policy is hindered by the lack of predictive factors for embryo selection. We have conducted a retrospective clinical study of a novel non-invasive method of embryo selection based on the depletion/appearance of amino acids in the culture medium. METHODS: Fifty-three cycles of IVF treatment using ICSI were studied. Embryos were cultured for 24 h in 4 microl drops of medium containing a physiological mixture of 18 amino acids. The spent medium was analysed for amino acid content by high performance liquid chromatography. RESULTS: The turnover of three amino acids, Asn, Gly and Leu, was significantly correlated with a clinical pregnancy and live birth. These correlations were independent of known predictors, such as female age, basal levels of FSH, embryo cell number and embryo morphological grade. CONCLUSIONS: Non-invasive assay of amino acid turnover has the potential to improve significantly the prospective selection of the most viable embryos, or single embryo, for replacement in an IVF cycle.     

Trends in embryo transfer practices and multiple gestation for IVF procedures in the USA, 1996-2002

BACKGROUND: Increasing use of IVF in the USA has been a major contributor to the rising national multiple birth rate. Many have advocated that reducing the number of embryos transferred is essential for addressing the IVF-associated multiple birth problem. METHODS: A population-based sample of 506 072 IVF transfers performed in the USA in 1996-2002 was used to investigate trends in embryo transfer practices and to determine whether any changes in practice patterns have impacted the multiple gestation risk associated with IVF. RESULTS: The proportion of procedures in which >or=3 embryos were transferred declined significantly for most patient groups between 1996 and 2002. However, declines for some groups were not sizeable (from 79 to 73% and from 76 to 71% for fresh, non-donor procedures among women aged 38-40 and 41-42 years respectively) and transferring >or=3 embryos remained the norm for all groups. As of 2002, single embryo transfer had not increased for most groups and remained uncommon. Some declines in overall multiple gestation rates were observed, although multiple gestation risk associated with 2 embryos transferred increased significantly for all groups. CONCLUSIONS: Despite changes in embryo transfer practices, multiple gestation risk remains high, in part due to increased multiple gestation rates associated with the transfer of two embryos.     

Impact of overweight and underweight on assisted reproduction treatment

BACKGROUND: Underweight and overweight may affect reproduction and interfere with treatment of infertility. The purpose of this report is to describe the independent effect of body weight on treatment with IVF and ICSI. METHODS: Records of 5019 IVF or ICSI treatments in 2660 couples were reviewed. The influence of body mass index (BMI) on treatment outcome was examined, after accounting for differences in age and infertility diagnosis. RESULTS: The cumulative live birth rate within three treatment cycles was 41.4% [95% confidence interval (CI) 32.1-50.7] in obese women with BMI > or =30 kg/m2 and 50.3 (95% CI 47.0-53.7) in normal weight women with BMI 18.5-24.9 kg/m2. Obesity was associated with an increased risk of early pregnancy loss occurring before 6 weeks gestation. Positive correlation between BMI and gonadotrophin requirement during stimulation and negative correlation between BMI and number of collected oocytes were observed. Underweight (BMI <18.5 kg/m2) was not related to an impaired outcome of IVF or ICSI. CONCLUSIONS: Obesity is associated with lower chances for live birth after IVF and ICSI and with an impaired response to ovarian stimulation.