Ovarian function in relation to the outcome of in vitro fertilization (IVF) treatment in regularly menstruating women with tubal infertility

Study Design Ovarian endocrine function was evaluated in 53 regularly menstruating women, 27 to 38 years of age, who failed to conceive at least 2 years following reconstructive surgery for tubal infertility. Thirty apparently healthy women, 24 to 40 years of age with proven fertility, served as controls. Blood samples were obtained daily on cycle days 2–4 and 22–26 to assess FSH, E2, and P4 levels.Results There was a tendency for women with more advanced tubal damage to be subjected to more extensive surgery. Based on extent of reconstructive surgery, the patients were divided into three groups. Group A (n=29) had less extensive surgery, limited to the fallopian tubes, group B (n=14) included patients with extended adhesiolysis, and group C (n=10) comprised patients that had the most extensive reconstructive procedures involving ovarian surgery. Significantly higher FSH levels were found in group C (P<0.001) compared to groups A and B in the early follicular phase. During the luteal phase, E2 levels were lower in groups B (P<0.01) and C (P< 0.001) compared to group A. P4 levels were lower in group C compared to groups A and B.Conclusion When the patients underwent IVF treatment higher grades of tubal damage, more extensive surgery and hormonal signs of ovarian insufficiency were highly related to treatment failure.     

Intracytoplasmic sperm injection (ICSI) in unexplained and stage I endometriosis-associated infertility after fertilization failure with in vitro fertilization (IVF)

Purpose: To investigate possible differences between unexplained and stage I endometriosis-associated infertility in ICSI cycles conducted after low fertilization (<20%) in preceding IVF cycles with normal semen parameters. Methods: Retrospective cohort study consisting of patients with unexplained (n=48) and stage I endometriosis-associated infertility (n=43) with a minimum of one IVF cycle with <20% fertilized oocytes and normal semen quality, treated with ICSI from January 1997 to January 2006. Age matched male factor infertility patients (n=91) were used as controls. Results: Diploid fertilization rate was significantly lower in the stage I endometriosis-associated infertility group compared to the unexplained infertility group. Score of the transferred embryos, implantation rate, pregnancy rate and outcome were similar in the two groups. Conclusions: ICSI appears to be an efficient treatment option after fertilization failure with IVF in unexplained and stage I endometriosis-associated infertility.     

Patients with stages III and IV endometriosis have a poorer outcome of in vitro fertilization-embryo transfer than patients with tubal infertility

Objective: To evaluate the outcome of IVF in patients with stages III and IV endometriosis.

Design: Retrospective study.

Setting: The Sara Racine IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Israel.

Patient(s): Fifty-eight patients with stages III and IV endometriosis and 60 patients with tubal infertility.

Intervention(s): IVF-ET for all couples.

Main Outcome Measure(s): Fertilization, pregnancy, and birth rates.

Result(s): The comparison between patients with endometriosis and those with tubal infertility indicated that the former had a poor IVF outcome in terms of reduced fertilization rate (40% vs. 70%), reduced pregnancy rate per cycle (10.6% vs. 22.4%), and reduced birth rate per cycle (6.7% vs. 16.6%). The differences were statistically significant.

Conclusion(s): The results show an unfavorable outcome of IVF-ET in patients with endometriosis when compared with those who have tubal infertility.     

Indications to tubal reconstructive surgery in the era of IVF

In recent years, the treatment of tubal infertility has witnessed a shift from reconstructive surgery to in vitro fertilization. However, tubal surgery retains specific advantages, and appropriate preoperative evaluation allows improved selection of patients who are candidates for tubal reconstructive surgery by identifying the patients with good reproductive prognosis. Of pivotal importance in the selection of patients is the intratubal direct evaluation performed at salpingoscopy. Term pregnancy rates of approximately 70% and 65% may be obtained in patients with periadnexal adhesions and bilateral distal tubal occlusion, respectively, when a normal tubal mucosa is observed at salpingoscopy.     

Does hydrosalpinx reduce the pregnancy rate after in vitro fertilization?

Objective: To determine the effect of hydrosalpinges on the pregnancy rate in an IVF program.

Design: Multicentric retrospective analysis of clinical and laboratory data.

Setting: Two assisted reproductive technology centers in university hospitals.

Patient(s): Four hundred forty-three women, under 38 years of age, with pure tubal infertility. The patients were classified into the following five groups: bilateral hydrosalpinges (n = 37), unilateral hydrosalpinx (n = 54), bilateral tubal occlusion (n = 207), unilateral tubal occlusion (n = 55), and severe tubal disease without complete occlusion (n = 90).

Main Outcome Measure(s): Pregnancy and implantation rates.

Result(s): The pregnancy and the implantation rates per transfer (12.3% and 5.4%) obtained by women with bilateral hydrosalpinges are significantly lower than the rates (means = 23.1% and 12%) for all other tubal infertility groups.

Conclusion(s): Bilateral hydrosalpinges have a deleterious effect on the outcome of IVF program.     

Importance of endometrial quality in women with tubal infertility during a natural menstrual cycle for the outcome of IVF treatment

Purpose: The importance of endometrial maturation at estimated time of implantation for the outcome of IVF treatment in regularly menstruating women with tubal infertility was evaluated. Methods: FSH was measured on cycle day 3, on days 10–15 urine and blood were collected to estimate the day of the LH peak, and E₂ and P₄ were measured during the luteal phase, on cycle days 19–26. An endometrial biopsy was obtained on days LH + 3 to LH + 6. Results: The number of subjects with delayed endometrial maturation was larger in the group of infertile women who did not become pregnant compared to pregnant women and controls. Those infertile women who did not become pregnant after IVF treatment also presented with a higher basal FSH on cycle day 3 and lower E₂ and P₄ AUC in the luteal phase. Six infertile women and two controls presented with mid- and late-proliferative endometrium in the luteal phase on cycle days LH + 3 to LH + 6, in the presence of adequate E₂ and P₄ secretion. Six morphological characteristics were compared in the three groups: (1) 17 infertile women who became pregnant, (2) 18 who did not become pregnant, and (3) 28 controls. The pregnant infertile women did not differ from the controls. The numbers of glandular and stromal mitoses were significantly higher in those women who did not become pregnant (P<0.01) compared with those who became pregnant. Endometrial biopsies obtained on cycle days LH + 5 and LH + 6 showed significant differences in glandular epithelial height (P<0.05) and number of vacuolated cells among the nonpregnant women (P<0.01), the pregnant women (P<0.05), and controls. Conclusions: A higher frequency of retarded endometrial development in women who did not become pregnant following IVF treatment was found. In some cases, endometrial insensitivity could most likely cause retarded endometrial development and failure of implantation after IVF treatment, which could not be overcome by routine luteal-phase support. However, our results do not allow conclusions concerning its relative importance compared to preembryo quality; this has to be investigated further.     

Effect of Chlamydial antibodies on the outcome of in vitro fertilization (IVF) treatment

Objective Our objective was to study the relationship between the presence of Chlamydia trachomatisantibodies and the success of IVF treatment.Design We evaluated 118 in vitro fertilization and embryo transfer (IVF-ET) treatment cycles from 51 couples with a history of infertility lasting for at least 2 years. All women starting a treatment cycle had their serum chlamydial antibody titers measured by indirect immunofluorescent technique. All patients received similar ovarian stimulation regimens and the oocytes collected were inseminated with similar concentrations of motile sperm. Clinical data from couples where the female partner had C. trachomatisab titers 40 have been compared with the equivalent data from couples where the female partner had C. trachomatisab titers <40.Results There was no statistically significant difference between the two groups concerning age, infertility period, oocytes collected, oocytes fertilized, and fertilization rate, and the pregnancy rates were comparable.Conclusion Previous exposure to C. trachomatisdid not alter the success rate of IVF-ET.     

Characterizing the endometrium in unexplained and tubal factor infertility: a multiparametric investigation

OBJECTIVE: To characterize endometrial development in unexplained and tubal factor infertility. DESIGN: Prospective study of 20 women with unexplained infertility, 22 with tubal factor infertility, and 21 fertile controls in the midproliferative, periovulatory, and midluteal phases of the menstrual cycle. SETTING: Reproductive Medicine Department of St. Mary's Hospital, Manchester, United Kingdom. PATIENT(S): Women awaiting assisted conception. INVESTIGATION(S): Serum hormone assays, transvaginal ultrasound, Doppler, and midluteal endometrial biopsies. MAIN OUTCOME MEASURE(S): Serum levels of E2, P, and LH, endometrial ultrasound morphometry, uterine and subendometrial artery Doppler, and endometrial histology and biochemistry. RESULT(S): Women with unexplained infertility demonstrated significantly reduced uterine artery flow velocity in all phases, significantly elevated uterine and subendometrial artery impedance in the periovulatory and midluteal phases, and significantly reduced endometrial texture in the midproliferative phase. Women with tubal factor infertility demonstrated significantly reduced uterine artery flow velocity, without a concomitant increase in impedance, and significantly greater expression of endometrial glandular and luminal keratan sulphate. CONCLUSION(S): Unexplained infertility is associated with a profound impairment of endometrial perfusion that might be amenable to treatment by perfusion enhancers. Tubal factor infertility is associated with endometrial developmental defects that might be corrected by salpingectomy. Endometrial ultrasound and Doppler studies are likely to become a vital tool in the investigation of infertility.     

In vitro fertilization (IVF)-surrogacy: Application of IVF to women without functional uteri

Women with absent or dysfunctional uteri consented to controlled ovarian stimulation, ovum aspiration, in vitro fertilization, and embryo culture. Cleaving preembryos were transferred to recipient (surrogate) women whose menstrual cycles were in approximate synchrony with the ovum donor. None of the embryo recipients received medication. Six cases are described, resulting in one spontaneous loss at 6 weeks, four full-term deliveries, and one ongoing pregnancy. HLA typing demonstrated all babies to be genotypic offspring of the gamete donors.     

The role of gamete intrafallopian transfer (GIFT) and tubal embryo transfer (TET) in the treatment of patients with patent tubes associated with male infertility factor

Purpose The relative effectiveness of gamete intrafallopian transfer (GIFT) and tubal embryo transfer (TET) combined with superovulation in the treatment of infertile patients with patent tubes were compared. Four hundred fifty consecutive cycles were divided into two periods. During the first period (216 cycles), the only technique employed was GIFT, couples being divided into two groups: group A, couples with normospermic partners (118 cycles); and group B, couples with male infertility factor (98 cycles). During the second period (234 cycles), 140 cycles of GIFT were performed in couples with normospermic partners (group C). TET was utilized in 94 cycles (group D), in the case of couples with male infertility factor.Results Results demonstrate that the pregnancy rate with GIFT in the case of oligoasthenospermic partners (group B) is significantly lower than that of normospermic partners (groups A and C) (P = 0.0001) and than that with TET in the case of oligoasthenospermic partners (group D) (P = 0.0001).Conclusion The implantation rate is also significantly different between these groups (B vs A, P =0.0001; B vs C, P =0.0001; B vs D, P =0.01).     

Association of Chlamydia trachomatis serology with tubal infertility in Nigerian women

AIM: To determine the association between tubal infertility and Chlamydia trachomatis in Nigerian women. METHODS: This case-control study is from the Departments of Obstetrics and Gynecology of two tertiary hospitals in Nigeria. One hundred and sixty-two infertile patients with tubal occlusion had 162 pregnant women matched for age as controls. Information on sociodemographic variables, sexual and reproductive risk factors, and history of previous pelvic infections were elicited using a study protocol. The prevalence of Chlamydia Trachomatis antibody was determined for cases and controls. RESULTS: The prevalence of serum Chlamydia antibody was significantly higher in cases (65.8%) compared with controls (17.3%; P < 001). The effects of Chlamydia antibodies on infertility were strengthened in the multivariate model controlling for Chlamydia antibodies and gynecologic symptoms, compared to the univariate model. However, the association was attenuated and non-significant when the effects of gynecologic symptoms, sociodemographic characteristics, contraceptive and sexual history were controlled in the conditional logistic regression model. The strongest independent predictors of infertility in the model were vaginal discharge, education less than tertiary and more than three lifetime sexual partners (proxies of sexually transmitted infections). CONCLUSIONS: There was no strong independent association between Chlamydia antibodies and the risk of being infertile in Nigerian women. By contrast, the proxies of sexually transmitted infections were significant predictors of infertility in the women. Efforts to address these factors, which are proxies of sexually transmissible infections, Chlamydia infection, and health-seeking behavior for these infections, will likely contribute to reducing the burden of infertility in Nigerian women.     

Addition of a gonadotropin releasing hormone (GnRH) antagonist and exogenous gonadotropins to unstimulated in vitro fertilization (IVF) cycles: Physiologic observations and preliminary experience

Purpose To describe our preliminary experience with the addition of a GnRH antagonist (Nal-Glu) and exogenous gonadotropins (follicle stimulating hormone; FSH) to unstimulated IVF cycles.Method Seven spontaneously ovulatory women underwent eight unstimulated IVF cycles at our institution. They were treated with a single dose of Nal-Glu, 50 g/ kg, or with a combination of Nal-Glu, 50 g/kg, and exogenous FSH, 150–300 IU, during the late follicular phase of spontaneous cycles. They then received 10,000 IU of human chorionic gonadotropin (hCG) to time accurately follicle aspiration in unstimulated IVF cycles.Results Two women underwent three cycles with Nal-Glu alone on the day of hCG administration. One pregnancy resulted. Five women underwent five cycles with 3 to 6 days of daily Nal-Glu and FSH. Four of these cycles resulted in aspiration after the FSH dose was increased to 300 IU. Nal-Glu and FSH allowed continued development of the dominant follicle without the occurrence of luteinizing hormone (LH) surge.Conclusions (1) Nal-Glu alone given 18 hr prior to hCG did not interfere with continued follicle viability or with the attainment of pregnancy. (2) Simultaneous Nal-Glu and FSH allowed for continued growth and development of the dominant follicle without the occurrence of an LH surge. (3) This preliminary experience confirms the feasibility of this novel approach, which may ultimately enhance the efficacy of unstimulated IVF cycles by eliminating premature ovulation and maximizing control of gonadotropin delivery to the developing follicle.Presented at the 39th Meeting of The Society for Gynecologic Investigation, San Antonio, Texas, March 18–21, 1992.     

In vitro fertilization outcome in women with endometrial tuberculosis and tubal tuberculosis

Abstract

Purpose: To evaluate in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) outcome in women with genital tuberculosis (GTB).

Methods: One hundred and fifty-five women with genital tuberculosis constituted the study group (Group A), consisting of 25 patients with endometrial tuberculosis (Group A1) and 130 patients with tubal tuberculosis (Group A2). Women with non-tuberculous tubal infertility were matched by age and study period served as controls (Group B).

Results: Patients with GTB had significantly reduced endometrial thickness, high-quality embryos rate, implantation rate as compared with controls (p?<?.05), no differences were found in other pregnancy parameters. In addition, the endometrial thickness, fertilization rate, high-quality embryos rate and implantation rate were also significantly lower in women with endometrial tuberculosis as compared with controls. And the cumulative pregnancy rate in endometrial tuberculosis was significantly decreased compared with tubal tuberculosis and controls (p?<?.05). However, IVF/ICSI pregnancy outcomes in patients with tubal tuberculosis showed no difference as compared with controls (p?>?.05). Also, rates of miscarriage, preterm birth, obstetrical complications, and neonatal problems did not differ among three groups.

Conclusions: In conclusion, IVF/ICSI-ET remains the most optimal method for the treatment of female infertility associated with tubal tuberculosis. However, patients with endometrium tuberculosis showed significantly reduced fertilization, implantation and cumulative pregnancy rates.     

Disordered zona pellucida-induced acrosome reaction and failure of in vitro fertilization in patients with unexplained infertility

OBJECTIVE: To determine the relationship between the zona pellucida (ZP)-induced acrosome reaction (AR) and fertilization rate and pregnancy rate in standard IVF and the frequency of disordered ZP-induced AR (DZPIAR) in patients with unexplained infertility. DESIGN: Prospective study. SETTING: Academic research and teaching tertiary hospital. PATIENTS: Patients with unexplained infertility with normal semen analysis. INTERVENTION: None. MAIN OUTCOME MEASURE: Semen analysis, the ZP-induced AR, and measurements of fertilization rate and pregnancy rate with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). RESULT(S): A statistically significant correlation was found for the ZP-induced AR and fertilization rate with standard IVF (n = 65). Patients with DZPIAR (ZP-induced AR of 16%, who had an average fertilization rate of 61%. The sensitivity and specificity of DZPIAR for prediction of IVF rates <30% and >or=30% were 80% and 86%, respectively. Of 260 patients screened, the frequency of DZPIAR was 29%. Ten patients with DZPIAR had an average fertilization rate of 15% and no pregnancy with initial IVF cycles, and a fertilization rate of 61% (with three live-birth pregnancies) with subsequent ICSI cycles. Another 33 patients with DZPIAR were treated with ICSI alone, with an average fertilization rate of 71% and a live-birth pregnancy rate of 17% per embryo transfer. Sixteen of the patients had live-birth pregnancies (including one set of twins) after undergoing an average of 3.2 embryo transfers. CONCLUSION(S): Patients with DZPIAR have a low or zero fertilization rate with standard IVF but high fertilization and pregnancy rates with ICSI. Up to 29% of patients with unexplained infertility with normal semen analysis may have this condition, which should be diagnosed and treated with ICSI rather then standard IVF.     

Natural-cycle in vitro fertilization (IVF) combined with in vitro maturation in infertile patients with polycystic ovarian syndrome (PCOS) requiring IVF

Objective

In this study, we report an experience of 59 natural-cycle IVF combined with in vitro oocyte maturation (IVF/M) cycles in patients with PCOS requiring IVF recruited based on limitations to afford a conventional IVF treatment in a 9-years period. Results of IVF/M were compared with 164 cycles of IVF in PCOS patients.

Rescue intracytoplasmic sperm injection (ICSI)-salvaging in vitro fertilization (IVF) cycles after total or near-total fertilization failure

Objective: To evaluate the effectiveness of delayed oocyte reinsemination by ICSI (rescue ICSI) after total or near-total fertilization failure (≤25%) in IVF.

Design: A retrospective clinical study.

Setting: Non–hospital-based IVF program.

Patient(s): Thirty IVF cycles with total fertilization failure and two cycles with ≤25% initial fertilization.

Main Outcome Measure(s): Fertilization and pregnancy rates after rescue ICSI.

Intervention(s): Rescue ICSI 19–22 hours after initial oocyte insemination.

Result(s): A fertilization rate of 60.2% was achieved with rescue ICSI (141 of 234 oocytes, 29 of 32 patients). Of 30 patients with total fertilization failure, 27 had fresh transfers with rescue ICSI embryos. Two additional patients with ≤25% initial fertilization had subsequent replacement of frozen-thawed rescue ICSI embryos. Six pregnancies resulted, including three singleton, one twin, one missed abortion, and one ectopic pregnancy (20.7%). One of the singleton pregnancies resulted from replacement of four frozen-thawed embryos and is the first known pregnancy achieved from cryopreserved rescue ICSI embryos.

Conclusion(s): Rescue ICSI should be considered in the presence of total or near-total fertilization failure in IVF. Early application of rescue ICSI (19–22 hours after insemination) may be critical for establishing fertilization within an optimal window and producing viable embryos and pregnancies.