Is elective single embryo transfer a cost-effective alternative to double embryo transfer?

Elective single embryo transfer (eSET) is increasingly being considered as a means to reduce twin pregnancies associated with in vitro fertilisation treatment. However, it is important to consider the cost-effectiveness of alternative strategies when considering a change in policy. A review of the literature showed only five studies assessing both costs and consequences of strategies involving eSET compared with double embryo transfer. Several limitations in these studies prevent a definitive conclusion on the cost-effectiveness of eSET being reached. Future economic evaluations need to compare strategies relevant to routine practice, include all relevant costs, measure and value longer term outcomes appropriately, and assess the cost-effectiveness of eSET across different subgroups of women.     

Is intravenous immunoglobulins (IVIG) efficacious in early pregnancy failure? A critical review and meta-analysis for patients who fail in vitro fertilization and embryo transfer (IVF)

Problem : Intravenous Immunoglobulins (IVIG) are widely used off label in the treatment of early reproductive failure. As IVIG is expensive, and may have side-effects, evidence of efficacy is needed. Previous results have suggested that the pre-conception treatment of primary recurrent abortion patients might be effective, but the data set has been too small for adequate statistical power. More recently it has been suggested that IVIG may improve the success rate of in vitro fertilization and embryo transfer (IVF) in patients with prior IVF failures, but clinical trials have given conflicting results that need explanation. Systematic reviews generating inconclusive results have focused on methodological rigor to the exclusion of biological plausibility. Methods : Review of current basic science of design, measurement, and evaluation of clinical trials and basic science mechanisms providing a rationale for treatment. Meta-analysis of published randomized controlled and cohort-controlled trials (updated with two unpublished data sets) evaluating IVIG treatment in IVF failure patients. Live birth rate was used as the most relevant endpoint. The ability of different sources of IVIG to suppress natural killer (NK) cell activity was determined using a standard ⁵¹Cr-release assay in vitro. Results and conclusions : Meta-analysis of three published randomized controlled trials (RCTs) of IVIG in IVF failure patients shows a significant increase in the live birth rate per woman (p = 0.012; Number Needed to Treat for 1 additional live birth, NNT = 6.0 women). Using live birth rate per embryo transferred, and adding data from two cohort-controlled trials to the meta-analysis further supports this conclusion (overall p = 0.000015, NNT = 3.7 women). Relevant variables appear to include properties and scheduling of the IVIG, and selection of patients with abnormal immune test results. Different IVIG preparations vary significantly in their ability to suppress NK activity in vitro. A rationale for use of IVIG is provided by a review of mechanisms of IVIG action and mechanisms underlying failure of chromosomally normal embryos.An erratum to this article can be found at     

Combined progesterone (IM + V) versus vaginal progesterone for luteal support in cleavage-stage embryo transfer cycles of good prognosis patients

Many reports led to the consensus on the use of progesterone (P) for luteal-phase support. Vaginal P application is the method of choice due to its simplicity and high patient convenience but is hampered by application difficulties and personal or cultural aversions. Inappropriate vaginal P use may alter successful implantation, leading physicians to consider alternate P application routes. A worldwide survey revealed that intramuscular plus vaginal P (combined P) is the method used in nearly one-third of in vitro fertilization (IVF) cycles, particularly in Asia and North America; unfortunately, the outcomes of this approach have not been clearly elucidated. In the current analysis, we evaluated any additional benefit of short course parenteral P in addition to vaginal P capsules during a specific period in terms of implantation, pregnancy rates, miscarriages and ectopic pregnancies in cleavage stage embryo transfer (ET) cycles of good-prognosis patients. Despite significantly higher implantation rates in the combined arm, clinical and ongoing pregnancies were comparable in both groups, whereas a trend toward increased pregnancy rates was observed with combined support. The available data are too limited to draw conclusions.     

Reduction in multiple pregnancy rate in donor oocyte–recipient gestational carrier (GC) in vitro fertilization (IVF) cycles in the USA with single-embryo transfer and preimplantation genetic testing

Purpose

To evaluate the utilization of single-embryo transfer (SET) and preimplantation genetic testing (PGT) in gestational carrier IVF cycles in the USA with donor oocyte and examine the impact on live birth and multiple gestation.

Methods

Retrospective cohort study using the Society of Assisted Reproductive Technology (SART) clinic database of 4776 donor oocyte–recipient IVF cycles in which a GC was used. The cycles were separated into 4 groups by use of PGT and number of embryos transferred as follows: (1) PGT and single-embryo transfer (PGT-SET); (2) PGT and multiple embryo transfer (PGT-MET); (3) no PGT and SET (NoPGT-SET); (4) no PGT and MET (NoPGT-MET). Primary outcomes were live birth rate (LBR) and multiple pregnancy rate (MPR).

Results

More than one blastocyst was transferred in 48.7% (2323/4774) of the cycles. When ≥1 blastocyst was transferred, with or without the use of PGT, the MPR was 45.5% and 42.0%, respectively. In comparison, in the PGT-SET and NoPGT-SET groups, the MPR was 1.4% (8/579) and 3.3% (29/883), respectively. Live birth rates increased with the use of PGT-A and with MET.

Conclusion

This study shows that SET, with or without PGT, is associated with a significantly reduced MPR in donor oocyte–recipient GC IVF cycles while maintaining high LBR. It also demonstrates that many infertility centers in the USA are not adhering to ASRM embryo transfer guidelines. Our findings highlight an opportunity to increase GC safety, which ultimately may lead to widened access to this increasingly restricted service outside the USA.

     

To transfer fresh or thawed embryos?

Worldwide freezing and thawing of embryos has been increasingly used since the first infant was born as a result of this technique in 1984. The use of frozen embryo replacement (FER) currently even exceeds the number of fresh cycles performed in some countries. This article discusses the pros and cons of FER versus fresh-embryo transfer with regard to both single-cycle and cumulative pregnancy and delivery rates. The review discusses the obvious advantages of FER: minimizing the proportion of pharmacological and surgical treatments, and lowering the risk of ovarian hyperstimulation syndrome and multiple pregnancies, thereby increasing the safety for mother and child. Finally the article describes the accumulating literature on perinatal and long-term child outcome after transfer of frozen/thawed embryos, including a discussion on the concerns regarding cryo techniques and their possible roles in the subsequent development of fetus and child. Because larger and more detailed data sets are available for early cleavage-stage embryo freezing and slow freezing, they are the main focus of this review.     

Endometrioma undergoing laparoscopic ovarian cystectomy: its influence on the outcome of in vitro fertilization and embryo transfer (IVF–ET)

PURPOSE: To evaluate the effect of laparoscopic ovarian cystectomy for endometrioma on the clinical outcome of IVF treatment. METHODS: Patients who received IVF treatment were retrospectively classified into two groups. Group 1 included 95 patients who received IVF due to tubal occlusion. Group 2 included 127 patients who had received laparoscopic ovarian cystectomy for endometrioma(s) followed by IVF treatment. Clinical outcomes of IVF treatment were compared between two groups. RESULTS: More oocytes were harvested per retrieval in Group 1 than Group 2 (p < 0.05). The fertilization rate was higher in Group 1 than Group 2 (p < 0.05). Although the implantation rate was higher in Group 2 (p < 0.05), the clinical pregnancy rate revealed no statistically significant difference between the two groups. CONCLUSIONS: Women who received ovarian cystectomy for endometriomas have fewer oocytes harvested during IVF treatment. However, their chance of pregnancy was comparable to patients with tubal problems who underwent IVF treatment.     

The sensitivity and specificity of hyperglycosylated hCG (hhCG) levels to reliably diagnose clinical IVF pregnancies at 6?days following embryo transfer

Objective

To determine the sensitivity and specificity of hyperglycosylated hCG (hhCG) measurements for the diagnosis of clinical pregnancies in the IVF setting and how soon post embryo transfer (ET) a pregnancy can be detected using an ultrasensitive (hhCG) assay. To determine if a single, early hhCG measurement can discriminate between biochemical and clinical pregnancies.

Design

A 4 center prospective blinded clinical trial was performed with patients undergoing IVF-ET. Patients had blood drawn and submitted for hhCG analysis on the day of ET and at days 4, 6, 8, and 12 thereafter. First morning urines were collected and submitted for hhCG analysis on days 0, 4, 6, 8, 10 and 12.

Setting

Fertility Centers

Outcome Measures

Clinical pregnancies were defined as an ultrasound study demonstrating a gestational sac and/or heart beat at appropriate gestational ages.

Results

Fifty-six of 58 enrolled patients completed the study. There were 25 clinical and 6 biochemical pregnancies. For blastocyst transfers, a single serum or urine hhCG measurement identified pregnancies (both biochemical and clinical) at 6 days post ET with 100% sensitivity and specificity. There were 6 biochemical pregnancies, all following blastocyst transfers. All of these pregnancies were identified by lower values.     

What factors determine placental glucose transfer kinetics?

Introduction

Transfer of glucose across the human placenta is directly proportional to maternal glucose concentrations even when these are well above the physiological range. This study investigates the relationship between maternal and fetal glucose concentrations and transfer across the placenta.

Methods

Transfer of d-glucose, ³H-3-o-methyl-d-glucose (³H-3MG) and ¹⁴C-l-glucose across the isolated perfused human placental cotyledon was determined for maternal and fetal arterial d-glucose concentrations between 0 and 20 mmol/l.

Results

Clearance of ³H-3MG or ¹⁴C-l-glucose was not affected by maternal or fetal d-glucose concentrations in either circulation.

Discussion

Based on the arterial glucose concentrations and the reported K_M for GLUT1, the transfer of d-glucose and ³H-3MG would be expected to show signs of saturation as d-glucose concentrations increased but this did not occur. One explanation for this is that incomplete mixing of maternal blood and the rate of diffusion across unstirred layers may lower the effective concentration of glucose at the microvillous membrane and subsequently at the basal membrane. Uncertainties about the affinity of GLUT1 for glucose, both outside and inside the cell, may also contribute to the difference between the predicted and observed kinetics.

Conclusion

These factors may therefore help explain why the observed and predicted kinetics differ and they emphasise the importance of understanding the function of transport proteins in their physiological context. The development of a computational model of glucose transfer may improve our understanding of how the determinants of placental glucose transfer interact and function as a system.     

羊水(综述)

近二十年来,由于羊水穿刺的开展以及检验技术的不断进步,使我们对羊水有了较多的认识。由于胎儿与羊水之间的密切关系,因此羊水能最好地反映胎儿的生理和病理状态。应用羊水的检查做胎儿情况的产前判断,已受广大妇产科工作者的重视并且积累了不少的经验。现仅就羊水的生理和病理的一些问题,简要介绍以供参考。Ⅰ羊水的生理一羊水的来源与代谢1.真羊水与假羊水:临床上所谓的羊水是指羊膜腔内的液体,即真羊水。但广义地     

口服避孕药时Fe~(59)、Cu~(65)和Zn~(70)的吸收

很多报告指出,口服避孕药(OCA)可以改变血清铁、铜、锌的含量,也可改变金属蛋白即运铁球蛋白、血浆铜蓝蛋白、α_2~-巨球蛋白和白蛋白含量,并认为金属的变化反映了运输蛋白质的变化。作者选择了19～25岁的妇女22人,14人口服避孕药,试验结果证明,两组铁、铜、锌的吸收率平均都在13.7±12.3、57.4±17.7、及37.8±15.6%之间,无明显差异。OCA者每天吸收的Fe~(59)、Cu~(65)和Zn~(70)分别为每天平均11.5±3.5毫克、1.9±0.7毫克及11.0±3.4毫克,未服OCA者三者的吸收量每天平均值分别为10.3±1.9、2.1±0.7和11.3±3.0毫克,也无显著不同。对血清铁含量、血浆蛋白结合铁(TIBC)、血浆酮蓝蛋白及血浆白蛋白测定的结果,OCA者平均分别为116±28微克%、32     

Mosaic embryo transfer after oocyte in vitro maturation in combination with non-invasive prenatal testing (NIPT)—first report of a euploid live birth

Purposes

The purpose of this study is to describe a healthy life birth after a mosaic embryo transfer in oocyte in vitro maturation (IVM).

Methods

Patient received minimal stimulation, starting on day 3 after menstrual period. No hCG trigger was administered. Oocyte retrieval was performed and oocytes were matured for 30 h. After denuding, mature oocytes were inseminated by ICSI. Embryos were cultured until blastocyst stage and biopsied.

Results

One euploid embryo after array comprehensive genome hybridization (aCGH) was diagnostic. However, the next-generation sequencing (NGS) re-analysis showed that embryo was a mosaic for chromosome 13 and 21. Nevertheless, pregnancy ultrasound scans and non-invasive prenatal test (NIPT–Verifi-Illumina) indicated a normal fetus development. Finally, a healthy baby was born after 38 weeks. Its weight was 4480 g, head circumference 36 cm, and total length of 51 cm. To confirm that the baby was chromosomically normal, an NGS test was performed in buccal cells, a normal profile was obtained.

Conclusions

Our finding confirmed that mosaic embryo transfer would bring a healthy offspring.

     

计划生育(Ⅱ)

二、单纯孕激素避孕药 使用口服避孕药的女性中有10％选择单纯孕激素避孕药（POP）。于月经周期第1天开始服用，每天1次，连续服用，无需7d停药期。但必须每天定时服药，前后误差不超过3h。如果有一次服药时间推迟3h以上，那么下次除了必须按时服药外。48h内还需加用其他避孕措施。