Infertility: Ultrasonic monitoring during replacement of frozen/thawed embryos in natural and hormone replacement cycles

We evaluated the results of cryopreserved/thawed embryo replacement(FER) to determine if the outcome following transfer in a naturalcycle in a defined group was different to that from a hormonereplacement cycle, and also to assess vaginal ultrasonographicfeatures that assist in predicting the timing of the transfer.At the London Fertility Centre, 149 consecutive FER cycles werestudied retrospectively. Women with proven ovulation and regularcycles were included during natural cycles (n = 77). The hormonereplacement cycle group included women with anovulation, irregularcycles and older women (n = 72). In the natural cycle group,transfer was performed following positive urinary luteinizinghormone (LH) surge and confirmation of ovulation by ultrasonography.With the hormone replacement therapy group, gonadotrophin-releasinghormone analogue was used to induce pituitary down-regulation,oestradiol valerate was supplemented followed by regular ultrasoundmonitoring, and FER 2 days following the initiation of progesterone,which was started once adequate endometrial development wasnoticed on ultrasonography. The pregnancy and ongoing/deliveryrates were analysed in relation to the treatment cycle, age,number and quality of embryos transferred. Ultrasonographicfeatures were examined to evaluate their relationship with theoutcome of treatment. The results showed that no differenceexisted between natural and hormone replacement cycles in pregnancyrates per cycle (26 and 25%), ongoing/delivery rate (20.8% inboth groups), and implantation rate (10.3 and 10.6%). Pregnancyrates were not influenced by the number of embryos transferred,stage at which the embryos were cryopreserved, or whether theywere extra embryos from in-vitro fertilization/embryo transfer,or gamete intra-Fallopian transfer. The pregnancy rate was low(7.4%) if the embryos had less than three blastomeres and ifthe fragmentation was >50% (0% pregnancy rate). With hormonereplacement cycles, age did not influence the outcome, and women40 years and older had a pregnancy rate of 29.4% per cycle.No pregnancies resulted in the natural cycle group if the maximumfollicular diameter was > 22 mm before ovulation. When poorendometrial development was noted (thickness < 8 mm and gradeC) no pregnancy resulted from FER in natural or hormone replacementcycles. The pregnancy rates were higher when the endometriumwas 8 mm thickness and grade B (42.4%) or grade A (21.2%). Weconcluded that FER outcomes in natural cycles were similar tothose arising with hormone replacement therapy provided goodselection criteria were used, and vaginal ultrasonography canassist in timing the day of replacement and identify cases tobe cancelled before the transfer.     

Mid-cycle serum levels of endogenous LH are not associated with the likelihood of pregnancy in artificial frozen-thawed embryo transfer cycles without pituitary suppression

BACKGROUND: The aim of the present study was to evaluate the association between clinical pregnancy and serum luteinizing hormone (LH) levels, assessed after 14 days of endometrial preparation with estradiol (E(2)) in the absence of pituitary suppression during a frozen-thawed embryo transfer (FRET) cycle. METHODS: A total of 513 patients undergoing their first FRET cycle (01/99 to 11/05) participated in this prospective study. Endometrium preparation for FRET was started on cycle day 1 and continued for a fixed period of 14 days with trans-dermal E(2) patches. On day 14, serum LH, progesterone and E(2) levels were assessed. On day 15, progesterone supplementation was initiated and patients underwent embryo transfer on day 17 or day 18. The association between clinical pregnancy and LH levels was evaluated in groups of patients defined according to Tukey's Hinges percentile analysis of LH levels on day 14. In addition, robust logistic regression was performed with the dependent variable clinical pregnancy and independent variables LH, progesterone, embryos score, cycle rank and gravidity. RESULTS: Age, BMI, parity, cycle rank, embryo number, embryo score, endometrial diameter, E(2) and progesterone were not significantly different in cycles with low (0.1-8.1 IU/l; n = 132), intermediate (8.2-19.4 IU/l; n = 238) and high (20.0-78.0 IU/l; n = 143) levels of LH, respectively. Clinical pregnancy rates were not significantly different in cycles with low [12.1%, 95% confidence intervel (CI) 7.6-18.8], intermediate (13.4%, 9.7-18.4) and high levels of LH (16.1%, 11.0-23.0). Robust logistic regression analysis indicated that embryo score [Odds ratios (OR) 1.04, 95% CI 1.02-1.06, P < 0.01] was statistically significantly associated with the likelihood of clinical pregnancy achievement, but not day 14 levels of LH or progesterone, gravidity or cycle rank. CONCLUSIONS: The likelihood of clinical pregnancy is not associated with serum LH levels on day 14 of an artificial FRET cycle. Hormonal monitoring of LH levels does not yield useful information with regard to cycle management and patient prognosis, and should therefore not be conducted.     

Screening before and during the use of oral contraceptives and hormone replacement therapy. The ESHRE Capri Workshop Group

Most users of oral contraceptives (OC), and many users of hormone replacement therapy (HRT) are apparently healthy, using a preparation for preventative purposes. It is understandable, therefore, that many clinicians feel that they should screen women using these preparations for hidden disease. Sometimes this has resulted in women being subjected to a variety of procedures. This medicalization of the provision of care can inhibit women from availing themselves of these services. All screening programmes must have evidence that: early detection will affect the natural history of the disease; the performance characteristics of the test must be known; the test should be cost-effective, acceptable to users and providers, should influence clinical decisions, and treatment should exist for abnormal results. The tests time to time suggested before and during the use of OC and HRT do not fulfill these needs. Whether any of the contraindications for OC use are present can be determined simply by taking a history and performing a physical examination including measurement of blood pressure. The same policy applies to the women who will start HRT. If facilities are available for screening mammography this test should be performed prior to starting HRT as the oestrogen can promote the growth of an existing subclinical breast cancer. It is not cost effective to perform an endometrial biopsy in women without abnormal genital bleeding prior to starting HRT. Routine measurement of bone density is also not cost effective or necessary since no current available agent reduces the risk of fractures in women with osteoporosis more than HRT.     

Serum placental protein 14 (PP14) reflects endometrial status during hormone replacement therapy.

Healthy post-menopausal women were randomly assigned to treatment groups receiving 28 day treatment cycles of oestradiol valerate (2 mg, days 1-28) sequentially combined with levonorgestrel (75 micrograms, days 17-28) (n = 19); oestradiol valerate (2 mg, days 1-28) continuously combined with cyproterone acetate (1 mg, days 1-28) (n = 18), or placebo (n = 22). Treatment continued for 2 years. After therapy, the women receiving the sequential combination had an early secretory phase (74%) or atrophic endometrium (26%). All women receiving the continuous combination or placebo had inactive or atrophic endometrium, or the tissue was inadequate for assessment. Biochemical parameters of endometrial secretion [oestradiol dehydrogenase (EDH), isocitrate dehydrogenase (ICDH)] measured in endometrial tissue and placental protein (PP14) measured in serum were all low in the groups receiving the continuous combination and placebo. During sequential treatment, all biochemical parameters showed significantly higher mean values. Serum PP14 accurately reflected this pattern. Furthermore, in the sequentially treated group, serum PP14 correlated highly significantly with EDH (r = 0.70; P less than 0.001) and ICDH (r = 0.57; P = 0.01). These correlations were of the same magnitude as the correlations between the endometrial markers, which indicates that serum PP14 reflects the endometrial status. Furthermore, serum PP14 measurements at 3 months and at 2 years of treatment were highly correlated, reflecting the long-term validity of the measurement. The present data suggest that PP14 measured in serum may be used to assess endometrial status. Further studies are required to determine whether serum PP14 will discriminate pathological endometrial conditions.     

Continuation rates for oral contraceptives and hormone replacement therapy. The ESHRE Capri Workshop Group

Despite the safety and effectiveness of low oestrogen-dose oralcontraceptives (OC) and postmenopausal hormone replacement thereis poor continuity of use of these agents by women. Patternsof use and the reasons affecting different frequencies of usein different countries are presented. Continuity and discontinuationrates are difficult to assess accurately but it is believedthat the main reasons why women discontinue use of these agentsare concerns about their perceived health risks and the presenceof, or fear of, adverse clinical effects, particularly unscheduleduterine bleeding and weight gain. More information is neededabout OC continuation rates in order to improve the acceptabilityof these safe, effective agents. Most women discontinue useof postmenopausal hormonal replacement within 2 years of initiatingthe therapy. Reasons include disappearance of symptoms of oestrogendeficiency, lack of awareness of health benefits of oestrogen,presence of side-effects (such as breast tenderness and weightgain), presence of uterine bleeding and increasing age. Suggestionsto increase continuation of OC include extensive individualpretreatment counselling with a different emphasis in differentage groups, education at the time of follow-up visits and telephonecalls, and extensive use of educational aids such as brochures,pamphlets and audio tapes, and improvement of pharmaceuticalpackaging information. In conclusion there is an urgent needto assess the value of these strategies by long-term large controlledstudies.     

Results of in-vitro fertilization in normal ovulatory women treated with pure follicle stimulating hormone. Analysis of the oestradiol response

The relationship between various measures of oestradiol (E2) secretion and the total number of oocytes retrieved (OR) and cleaved embryos (CE) was characterized in normal ovulatory women stimulated with pure follicle-stimulating hormone (FSH) in a programme for in-vitro fertilization and embryo transfer (IVF-ET). Patients in this study included women with tubal factor as their only cause for infertility. Cycles were monitored with serum E2 concentration and ultrasonography. Human chorionic gonadotrophin (HCG) was administered when two follicles had a maximum diameter greater than 15 mm. The variables used to characterize the E2 secretory response included: (i) the difference between the highest and lowest E2 concentration during stimulation; (ii) the ratio of terminal to initial E2 concentration; (iii) E2 concentration on the day of HCG administration; and (iv) the slope of the E2 curve. These measures of E2 secretion each correlated with both the number of OR and the number of CE. When all E2 variables were considered simultaneously in a stepwise multivariate regression procedure, variations in the number of OR (r2 = 0.84) or CE (r2 = 0.77) could be explained by variation in the E2 secretory profile. Equations derived from these E2 variables may help to identify and improve problem areas within IVF-ET programmes when actual results differ from expected.     

A comparison of pregnancy rates for 131 donor oocyte transfers using either a sequential or fixed regime of steroid replacement therapy

This study describes the overall results of 131 donor oocyte transfers between 1982 and 1989 when 30 pregnancies resulted (23% pregnancy rate/transfer). A retrospective comparison of results between an earlier sequential hormone replacement regime and a more recent low dosage, variable length oestrogen replacement shows that the latter offers greater flexibility and a promising trend towards higher pregnancy rates.     

Lack of placental protein 14 production in pregnancy after frozen embryo transfer, down-regulation of anterior pituitary and administration of exogenous oestradiol and progesterone

The circulating levels of placental protein 14 (PP14) and progesterone were measured in three pregnancies resulting from the transfer of cryopreserved embryos. Two of these women had suppressed ovarian activity as a result of pituitary down-regulation with the luteinizing hormone-releasing hormone agonist (buserelin) prior to treatment with exogenous oestradiol and progesterone. After 14 days of oral oestradiol treatment and if the endometrial thickness was greater than 7 mm, progesterone was given intramuscularly for a further 14 days with embryo transfer on the third day of this treatment. On confirmation of pregnancy by human chorionic gonadotrophin analysis, progesterone administration was altered to transvaginal pessaries for maintenance of adequate progesterone levels and endometrial support. In the two women with ovarian suppression, PP14 levels remained below the 2.5th centile of the normal range for pregnancy. In the third pregnancy, embryo transfer was performed 3 days after a spontaneous luteinizing hormone surge in a normal menstrual cycle. In this pregnancy, PP14 levels were within the normal range. Ultrasonic examination confirmed three normal ongoing singleton pregnancies. These results suggest that the majority of PP14 production in normal pregnancy is under ovarian or anterior pituitary control and that the influence of progesterone is of a secondary nature.     

Endometrial histomorphometry of trimegestone-based sequential hormone replacement therapy: a weighted comparison with the endometrium of the natural cycle.

Histomorphometric changes in the endometrium were evaluated under the effect of a trimegestone-based sequential hormone replacement therapy (HRT) regimen, and the findings were compared to those in endometrium of the natural cycle. Endometrial samples were taken from postmenopausal women who completed a randomized, double blind, dose-ranging study of oral trimegestone (0.05, 0.1, 0.25 and 0.5 mg per day) from day 15 to day 28 with continuous micronized oestradiol 2 mg daily for six treatment cycles. The HRT-treated endometrium, irrespective of the dose, had a smaller mean total glandular area, smaller average glandular diameter, smaller mean total vascular space area and diameter than the luteal phase. Stromal cellularity was similar in the four dose groups. There were reduced glandular secretions in the endometrium from the high dose group. The relative weighting of these histological parameters was evaluated by linear discriminant analysis. The weighted values were dose independent, and may therefore represent either a specific effect of trimegestone, number of days administered, or both. We have constructed an equation to assign a value for a histological parameter which determines the position on linear discriminant functions. These assigned values can be used in other sequential HRT regimens to determine the relative influence of a given progestogen on endometrial morphology in relation to different phases of the natural cycle.     

A transdermal regimen for continuous combined hormone replacement therapy in the menopause

Transdermal systems for oestrogen therapy in the menopause have become very popular. The compliance, however, is impeded by the cyclic addition of oral progestins which leads to monthly withdrawal bleeds. In this pilot study a skin patch releasing 0.05 mg oestradiol and 0.25 mg norethisterone acetate per day, which was originally designed for sequential therapy, was used in a continuous manner. Results were quite favourable. Menopausal complaints were efficiently relieved and the Kupperman score dropped from 27.6 to 5.0. Out of 10 women, 1 had mild breakthrough bleeding, and 7 patients recorded one or several spotting episodes, mainly within the first 3 treatment months. No endometrial hyperplasia was observed and there was no significant change in plasma lipids, i.e. cholesterol, triglycerides, HDL-, HDL2-, HDL3-cholesterol, LDL-cholesterol and apolipoproteins A1 and B. The regimen might be a useful alternative to oral continuous combined replacement therapy.     

Endocrinology: Luteal phase oestradiol and progesterone levels are stronger predictors than follicular phase follicle stimulating hormone for the outcome of in-vitro fertilization treatment in women with tubal infertility

Basal follicle stimulating hormone (FSH) in a natural cycle,FSH on cycle days 3 and 10 in a domiphene citrate-stimulatedcycle and oestradiol and progesterone area under the curve (AUC)in the luteal phase of the ciomiphene citrate-stimulated cyclewere evaluated as hormonal predictors for the outcome of FVFtreatment in 53 normally cycling women with tubal infertility.The pregnant women had significantly fewer treatment cycles(P < 0.001) and needed fewer ampoules of gonadotrophins (P< 0.001). They also had more oocyte retrievals (P < 0.001),more oocytes per retrieval (P < 0.01), higher fertilizationrate (P < 0.001) and more replaced pre-embryos per replacement(P < 0.01) as compared with non-pregnant women. Significantdifferences were found in FSH concentrations on cycle days 3(P < 0.05) and 10 (P < 0.001) after domiphene citratestimulation and for oestradiol and progesterone AUC in the lutealphase (P < 0.001) between those women who became pregnantand those who did not become pregnant after IVF treatment Lutealoestradiol and progesterone had considerably stronger predictivevalue for the outcome of IVF treatment as compared to basalFSH and domiphene citrate challenge test.     

Endometrioma of uterine serosa in a woman with mosaic Turner's syndrome receiving hormone replacement therapy: case report

Endometriosis in Turner's syndrome patients has only been reported in five isolated cases. We present here an endometrioma on the uterine serosa and pelvic endometriosis arising in a mosaic Turner's patient receiving hormone replacement therapy (HRT). The 24 year old patient with mosaic Turner's syndrome [45,X; 46,X pseudo dicentric Y (q11.23)], on cyclic HRT after laparoscopic gonadectomy 5 years previously, was found to have an adnexal mass on routine examination. Given her history, due to the fear of a malignant process arising from a potential gonadal remnant, she underwent a laparoscopy and was found to have a 5 cm serosal endometrioma arising on a stalk from the uterine fundal surface as well as pelvic endometriosis. De-novo endometrioma and endometriosis occurred in a mosaic Turner's patient after gonadectomy on cyclic HRT. The presentation was also unusual with a pedunculated endometrioma arising from the uterine serosa. Due to the fact that the patient did have cyclic menstrual flow, her endometriosis may have arisen from retrograde menstruation or coelomic metaplasia induced by exogenous hormones.     

Cytohormonal and morphological alterations in cervicovaginal smears of postmenopausal women on hormone replacement therapy

The objective of the study was to study the cytohormonal and morphological alterations in cervicovaginal smears associated with the use of hormone replacement therapy (HRT) and to assess the utility of vaginal cytology in determining the response to HRT. Ninety postmenopausal women (30 on estrogen-progesterone combination (HRT) for 1 to 24 mo (user 1), 30 on estrogen therapy (ERT) for 1 to 44 mo (user 2), and 30 not on any hormones (nonusers)) were included in the cross-sectional study. Their lateral vaginal wall smears and cervical smears were examined for hormonal and morphological assessments, respectively. The smear pattern showed predominance of parabasal cells in 46.6% of nonusers, while none of the users had >70% parabasal cells. A high percentage (>70%) of intermediate cells was found in 46.6% of users and only in 16.6% of nonusers. A high maturation value (MV) was found in more than 75% of users but in only 16.6% of nonusers. The women with high MV (>50) were significantly less symptomatic than did nonusers. Atrophic changes were present in cervical smears of 14/20 (46.6%) nonusers when compared with 1/60 (1.66%) users. Atypical squamous cells of undetermined significance (ASC-US) were diagnosed in seven users and three nonusers. It persisted on follow-up in four users and one nonuser. Histology revealed one mild dysplasia among users. Lactobacilli were more frequently observed in users. The cytohormonal pattern on vaginal smears correlates well with the response to hormonal therapy and clinical symptoms. Awareness of the morphological alterations associated with the use of replacement hormones would enable the cytologists to reduce the false-positive diagnoses while evaluating postmenopausal smears.     

Effects of alendronate and hormone replacement therapy, alone or in combination, on bone mass in postmenopausal women with osteoporosis: a prospective, randomized study

The effectiveness of hormone replacement therapy (HRT) and alendronate, alone and in combination, was evaluated in 120 postmenopausal patients with osteoporosis with bone mineral density (BMD) measurements at least 2 SD below the mean value for young premenopausal subjects. They had no contra-indications to HRT or alendronate use and were randomized to three different treatment groups. Group I was treated with micronized 17 beta-oestradiol 2 mg and norethisterone acetate 1 mg/day per os, group II received alendronate 10 mg/day per os and group III received micronized 17 beta-oestradiol 2 mg, norethisterone acetate 1 mg/day per os and alendronate 10 mg/day per os for 1 year. Elementary calcium 1500 mg/day was supplied to patients in all three groups. Spinal and femoral neck BMD and markers of bone mineral metabolism were measured on each patient before treatment and 6 and 12 months after treatment in 95 patients. At the end of the 12th month, significant increases in spinal and femoral neck BMD were found in all groups. Increases in spinal BMD were significantly higher in patients treated with alendronate and alendronate with HRT when compared with patients treated with HRT only. No significant difference was found in femoral neck BMD changes between the groups. Significant decreases in bone resorption and markers of bone formation were observed in all groups. Alendronate was found to be more effective than HRT and could have a very beneficial effect when added to the HRT regimen in patients with postmenopausal osteoporosis. Alendronate might also be used in postmenopausal patients with osteoporosis when HRT is contra-indicated or when there is reluctance to use hormonal treatment.     

Transfer of pre-embryos donated and fertilized in vivo to recipients given a steroid replacement therapy

This study describes eleven procedures of non-surgical recoveryof preimplantation conceptuses from the uteri of eight fertiledonor women and the transfer of the recovered pre-embryos intothe uteri of infertile recipients with primary ovarian fallure,or with hypothalamic-pituitary failure. Conjugated oestrogensand progesterone were administered to recipients as replacementsteroids during the first 20 weeks of pregnancy, in order toproduce a secretory endometrium allowing nidation and developmentof the transferred conceptuses. Five pre-embryo transfers resultedin two viable pregnancies and one early abortion. Non-surgicalpre-embryo transfer is a simple and practical method for providingdonated ova to women lacking efficient ovarian function.     

Self-assessment of somatic and psychic symptoms during a two months period of hormone replacement therapy in perimenopausal women

Summary The drastic decrease in sex steroids production at menopause is often related to the development of somatic and psychic symptoms in women. We examined the effects of a two months hormone replacement therapy (HRT) on weekly self-assessments of menopausal symptoms, mood and sleep disturbances. In addition, spatial perception and motor performances abilities were measured before and after 8 weeks of HRT. Twentythree healthy perimenopausal women (mean 50 ± 4.8 years of age) with no previous hormone therapy and a Kuppermann-Index ≥15 were included. Before therapy and in weekly intervals during two months of treatment women reported upon their menopausal symptoms (MENOI), their mood state (POMS) and sleep disturbances (VISM). Psychological examinations were done before HRT and two months later under hormone replacement therapy. All 23 patients showed a significant improvement of the self report of climacteric, affective symptoms and of sleep disturbances, and a tendency to improvement in cognitive performance with respect to pretreatment measures. This indicates that hormone replacement therapy in perimenopausal women is associated with clinical improvement in somatic and psychic symptoms and a cognitive enhancement in some aspects. These benefits of the HRT must play a role in cost-effectiveness analyses of HRT.     

Hormone replacement therapy can augment vascular relaxation in post-menopausal women with type 2 diabetes

BACKGROUND: Diabetes is a major risk factor for coronary heart disease in women and event rates increase substantially after the menopause. Observational studies have suggested that estrogens may provide cardioprotection by regulating endothelial nitric oxide synthase. METHODS: In order to examine the effect of hormone replacement therapy (HRT) on endothelium-dependent and -independent vascular relaxation in post-menopausal women with type 2 diabetes, an open study was conducted in which gluteal biopsies were collected from 17 women before and after 6 months of transdermal 17 beta-estradiol (80 microg twice weekly) in combination with oral norethisterone (1 mg daily). Small arteries (<550 microm) were dissected from fat and mounted on a wire myograph for assessment of relaxation in response to acetylcholine (ACh), bradykinin (BK) and sodium nitroprusside (SNP). RESULTS: Maximal relaxation responses to ACh, BK and SNP in women with diabetes and non-diabetic control subjects were 52 +/- 8 versus 96 +/- 2% (P < 0.05), 76 +/- 7 versus 97 +/- 1%, (P < 0.05) and 91 +/- 2 versus 98 +/- 1% (P < 0.05) respectively. After 6 months of HRT, maximal relaxation responses to ACh, BK and SNP in women with diabetes (compared with pre-HRT) were: 88 +/- 4 (P < 0.05), 93 +/- 3 (P < 0.05) and 98 +/- 1% (P < 0.05) respectively. At baseline and after HRT, EC50 (concentration required to obtain 50% of maximum response) data exhibited similar changes. CONCLUSIONS: HRT had potentially beneficial effects on vascular relaxation. Data were consistent with improvements in endothelial function, vascular smooth muscle function, or both. Controlled studies are required to confirm and extend these findings.     

Changes in body composition during post-menopausal hormone therapy: a 2 year prospective study

BACKGROUND: Post-menopausal hormone therapy (pHT) induces changes in both body composition and bone mineral density (BMD). METHODS: In 109 post-menopausal women beginning either tibolone 2.5 mg (n=29), tibolone 1.25 mg (n=42) or estradiol 2 mg plus norethisterone acetate 1 mg (E2 + NETA) (n=38), we assessed body composition, total and regional BMD by dual energy X-ray absorptiometry, and the serum bone alkaline phosphatase (BAP), osteocalcin and the urinary excretion to type I collagen C-telopeptide (CTX) at baseline and after 2 years. RESULTS: At baseline, BMD at all sites correlated negatively with age and years since menopause, and positively with lean mass and fat mass (r=0.42, P<0.001 and r=0.26, P=0.006 at the total femur). During treatment, BMD increased at all sites (P<0.001), and serum BAP, osteocalcin, and urinary CTX decreased in all groups (P<0.001). Lean mass increased whereas android fat and android obesity index decreased. The increase in BMD at all sites correlated positively with changes of lean mass at 2 years. CONCLUSIONS: Both fat mass and lean mass are related to BMD in post-menopausal women, the relationship being strongest with lean mass; an increase in lean mass and a change in distribution of body fat are observed during treatment with E2 + NETA and tibolone.     

Experience with the elective transfer of two embryos under the conditions of the german embryo protection law: results of a retrospective data analysis of 2573 transfer cycles

The German embryo protection law (Embryonenschutzgesetz, ESchG) does not allow embryo selection. Therefore, only as many oocytes at the pronuclear stage (PN), as are planned to be transferred, are allowed to be cultured. It is not known whether, under these conditions, it is possible to reduce the number of embryos for transfer without a corresponding reduction of the overall pregnancy rate (PR). We retrospectively analysed 2573 consecutive transfer cycles following either in-vitro fertilization (IVF) or IVF/intracytoplasmic sperm injection. Out of these cycles, 234, 329 and 792 were performed with one, two, and three embryos respectively, because only that number was available (non-elective transfer). Another 123 and 1095 transfer cycles were performed with two and three embryos, respectively, which were selected from a higher number of PN oocytes (elective transfer). The clinical ongoing PR were 3.9, 9.1 and 17.7% respectively for the groups with non-elective transfer of 1, 2 and 3 embryos, and 22.0 and 22.5% for the groups with elective transfers with two and three embryos, respectively. There was no statistically significant difference in PR between the two elective embryo transfer groups up to the age of 40 years. The multiple pregnancy rate was reduced by 7.9%. The reduction of the number of embryos transferred from three to two can be performed even under the conditions of the ESchG without an effect on the overall PR.