Pregnancy: Heterotopic pregnancy obtained after in-vitro fertilization and embryo transfer following bilateral total salpingectomy: case report

Heterotopic (coexistent ectopic and intra-uterine) pregnancyis common following in-vitro fertilization and multiple embryotransfer. Total bilateral salpingectomy is generally consideredto eliminate the risk of ectopic, and hence heterotopic pregnancy.This is, however, not strictly correct as it does not eliminatethe risk of interstitial tubal pregnancy. This is the firstreported case of a heterotopic pregnancy following total bilateralsalpingectomy. The diagnostic pitfalls and a suggested methodof avoiding them are discussed.     

Simultaneous bilateral tubal pregnancy following in-vitro fertilization and embryo transfer

A case of simultaneous bilateral tubal pregnancy resulting from in- vitro fertilization and embryo transfer is presented. Repeated transvaginal ultrasound examinations confirmed an intrauterine sac but no fetus. A diagnosis of early missed abortion was incorrectly made and a curettage was performed. The pathological examination showed the presence of decidua and Arias-Stella phenomenon but no chorionic villi. Diagnostic laparoscopy and laparotomy performed 40 days after embryo transfer (eighth week of gestation), revealed bilateral tubal pregnancy. Bilateral salpingectomy was performed.      

Transfusion-dependent homozygous {beta}-thalassaemia major: successful twin pregnancy following in-vitro fertilization and tubal embryo transfer

Homozygous -thalassaemia (thalassaemia major) is a severe, transfusion-dependentanaemia that also causes infertility due to endocrine impairment.Very few pregnancies are reported among such patients and thereis only one report in the literature referring to a pregnancyachieved with ovulation induction and intra-uterine insemination.We report here the first successful twin pregnancy followingin-vitro fertilization and tubal embryo transfer in a transfusion-dependenthomozygous -thalassaemic woman with an oligoastheno-zoospermicpartner. Prior to ovarian stimulation, desferrioxamine was discontinueddue to potential fetotoxicity. Pre-gestational transfusionaland chelating therapies were resumed after delivery. In suchpatients, ovulation induction and assisted reproductive techniquesappear crucial in achieving pregnancy with concurrent haematologicalbalance without desferrioxamine administration.     

Bilateral salpingectomy does not compromise ovarian stimulation in an in-vitro fertilization/embryo transfer programme

The question whether salpingectomy has a negative influenceon ovarian function and the outcome of pregnancy in an in-vitrofertilization (IVF) and embryo transfer treatment programmeis not yet answered. We performed a retrospective case-controlstudy to investigate the possible negative effect of salpingectomyon ovarian response to human menopausal gonadotrophins (HMG)during IVF and embryo transfer. The study group was composedof 26 patients with bilateral salpingectomy. In 67 cycles weanalysed different parameters of ovulation such as the numberof days of ovarian stimulation, numbers of ampoules of HMG,pre-ovulatory oestradiol concentrations and the numbers of oocytesretrieved. These parameters were compared to a control groupof 134 cycles in 134 women with healthy Fallopian tubes. Nodifferences were found. Implantation ratio, pregnancy rate andoutcome were the same in both groups. We conclude that bilateralsalpingectomy had no detrimental effect on ovarian performanceduring IVF and embryo transfer treatment nor on the outcome.     

Improvement of clinical pregnancy rate and implantation rate of in-vitro fertilization--embryo transfer patients by using methylprednisone

A prospective non-randomized study was undertaken to test whetherimmunosuppression improves implantation and pregnancy ratesin an in-vitro fertilization—embryo transfer (IVF-ET)programme in patients with tubal factor infertility. Treatmentinvolved ovarian stimulation, transvaginal oocyte retrieval,IVF-ET, and assessment of short-term administration of largedoses of corticosteroids (60 mg of methyl-prednisone x 4 days).When compared to the group that did not receive immunosuppressivedoses of methylprednisone (group A; mean age 31.85 ±4.09 years), those subjects who were treated (group A2) showeda statistically significant increase in pregnancy (P < 0.01)and take home baby rate (P < 0.01). Similar results wereobserved in subjects who received corticosteroids in their firstIVF-ET attempt (group B; mean age 34.32 ± 4.98 years).Our results suggest that immunosuppressive doses of corticosteroidsadministered for a short period of time to patients undergoingIVF-ET could significantly improve the implantation and pregnancyrates. Possible mechanisms of action of corticosteroids areproposed.     

Severe ovarian hyperstimulation syndrome and combined intrauterine and tubal pregnancy after in-vitro fertilization and embryo transfer

Ovarian hyperstimulation syndrome (OHSS) and hetero-topic pregnancyare two well recognized entities occurring after in-vitro fertilization(TVF). This is the first reported case of a severe OHSS andcoexistent heterotopic pregnancy after FVF and embryo transfer.Diagnosis of tubal pregnancy was obscured both by stimulatedovaries which prevented accurate ultrasound definition and thecoexistence of an intrauterine pregnancy which accounted forhuman chorionic gonadotropbin (HCG) concentrations and alsofor aggravation of the OHSS. The roles of transvaginal ultrasound,diagnostic laparoscopy and early paracentesis in the managementof this rare complication of assisted reproductive technologiesare discussed.     

The effect of smoking on the outcome of in-vitro fertilization--embryo transfer

This study investigated the influence of cigarette smoking on the outcome of in-vitro fertilization-embryo transfer. Forty-one women under the age of 37 years, suffering from mechanical infertility, were suppressed with gonadotrophin releasing analogue from day 21 of the cycle. Twenty women were smokers and 21 women were non-smokers. Gonadotrophin releasing analogue was injected daily before ovarian stimulation with gonadotrophin was begun. The follicular phase was longer and the number of human menopausal gonadotrophin ampoules required to reach adequate stimulation were higher in smokers. The peak serum oestradiol level was not significantly different in smokers compared to non-smokers. However, follicular fluid levels of oestradiol were significantly lower in smokers than in non-smokers (657 +/- 367 versus 1077 +/- 786 ng/ml) respectively. Furthermore, the fertilization rate was also lower in smokers than in non-smokers (40.9 versus 61.7%) respectively. Four pregnancies were achieved in the non-smokers group, while only one ectopic pregnancy was diagnosed in the smokers group. These findings suggest that cigarette smoking has a detrimental effect on the outcome of in-vitro fertilization and embryo transfer.     

Sex selection may be inadvertently performed in in-vitro fertilization--embryo transfer programmes

The present study aims to ascertain whether sex selection maybe inadvertently performed in human in-vitro fertilization (IVF)and embryo transfer (IVF-embryo transfer) programmes when selectingfor high quality embryos (those with the fastest cleaving ratesand/or the best morphology) at the fresh transfer cycle. Allpatients entering into the study were treated with gonadotrophinsafter pituitary suppression with gonadotrophin-releasing hormoneagonists (GnRHa) and had intrauterine embryo transfer on day2 post-insemination. These patients were retrospectively dividedinto three groups according to whether the difference in meannumber of cells between embryos transferred and all embryosavailable for transfer in a given cycle was less than (negativeselection), equal to (no selection) or greater (positive selection)than zero. In cycles resulting in singleton births, the sexratio of the resulting babies was significantly (P 0.005) shiftedtoward the female (88.8%) and to the male (90.0%) in the negativeand positive selection groups respectively. No shift in sexratio was observed in cycles resulting in multiple births. Maternalage was another independent factor affecting sex ratio at birth.Sex ratio was significantly (P 0.05) skewed in favour of males(62.7%) and females (71.4%) in women <35 and 235 years ofage respectively. Maternal age, number of embryos transferredand the event of selecting or not selecting the slowest cleavingembryos for transfer were entered automatically in a three-groupdiscriminant model for distinguishing cycles resulting in onlyboys, both boys and girls, and only girls. These data suggestthat (i) sex selection may be inadvertently performed in IVF-embryotransfer programmes when selecting for high quality embryosat the fresh transfer cycles; (ii) human endometria may be favourable,indifferent or hostile to either fast cleaving or slow cleavingembryos depending on maternal age; and (iii) ‘natural’sex selection may be performed for social, psychological ormedical reasons.     

Early pregnancy wastage following late implantation of embryos after in-vitro fertilization and embryo transfer

Serial plasma concentrations of human chorionic gonadotrophin (HCG), progesterone and oestradiol were measured in pregnancies after in-vitro fertilization and embryo transfer. The first detection day of HCG after embryo transfer (8.4 +/- 1.1) and the HCG doubling time (DT) of 64 normal singleton pregnancies were compared to those of 14 first-trimester miscarriages. The same parameters were evaluated in nine late-implanted conceptions, seven of which resulted in early pregnancy wastage. The HCG DT of late-implanted pregnancies was consistent with that of singleton term pregnancies in the first 12 days, while first-trimester miscarriages which had implanted at the usual time had a significantly longer DT from implantation onwards. The reduced trophoblastic secretory rate suggests poor embryo quality in these cases. A decreased progesterone/oestradiol ratio was observed in late-implanted pregnancies but because of the small number of individuals, no definite conclusion can be drawn. More patients with delayed implantation should be tested to justify this observation.     

Delivery rates after in-vitro fertilization following bilateral salpingectomy due to hydrosalpinges: a case control study.

This retrospective case-control study assessed the impact of bilateral salpingectomy due to uni- or bilateral hydrosalpinges on the outcome of in-vitro fertilization (IVF) in a large consecutive series of patients. The effect of bilateral salpingectomy due to hydrosalpinges on pregnancy outcome was compared in 139 patients (263 cycles) and 139 age-matched controls with tubal infertility without hydrosalpinges (296 cycles). The delivery rates per initiated cycle as well as the implantation rates were equal in the two groups (21.7 versus 21.6% and 19 versus 21%). The number of embryos, the cleavage stage, and the embryo morphology score were equal in the two groups. Among 92 patients treated with 182 IVF cycles who underwent salpingectomy between 1.5 and 5 years prior to their first IVF cycle, the delivery and the implantation rates were 22.5 and 20.5% respectively. Of the patients with salpingectomy after an average of 1.7 failed IVF cycles and who re-entered the IVF programme 3 and 6 months subsequent to surgery, 47 were treated with 83 IVF cycles. The live birth and the implantation rates after surgery in this group were 20.5 and 20% respectively. It is concluded that bilateral salpingectomy due to hydrosalpinges restores a normal delivery as well as implantation rate after IVF treatment compared to controls. A favourable outcome is also found in patients operated on after repeated IVF failures. Furthermore, a normal live birth rate as well as a high implantation rate is maintained for at least three IVF cycles subsequent to surgical treatment.     

Retrograde tubal embryo transfer in natural cycle in-vitro fertilization

Two modes of embryo transfer, uterine and tubal, were compared following natural cycle in-vitro fertilization (IVF). Only patients with patent Fallopian tubes were included in the study. Tubal embryo transfer was performed by retrograde tubal cannulation without analgesia on an outpatient basis. Tubal transfer conferred no benefit compared with uterine transfer in male factor infertility with positive fertilization (pregnancy rates of 15.8% in both groups). Although tubal embryo transfer in the patients with unexplained infertility improved the pregnancy rates from 7.8% in uterine transfer (5/64) to 17.6% in the tubal transfer group (13/74), this improvement was not statistically significant.      

Pregnancy: The prediction of ectopic pregnancy after in-vitro fertilization and embryo transfer

Data from 135 patients who suffered ectopic pregnancies andfrom 135 patients who progressed to singleton deliveries afterin-vitro fertilization and embryo transfer have been analysedretrospectively. The ectopic pregnancies represent all suchcases observed at Bourn Hall Clinic between 1983 and 1993. Thedelivered group was randomly selected from the same time period.The ectopic pregnancies included 20 heterotopic, eight ovarianand six bilateral tubal pregnancies; the remainder were singletontubal pregnancies. The aim of this study was to identify thevariables which differed systematically for the two groups ofpatients and to explore whether such variables could be usedto predict ectopic pregnancy at an early stage. The mean plasmaconcentration of human chorionic gonadotrophin and progesteronefor the ectopic pregnancy group was significantly lower thanthat for the singleton delivery group (P < 0.001). However,there was such a degree of overlap that it was impossible todevise a cut-off concentration for either hormone which wouldoffer a clinically useful predictor of ectopic pregnancy. Nevertheless,using the discriminant function analysis of these data, togetherwith the history of pelvic inflammatory disease, we could predictup to 90% of cases of ectopic pregnancy by day 23 after embryotransfer, long before ultrasound imaging would be useful.     

Multiple pregnancy after in-vitro fertilization and embryo transfer: report of a quadruplet pregnancy and delivery

The first baby from in-vitro fertilization (IVF) was born in England in 1978 as a result of retrieval of a single preovulatory oocyte in the course of a natural cycle (Steptoe and Edwards, 1978). At present most programmes of IVF throughout the world do not use natural cycles producing only one oocyte, but rather multiple oocyte cycles produced by clomiphene citrate (CC), human menopausal gonadotrophin (HMG), or pure follicle stimulating hormone (FSH), either separately or in combination, sequentially or concomitantly, for the induction of multiple follicular maturation.     

Embryo transfer under ultrasound guidance improves pregnancy rates after in-vitro fertilization

Between October 1998 and January 1999, we examined the influence of ultrasound guidance in embryo transfer on pregnancy rate in 362 patients from our in-vitro fertilization (IVF)-embryo transfer programme. These patients were prospectively randomized into two groups: 182 had ultrasound-guided embryo replacement, and 180 had clinical touch embryo transfer. There were no statistically significant differences between the two groups with respect to age, cause of infertility and in the characteristics of the IVF cycle. The pregnancy rate was significantly higher among the ultrasound-guided embryo transfer group (50%) compared with the clinical touch group (33.7%) (P < 0.002). Furthermore, there was also a significant increase in the implantation rate: 25.3% in the ultrasound group compared with 18.1% in the clinical touch group (P < 0.05). In conclusion, ultrasound assistance in embryo transfer significantly improved pregnancy and implantation rates in IVF.     

Spontaneous intrauterine pregnancy following salpingectomy for a unilateral hydrosalpinx

The effect of salpingectomy for unilateral hydrosalpinx with a contralateral normal tube was evaluated in two infertile patients in which unilateral hydrosalpinx, visualized by vaginal ultrasound, was treated by unilateral salpingectomy as a preparatory step before IVF. Spontaneous pregnancy occurred in both patients while waiting to be enrolled in an IVF trial. In conclusion, unilateral salpingectomy for hydrosalpinx in the presence of a contralateral healthy tube could result in spontaneous pregnancy.     

Ectopic pregnancy after tubal sterilization

We report 13 cases of ectopic pregnancy following tubal ligation out of 287 ectopic pregnancies seen during a six year period (1984-1989). These findings suggest that tubal sterilization does not invariably confer infertility. Ectopic pregnancy must not be disregarded in women who have undergone tubal ligation, especially if two or more years have elapsed since the sterilization.