Programmed oocyte retrieval during routine laparoscopy and embryo cryopreservation for later transfer

Fixed-schedule ovulation induction and cryopreservation of the obtained embryos was performed in women undergoing a preliminary laparoscopy for infertility investigation before possible inclusion in an in vitro fertilization program. The cycle before follicular stimulation was modified by a progestogen or an estrogen-progestogen contraceptive pill. Ovarian inaccessibility precluded follicular aspiration in four of 34 patients but at least one oocyte was obtained in 29 of the remaining 30. Although fewer oocytes were obtained in these patients than in a control group undergoing in vitro fertilization treatment, one or more embryos were obtained in 22 patients in the study group. All embryos were frozen and to date 25 embryos from 17 patients have been thawed. Embryos have been placed in 16 of the 17 patients and six pregnancies have been initiated. Three are currently ongoing, one ectopic pregnancy was recorded, and two pregnancies were classified as "chemical." Programmed oocyte retrieval and embryo cryopreservation resulted in an extra chance of pregnancy in patients undergoing a laparoscopy for infertility investigation.     

Avoidance of oocyte retrieval on the weekend through the use of scheduled ovarian hyperstimulation for in vitro fertilization and embryo transfer

Objective: To avoid oocyte retrieval for IVF-ET during the weekend, the scheduled method of ovarian hyperstimulation, in which oocyte retrieval is planned in advance for Monday through Wednesday, was evaluated.Design: A retrospective study.Setting: The IVF-ET unit of the Department of Obstetrics and Gynecology at Tokushima University Hospital.Patient(s): One hundred seventy-eight cycles in patients undergoing ovarian hyperstimulation for IVF-ET were stimulated according to the scheduled method of ovarian hyperstimulation (scheduled group). One hundred seventy-one cycles in patients of similar age and with comparable causes of infertility were stimulated according to the conventional method of ovarian hyperstimulation for IVF-ET (conventional group).Intervention(s): In the scheduled method, under GnRH-a, the day of oocyte retrieval was determined in advance for IVF-ET. Ovarian stimulation with FSH and hMG was started 12 days before oocyte retrieval.Main Outcome Measure(s): The cancellation and clinical pregnancy rates (PRs), the days of oocyte retrieval, and other clinical parameters were evaluated in the two groups.Result(s): The cancellation rates in the scheduled and conventional groups were 9.6% and 4.7%, respectively. In about 75% of cycles in the scheduled group, oocyte retrieval was conducted on the scheduled day. When oocyte retrieval was scheduled for Monday through Wednesday, overtime work on the weekend could be avoided in 91% of the cycles without cancellation. The clinical PR was comparable between the two groups.Conclusion(s): The scheduled method of ovarian hyperstimulation for IVF-ET was useful for avoiding oocyte retrieval on the weekend.     

Multi-chorionic pregnancies following single embryo transfer at the blastocyst stage: a case series and review of the literature

Objective

To report cases of in vitro fertilization-frozen embryo transfer (IVF-FET) with single blastocyst transfer resulting in di- or tri-chorionic pregnancies, and to review the literature on monozygotic, multi-chorionic pregnancies originating at the blastocyst stage.

Design

Retrospective case series and literature review.

Materials and methods

All in vitro fertilization cycles (fresh, frozen, autologous, and donor oocyte) performed between June 2012 and June 2017 at the University of California, San Francisco Center for Reproductive Health, were reviewed retrospectively. Cycles with cleavage-stage embryos or transfer of more than one blastocyst were excluded. Cycles were analyzed to determine if clinical pregnancy occurred with the presence of two or more gestational sacs noted on initial ultrasound. An in-depth chart review was performed with further exclusions applied that would lend credence to dizygosity rather than monozygosity such as fetal/neonatal sex discordance, fresh embryo transfer, and natural cycle FET (in which concomitant spontaneous pregnancy could have occurred). Demographic, clinical and IVF-FET cycle characteristics of the resulting patients were collected. Additionally, a review of the English language literature was performed (PUBMED, PMC) using the search words monozygotic twins, dichorionic diamniotic, in vitro fertilization, and single embryo transfer in order to identify cases of DC-DA monozygotic twinning from 1978 to 2017. Resulting articles were reviewed to eliminate all cases of dizygosity and day 3 embryo transfers. We obtained the following data from the literature search: basic patient demographics, type of fertilization, type and day of embryo transferred, number of embryos transferred, gestational ultrasound details, presence of any genetic testing if performed after delivery, and number of live births.

Result(s)

Two thousand four hundred thirty-four women underwent fresh or frozen single embryo transfer between June 2012 and June 2017 at the University of California, San Francisco Center for Reproductive Health. Of these, 11 women underwent a single blastocyst transfer with subsequent clinical pregnancies identified as multi-chorionic gestations. Four were in downregulated controlled FET cycles, in which concomitant spontaneous pregnancy could not have been possible. We then reviewed all cases of monozygotic dichorionic-diamniotic (DC-DA) splitting in IVF patients reported in the literature from 1978 to 2017. These eight cases demonstrate monozygotic splitting after the blastocyst stage, which challenges the existing dogma that only monochorionic twins can develop after day 3 post-fertilization.

Conclusion(s)

The accepted theory of monozygotic twinning resulting from the splitting of an embryo per a strict post-fertilization timing protocol must be re-examined with the advent of observed multi-chorionic pregnancies resulting from single blastocyst transfer in the context of IVF.

     

Extended embryo culture reduces the implantation rate on day 4 and day 5 when only a maximum of three embryos are cultured beyond the pronuclear stage

OBJECTIVES: To study the potential of embryo transfer after 3, 4 or 5 days of embryo culture under the German embryo protection law according to which only a maximum of three zygotes are allowed to be cultured for embryo transfer. STUDY DESIGN: In a prospective study, 273 patients with assisted reproductive treatment were randomly allocated for transfer on days 3, 4 or 5. Pregnancy and implantation rates were evaluated in regard to day of transfer and results were compared by Chi-square or ANOVA test. RESULTS: Out of 234 transfer cycles, 79 were performed on day 3, 76 on day 4 and 79 on day 5. Pregnancy and implantation rates were 41.8%/27.1% for transfer on day 3, 27.6%/14.1% for day 4 transfer and 16.5%/8.8% for transfer on day 5. These results were significantly different for pregnancy rates on day 3 versus day 5 (P < 0.001) and for implantation rates on day 3 versus day 4 (P < 0.005) and day 3 versus day 5 (P < 0.001). CONCLUSIONS: These findings suggest that extended embryo culture is not beneficial when the option for embryo selection at later stages of development is not available.     

胚胎发育速度及形态评级和受精卵原核评级联合选择移植胚胎的研究

目的探讨胚胎发育速度及形态评级并参考受精卵原核评级（联合评级）,对行体外受精-胚胎移植及卵母细胞质内单精子注射后移植胚胎筛选的意义.方法回顾性分析我院2003年5-12月,采用联合评级筛选进行胚胎移植的434个周期,共2714个正常受精卵的资料.根据受精卵原核发育是否同步,分为原核发育同步组和原核发育不同步组,观察不同原核等级受精卵的发育潜力;首先根据胚胎发育速度及形态评级,再根据受精卵原核等级的联合评级选择移植胚胎.根据移植胚胎中是否含有原核发育同步的胚胎,比较原核发育同步组与原核发育不同步组受精卵进行胚胎移植后的临床妊娠率和着床率.结果2714个正常受精卵中,原核发育同步组受精卵1774个,其中优质胚胎743个,优质胚胎率为41.88%;原核发育不同步组受精卵940个,其中优质胚胎319个,优质胚胎率为33.94%,两组比较,差异有统计学意义（P＜0.01）.原核发育同步组中胚胎移植周期395个,临床妊娠率为47.85%（189/395）,着床率为27.49%（273/993）;原核发育不同步组中胚胎移植周期39个,临床妊娠率为43.59%（17/39）,着床率为25.00%（21/84）.两组比较,差异无统计学意义（P＞0.05）.结论采用联合评级,受精卵原核发育同步组与发育不同步组胚胎的临床妊娠率及着床率无差异;参考原核评级不能预测更高的妊娠率和着床率,但能预测胚胎发育的潜力.     

Normal pregnancy resulting from a non-pronuclear oocyte at the time of examination for fertilization

PURPOSE: To report the case of a patient undergoing in vitro fertilization (IVF) in which a non-pronuclear (0PN) oocyte resulted in a normal pregnancy. METHODS: A 36-year-old woman underwent an IVF-embryo transfer treatment cycle. RESULTS: Four oocytes were retrieved for insemination by IVF. Examination for fertilization revealed two polypronuclearpolygynic and two non-pronuclear oocytes. The non-pronuclear oocytes were observed further for development. One embryo developed from the non-pronuclear cohort and was transferred at the 8-cell stage on day 3. Subsequently, a pregnancy developed, and resulted in the delivery of a healthy term infant. CONCLUSIONS: Non-pronuclear oocytes may represent a source of developmentally competent embryos, and further observation of this cohort should be considered, particularly in situations involving a low yield of oocytes at retrieval.     

Rescue hCG to treat empty follicle syndrome after the use of a GnRH agonist as oocyte maturation trigger: First report on fresh embryo transfer and clinical pregnancy

We present a case series and literature review on the use of rescue human chorionic gonadotropin (hCG) in cases of empty follicle syndrome (EFS) after a gonadotropin-releasing hormone agonist (GnRHa) trigger. EFS was diagnosed after failure to collect any oocytes from one ovary. In such cases, a single dose of hCG was administered and the oocyte retrieval was repeated 36 h later. The main outcome measures were the number of mature oocytes (M2) and embryos (2PN), incidence of hospitalisation for severe ovarian hyperstimulation syndrome (OHSS) and clinical pregnancy when fresh embryo transfers occurred. Our population consisted of 322 patients, who had a GnRH agonist as oocyte maturation trigger (2-mg subcutaneous buserelin). Six patients (1.8%) developed EFS after the use of a GnRHa trigger. Mature oocytes were retrieved in 5 patients after the use of rescue hCG. One patient developed severe OHSS. Two patients had a fresh embryo transfer and one clinical pregnancy was reported. This is the first case series to report fresh embryo transfers and a clinical pregnancy with the use of rescue hCG after failure of the GnRHa trigger.     

Clinical-pathological study of the infant and fetal mortality for a ten-year period at the chicago lying-in hospital

A summary of the probable causes of all stillbirths and infant deaths at the Chicago Lying-in Hospital for a ten-year period is found in Table III. Interference with the circulation of the fetus while it is still in utero appears to cause more deaths than any other condition. With death occurring before the onset of labor this is most commonly premature placental detachment; with death during labor it is most often cord prolapse or entanglement; and in death after birth it is most often placenta previa. In actual numbers premature placental detachment occurred with one and one-half times the frequency of the other conditions.Second in importance is prematurity, although it is highly probable that this should rank first because the combination of a harmful maternal complication and prematurity is doubtless more likely to result in a fatality after birth than would be the same complication acting on an infant at term. The fetuses who die before the onset of labor and the majority of those dying during labor cannot be considered to have died because of prematurity. The total number of prematures who die without specific lesions and whose deaths are probably due to inadequate development make up 25.6 per cent of deaths after birth, but only about 12 per cent of the total mortality.Birth trauma accounts for 13 per cent of the deaths. Included with the infants showing specific intracranial hemorrhage are 31 infants who either were not subjected to autopsy or who exhibited no gross bleeding, but in whom there was difficulty in effecting delivery or in whom there was clinical evidence of trauma in the infant after birth.Major malformations are almost equal to trauma as a cause of death. In deaths occurring in the neonatal period, malformations are second only to prematurity as a causative factor.Infections are not common during this period, and the few which are found consist almost entirely of pneumonia.Erythroblastosis, syphilis, and a few miscellaneous conditions make up the remainder of the conditions producing death.     

The graduated embryo score predicts the outcome of assisted reproductive technologies better than a single day 3 evaluation and achieves results associated with blastocyst transfer from day 3 embryo transfer

OBJECTIVE: To evaluate the graduated embryo score (GES) for predicting assisted reproductive technology (ART) outcome compared to a single morphologic evaluation on day 3 of culture (grade A: > or =7 cells; <20% fragmentation). DESIGN: Prospective cohort analysis. SETTING: Private practice. PATIENT(S): Women aged <40 years with a normal uterine cavity treated with ART (n = 106). INTERVENTION(S): Embryos were graded by GES and by day 3 morphologic characteristics alone before ET. Cycle outcomes were compared with embryo grade. MAIN OUTCOME MEASURE(S): Ongoing gestation and implantation rates. RESULT(S): Overall ongoing gestation and implantation rates were 48% and 26%, respectively. With 1+ embryo GES > or =70 (n = 77), the rates were 62% and 36%, respectively, which were significantly higher than for those with 0 embryos GES > or =70 (n = 29). With 1+ grade A embryo (n = 102), the rates were 50% and 27%, respectively. Transfer of more than one embryo GES > or =70 did not improve the pregnancy rate, but did increase the risk of multiple gestations. A single day 3 evaluation had an extremely low specificity (7%) compared to GES (47%). Graduated embryo scoring (GES) was an excellent predictor of pregnancy and implantation rates from blastocyst transfer. Day of transfer did not affect pregnancy rates, although implantation was higher from day 5 embryo transfer (ET) than from day 3 ET, as fewer embryos were transferred. CONCLUSION(S): Transfer of one or more embryo GES > or =70 predicts pregnancy and implantation rates better than a single morphologic evaluation on day 3 and achieves ART outcomes associated with blastocyst transfer from day 3 ET, making extended culture unnecessary for most patients.     

Impact of technical difficulties,choice of catheter,and the presence of blood on the success of embryo transfer--experience from a single provider

Purpose: To investigate the impact of technical difficulties, choice of catheter, and the presence of blood during embryo transfer on the results of in vitro fertilization and ICSI. Methods: A cohort of 784 consecutive cycles in 655 in vitro fertilization and ICSI patients were studied. Results: Negotiating the cervix, using the volsellum, presence of blood on the catheter wall or on the cervix did not affect the results. Changing the catheter and blood on the catheter tip reduced the pregnancy (P < 0.05 and P < 0.05) and implantation rates (P < 0.001 and P < 0.01). The Ultrasoft catheter produced higher pregnancy (P < 0.0005) and implantation rates (P < 0.01) compared to the more rigid Frydman catheter. Conclusions: Negotiation of the cervix, the use of a volsellum, and the presence of blood on the catheter wall or on the cervix do not affect the results. Changing the catheter and blood on the catheter tip significantly diminish the pregnancy and implantation rates. Soft catheters perform better.     

加强哮喘苗期患儿合理用药和中医健康教育的思考

哮喘苗期理论创新性地将哮喘病的防治提前到了无任何哮鸣喘促症状的时期。加强小儿哮喘苗期的药物治疗和中医健康教育,是哮喘防治的关键策略,可以有效预防哮喘的典型发作。本文就此进行分析,介绍了合理用药的对证治疗和防哮汤加味或益气固本胶囊序贯治疗两个阶段。从节乳食、防外感、慎起居、适锻炼、中医体质辨识、体质调摄入手,开展形式多样的中医健康教育实践。     

Changes in the approach for invasive prenatal diagnosis in 35,127 cases at a single center from 1977 to 2004

OBJECTIVES: To evaluate the changes in the approaches used for invasive prenatal diagnosis for beta-thalassemia and karyotyping at a single center from 1977 to 2004. METHODS: For beta-thalassemia, in 1977 placentacentesis, in 1982 amniocentesis, in 1983 fetoscopy and cordocentesis, in 1983 trancervical chorionic villi sampling (TC-CVS), in 1984 cardiocentesis, in 1986 transabdominal CVS, and in 2002 preimplantation genetic diagnosis (PGD) were introduced. For karyotyping, in 1977 amniocentesis, in 1983 cordocentesis and cardiocentesis and TC-CVS, in 1986 TA-CVS and in 1991 hepatic vein sampling were introduced. Rates of approaches used were retrospectively considered, for 5 different groups (1977-1981; 1982-1985; 1986-1993; 1994-1999; 2000-2004). RESULTS: 35,127 invasive prenatal diagnoses were considered, and 42 PGD included. For beta-thalassemia 6,547 diagnoses were performed and 42 PGD. Since 1986-1993, TA-CVS was the only approach used except for 42 PGD in the 2000-2004 group. For karyotyping 28,538 diagnoses were performed. Amniocentesis and TA-CVS have been the most frequently used in the last years, while cordocentesis and hepatic vein sampling have shown a decline after their introduction. CONCLUSION: TA-CVS is now the only technique used for beta-thalassemia. For karyotype, amniocentesis and TA-CVS are the most frequently used procedures. Obstetrical and laboratory experience, the availability of screening, and other individual factors, have influenced the choice, towards an earlier approach in pregnancy.