Emotional experiences of in vitro fertilization participants

Data were collected from self-administered question-naires returned by 33 female participants and 18 of their partners in the University of British Columbia's in Vitro Fertilization/Gamete Intrafallopian Transfer (IVF/GIFT) Program during a 2-month period. Emotional reactions to each of the stages of IVF/GIFT by treatment phase were measured. Responses were then grouped into the following categories: anxiety, depression, loss of control, and positive feelings. For female participants, anxiety was reported most frequently throughout the treatment process and loss of control was highest following embryo replacement. Male and female participants reported high rates of depression at the completion of the treatment cycle. The findings from this pilot study outline the emotional experiences of male and female participants under-going IVF/GIFT by treatment phase and indicate their desire for support services.     

Emotional aspects and support in in vitro fertilization and embryo transfer programs

Little is known about the emotional demands upon women of the step-by-step procedures characteristic of involvement in an in vitro fertilization/embryo transfer (IVF-ET) program. In this study, 77 women provided their perceptions of the emotional demands of IVF-ET and explanations for failed attempts, as well as describing their coping strategies and sources of emotional support. Nominated as the two most difficult stages of IVF were the wait for a possible pregnancy after the procedure and the blood tests and injections prior to hospitalization. Women were overly optimistic with a first attempt, with 70% being moderately to highly optimistic about success. Levels of optimism, however, generally declined across attempts. About half of the women intended to stop after four attempts, and almost all would stop after six treatment cycles. Women attributed their lack of success to a wide range of factors, including the low success rate, being anxious or stressed, bad luck, or problems associated with their condition and the procedure. Asked how they coped with the program, the women reported that the major strategy was to adopt the attitude that they might be successful in the long term. Other coping strategies involved keeping busy, staying calm, and seeking the support of other IVF women and husbands. Husbands were listed as the major source of emotional support, followed by other infertile women and nurses, counselors, and doctors. Finally, the majority of women believed that although they would be less fulfilled if they did not have a child through IVF-ET, nevertheless there were alternative sources of satisfaction which they would pursue. For most, continued infertility was not seen as detrimental to the quality of their marriages.     

Differences in the luteal phases after failed or successful in vitro fertilization and embryo replacement

Luteal phases after in vitro fertilization (IVF) and embryo replacement have been studied in 241 cycles. A positive correlation was observed between the follicular estradiol (E₂) peak and the progesterone (P) level on day 3 of the luteal phase, but not correlation was found between the E₂-peak value and the luteal-phase duration or midluteal P concentration. When the trials were classified in relation to their outcome (i.e., clinical pregnancies, chemical pregnancies, or failures), the mean P level on day 3 of the luteal phase was significantly higher in clinical pregnancies than in chemical pregnancies and in failures. Mean E₂ levels on day 3 were not significantly different among the three groups. Values of the E₂/P ratio were significantly higher in chemical pregnancies than in the other groups. No significant differences were observed among the three groups on day 8. When comparing trials ending in failure to those leading to clinical pregnancy for the same patients, pregnancies were obtained in cycles in which early luteal P was higher and the early luteal E₂/P ratio was lower than in failures cycles. These data suggest that high P levels and a low E₂/P ratio in the early luteal phase might have a favorable influence on the implantation process in human IVF.     

Satellite in vitro fertilization: The Oregon experience

Objective: This study was designed to compare the results of preliminary evaluation, ovarian hyperstimulation, and monitoring of patients at a distant in vitro fertilization satellite center with those treated at the main campus of the program.Study design: Fifty-four patients completing oocyte retrieval cycles at the Eugene satellite Oregon Health Sciences University in vitro fertilization program for the period Jan. 1, 1991, through Dec. 31, 1993, were compared with 222 patients at the main campus for age, peak estradiol level, number of oocytes, retrieved, number of embryos, clinical pregnancy rate, and pregnancy outcome.Results: There were no statistically significant differences between the Eugene in vitro fertilization satellite center and the main campus for any of the factors analyzed with the exception of clinical pregnancy rate. The clinical pregnancy rate per cycle at the Eugene satellite center was 39% while the Portland main campus rate was 23% (p = 0.027), presumably because of a larger number of couples with severe male factor infertility at the central site.Conclusion: A distant in vitro fertilization satellite program was highly successful in the Oregon experience. In addition to greater convenience to the patients, the program was highly comparable to main campus program in measured parameters of ovarian hyperstimulation, oocyte retrieval, number of embryos, and pregnancy rate.     

Ultrasonically guided oocyte recovery for in vitro fertilization: An improved method

Ultrasonically guided follicular aspiration is now routinely used for in vitro fertilization (IVF) in many centers. We present an improved method for oocyte recovery. One hundred nine consecutive patients with mechanical infertility submitted for IVF were included in the study. Superovulation was induced with human menopausal gonadotropin (hMG)/human chorionic gonadotropin (hCG). Oocyte recovery was ultrasonically guided, the bladder filled with phosphate-buffered saline (PBS), and a cannula with trocar used for single percutaneous puncture. The aspiration needle was of 1.6 mm in internal diameter. When compared to published data using smaller-bore needles, it seems that this improved needle increased the number of oocytes recovered to a mean of 6.5 and the number of embryos replaced to a mean of 3.9 per patient, with a pregnancy rate of 20% per transfer.     

Super high estradiol response to gonadotropin stimulation in patients undergoing in vitro fertilization

The likelihood of establishment of a term pregnancy from in vitro fertilization (IVF) is related to the estradiol (E₂) pattern and peak level. To examine the influence of super high E₂ peak levels (>-2000 pg/ml), we reviewed the clinical outcomes of all IVF cycles with follicular phase E₂ levels >2000 pg/ml from May 1982 through June 1987. Among 1651 IVF cycles initiated during this time, 102 cycles (6.2%) had super high E₂ levels. Twenty-seven of these cycles occurred in 34 IVF attempts in 12 women. Stimulation was performed with human menopausal gonadotropin (hMG) in 96 cycles and follicle-stimulating hormone (FSH) in 6 cycles. A mean of 9.3±0.7 oocytes per cycle was recovered, of which 5.5±0.5 fertilized and underwent cleavage. In 11 cycles, with a mean of 6.8 oocytes recovered, none fertilized. Polyploid fertilization occurred in 23 of 90 cycles (25.6%), and 40 of 558 fertilized oocytes (7.2%). From these cycles, 10 clinical pregnancies (9.8%) have resulted: 6 pregnancies in 59 cycles with luteal-phase progesterone support (10.2%) and 4 pregnancies in 31 cycles without luteal-phase progesterone support (12.9%). Among the 1549 cycles with peak E₂ levels <-2000 pg/ml, 143 (9.2%) resulted in clinical pregnancies. We conclude that there is a small subset of patients who will have super high E₂ responses to gonadotropin stimulation and that there is a tendency to stimulate repetitively in this fashion. With regard to pregnancy outcome (1) pregnancy rates are not elevated in this sub-group of high E₂ responses, and (2) there does not appear to be an advantage of luteal-phase progesterone support in these super high E₂ cycles.     

The effect of endometriomas on in vitro fertilization outcome

To determine the effect of ovarian endometriomas on in vitro fertilization (IVF) outcome, two groups of patients were studied. Group I consisted of seven patients with ovarian endometriomas and severe pelvic adhesions treated for a total of 12 cycles. Group II patients consisted of eight patients with hydrosalpinges and comparable pelvic adhesions treated for a total of 27 cycles. There were no differences in the number of days required for stimulation or in the serum estradiol levels attained between the two groups. Group I patients were noted to have significantly fewer preovulatory follicles (1.42 vs 3.33,P<0.005), cycles with fertilization (28 vs 84%,P<0.005), and embryos transferred (0.78 vs 2.56,P=0.01) than Group II patients. Three pregnancies occurred in Group II, while there were no conceptions among Group I patients. This study suggests that the presence of an ovarian endometrioma(s) has an adverse effect on IVF outcome and suggests that patients with ovarian endometriomas should have them removed prior to undergoing IVF.Presented in part at the 44th Annual Meeting of the American Fertility Society, Atlanta, Georgia, 1988.     

Psychological studies of in vitro fertilization/embryo transfer participants

During the last decade, reproductive endocrinology has provided new technologies for treatment of infertilityone of which is in vitro fertilization/embryo transfer (IVF/ET). The use of this technology has been accompanied by considerable interest in understanding the psychology of those seeking IVF/ET and in understanding psychological reactions during and after IVF/ET. This paper reviews the psychological research within the IVF/ET literature as divided into three major areas: first, psychological profiles of women and their partners requesting IVF/ET; second, clinical reports which describe the psychological experience of IVF/ET and provide recommendations for counseling both before and during IVF/ET; and third, follow-up studies of IVF/ET participants. This paper is designed to highlight initial findings in these three areas of research and thus provide a context for future research directions. Specific suggestions for future study include redirecting research effort from investigations of psychopathology to detecting stress which may affect IVF/ET outcome.     

Emotional adaptation following successful in vitro fertilization

OBJECTIVE: To assess the emotional impact of infertility after successful IVF and to compare parents who have undergone IVF (IVF parents) and parents who have not undergone IVF (non-IVF parents) regarding parental stress and the marital relationship during the transition to parenthood. DESIGN: A study with qualitative and longitudinal quantitative assessments. SETTING: University IVF clinics and antenatal clinics in Stockholm. PATIENT(S): Fifty-five IVF mothers, 53 IVF fathers, 40 non-IVF mothers, and 36 non-IVF fathers. INTERVENTION(S): IVF parents were interviewed. All subjects completed self-rating scales in early pregnancy and at 2 and 6 months postpartum. MAIN OUTCOME MEASURE(S): Interviews about perception of infertility and scalar measurement of parental stress and the marital relationship. RESULT(S): Negative feelings related to infertility were not easily overcome among the IVF parents. Their levels of stress related to parenthood were similar to those of non-IVF parents, and both groups reported decreased satisfaction with the marital relationship during the transition to parenthood. CONCLUSION(S): The inability to conceive naturally continues to affect the current lives of a proportion of IVF parents. The results suggest that IVF parents may benefit from counseling with regard to the potential long-term impacts of infertility, disclosure issues, and decisions regarding future children. However, levels of parental stress and patterns of partner satisfaction are similar to those of parents with children conceived "naturally."     

Serum CA-125 and inhibin B levels in the prediction of ovarian response to gonadotropin stimulation in in vitro fertilization cycles

There is much controversy about the relationship between serum CA-125 levels during in vitro fertilization (IVF) cycles and ovarian function. To evaluate the prognostic value of serum CA-125 and inhibin B measurements in predicting ovarian response to gonadotropin stimulation, we compared the CA-125 and inhibin B levels of poor and normal responders on the first day of ovarian stimulation, on the day of ovulation induction (OI) and at oocyte pick-up. Sixteen patients with poor ovarian response (???3 oocytes, serum estradiol (E₂) ??900?pg/ml at OI) in IVF/intracytoplasmic sperm injection cycles were matched with normal responders (???6 oocytes, E₂ ??1800?pg/ml) by age, spontaneous cycle day-3 follicle-stimulating hormone level and cause of infertility. Inhibin B concentrations were significantly lower at all three time points in poor responders, but CA-125 levels were not. No statistically significant correlation was found between CA-125 levels and any of the clinical or laboratory parameters examined. Thus, CA-125 measurements during stimulation are not useful in predicting or identifying poor ovarian response to gonadotropin stimulation in IVF cycles. The lack of difference in CA-125 concentrations between poor and normal responders and lack of correlation with E₂ or inhibin B levels suggest that ovarian steroidogenesis and other granulosa cell functions do not influence the production of CA-125. Inhibin B, however, seems to predict ovarian response as early as at the start of stimulation.     

Cycle characteristics and outcome in relation to ovarian response during in vitro fertilization

Purpose This retrospective analysis of 148 non-male factor couples sought to determine whether oocyte or embryonic quality was compromised by the magnitude of the ovarian response following clomiphene citrate/human menopausal gonadotropin stimulation for in vitro fertilization.Methods Increased oocyte numbers were associated with decreased fertilization rates (r =–0.36, P <0.001) and estradiol/follicle ratios (r =–0.443, P <0.001), although the quality of the resulting embryos was not affected. Despite reduced fertilization, higher oocyte numbers yielded additional healthy embryos (r =0.70, P <0.001) for immediate replacement or cryopreservation. Implantation rates did not differ among groups and no predictive variables were identified. Results These results suggest that endometrial receptivity and implantation were not adversely affected by increasing estradiol levels. The decline in oocyte quality associated with the retrieval of larger numbers of oocytes appeared to be offset by the availability of additional embryos for immediate replacement and cryopreservation.     

Use of serum inhibin A and human chorionic gonadotropin measurements to predict the outcome of in vitro fertilization pregnancies

OBJECTIVE: To assess the clinical value of maternal serum inhibin A measurements in early pregnancy in the prediction of outcome of IVF pregnancies and to compare the predictive accuracy of inhibin A concentrations with serum hCG concentrations. DESIGN: Retrospective study.University-based IVF program. PATIENT(S): One hundred fifty IVF pregnancies of 150 couples were studied during a 4-year period. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The association between pregnancy outcome and age, number of collected oocytes, number of transferred embryos, and serum hCG and inhibin A concentrations in early pregnancy was studied with logistic regression. Predictive accuracy of inhibin A and hCG concentrations was calculated by receiver-operating characteristic (ROC) analysis. RESULT(S): Lower serum concentrations of inhibin A and hCG were associated with increased odds for preclinical abortion and early pregnancy loss, whereas higher inhibin A and hCG concentrations were observed in multiple ongoing pregnancies. Inhibin A measurements were superior to hCG in the prediction of preclinical abortions; no significant difference was observed between the predictive value of hCG, inhibin A, or their combination in differentiating between ongoing pregnancies and early pregnancy losses. The discriminative potential of inhibin A for prognosticating multiple ongoing pregnancies was lower than that of hCG. CONCLUSION(S): Although serum inhibin A concentrations are more accurate than hCG levels for predicting preclinical abortion after IVF, they had no advantage in forecasting ongoing or multiple ongoing pregnancies, suggesting that routine assessment of serum inhibin A concentrations during follow-up of IVF pregnancies is unjustified.     

Hysteroscopy in a program of in vitro fertilization

Two hundred twenty-four women underwent hysteroscopic evaluation without anesthesia after at least two failed attempts of in vitro fertilization and embryo transfer. One hundred fifty-three (68%) women were diagnosed as having mechanical infertility, and abnormal hysteroscopic findings were observed in 32 (21%). Forty-one women were diagnosed as having unexplained infer-tility (18%) and six (15%) had abnormal findings with hysteroscopy. Of the 30 couples who entered the in vitro fertilization regimen program because of male infertility, 4 (13%) had abnormal findings. The overall rate of abnormal findings was 19%; cervical canal and intrauterine abnormalities were found in 10 and 32 patients, respectively. Ten patients were treated during hysteroscopic evaluation procedure, and four patients subsequently underwent operative hysteroscopy under general anesthesia. We suggest that diagnostic hysteroscopy should be a routine procedure before in vitro fertilization and embryo transfer therapy.     

The relationship of semen parameters to fertilization in patients participating in a program of in vitro fertilization

Approximately 80% of the patients in a program of in vitro fertilization (IVF) will fertilize an oocyte. The purpose of this study was to determine which parameters of the semen analysis influence fertilization in vitro. Of 120 patients participating in an in vitro fertilization program, 98 achieved fertilization of at least one mature oocyte and 22 did not. Ovulation induction was standardized and patients whose sperm was exposed to at least one mature oocyte (by light microscopy) were included in the study. Semen washing was accomplished using a swim-up technique. Semen parameters were assessed both before (raw) and after washing. Following insemination with 100,000 motile sperm, fertilization was determined by the presence of pronuclei or cleavage. Mean sperm count and motility were higher in patients who fertilized. However, morphology was similar. Fertilization was more likely to occur with a raw density>104 million/ml and a motility>64%, as well as with a density>18 million/ml and a motilkity>86% following washing. Furthermore, washing lowered sperm counts by 75% and increased motility by 25% but had no effect on morphology. This study demonstrates that sperm count and motility, but not morphology, influence fertilization in a program of in vitro fertilization and that patients with higher counts and motility have and greater probability of fertilization.Presented at the Third Annual Congress of Andrology, April 27–May 2, 1985, Boston, Massachusetts.     

Ovarian response in three consecutive in vitro fertilization cycles

OBJECTIVE: This study was designed to assess the ovarian response in the same patient in consecutive IVF cycles. DESIGN: Retrospective study. SETTING: Assisted reproductive unit at a university hospital. PATIENT(S): One hundred ninety women who underwent three consecutive cycles of IVF. INTERVENTION(S): All women used a combination of pituitary desensitization and gonadotropin stimulation protocol and underwent oocyte retrieval. MAIN OUTCOME MEASURE(S): Number of follicles produced and number of oocytes retrieved. RESULT(S): There were no significant differences in the number of follicles produced, number of oocytes retrieved, and number of embryos created by the same woman among the three cycles of treatment. CONCLUSION(S): Consistent ovarian response can be achieved during the first three consecutive IVF cycles.     

Intracytoplasmic sperm injection overcomes previous fertilization failure with conventional in vitro fertilization

Objective: To evaluate the outcome of intracytoplasmic sperm injection (ICSI) in patients with previous idiopathic fertilization failure (≤20% fertilization rate) after conventional IVF.

Design: Retrospective analysis.

Setting: IVF program at a university medical center.

Patient(s): Twenty-five patients who underwent 38 ICSI cycles after experiencing unexplained fertilization failure with conventional IVF (group A) and 87 patients who underwent 118 ICSI cycles for male factor indications during the same period (group B).

Intervention(s): Intracytoplasmic sperm injection was performed in a subsequent cycle after fertilization failure with conventional IVF.

Main Outcome Measure(s): Outcomes of IVF were compared between groups A and B.

Result(s): Fertilization was achieved with ICSI in all patients with previous fertilization failure. The mean (±SD) fertilization rate (68% ± 21% vs. 64% ± 22%), implantation rate per embryo (22.6% vs. 20%), and delivery rate per cycle (47.3% vs. 49.1%) did not differ significantly between groups A and B. Overall, 72% of patients with previous unexplained fertilization failure had a successful pregnancy after ICSI.

Conclusion(s): Intracytoplasmic sperm injection can overcome unexplained fertilization failure caused by a potentially occult gamete abnormality, with the same fertilization, implantation, and pregnancy rates as are seen in patients with abnormal sperm parameters.     

Hypersensitivity to progesterone-in-oil after in vitro fertilization and embryo transfer

OBJECTIVE: To report the occurrence and management of pulmonary compromise, marked leukocytosis, and eosinophilia in a patient receiving P-in-oil after IVF and embryo transfer. DESIGN: Case report.A tertiary referral reproductive medicine unit. PATIENT(S): A 29-year-old patient receiving P-in-oil supplementation after IVF embryo transfer. INTERVENTION(S): Extensive diagnostic testing and surveillance for hypersensitivity to P in sesame oil; development of an alternative oil-based P-in-oil suspension. MAIN OUTCOME MEASURE(S): Tolerance of alternative P vehicle; clinical pregnancy. RESULT(S): The patient tolerated an alternative P oil vehicle and successfully achieved a clinical pregnancy after frozen embryo transfer. CONCLUSION(S): Although rare, hypersensitivity reactions may occur in patients receiving P-in-oil supplementation after IVF embryo transfer. Testing for tolerance and subsequent use of alternative P vehicles may be an effective strategy in managing patients with sensitivity to P-in-oil.