Vital initiation of pregnancy (VIP) using human menopausal gonadotropin and human chorionic gonadotropin ovulation induction: phase II--1981

In a program for in vitro fertilization, laparoscopies for oocyte aspiration were performed on 24 patients receiving human menopausal gonadotropin and human chorionic gonadotropin. Of the 40 preovulatory oocytes that were recovered from these patients, 33 (83%) were fertilized and 30 (75%) cleaved and were transferred. Ten immature oocytes were collected, and attempts were made to mature these in vitro prior to insemination. All ten oocytes (100%) did fertilize, and seven (70%) cleaved and were transferred. Morphologic variation was noted between cleaving conceptuses, even in those conceptuses responsible for establishing pregnancies. Five pregnancies resulted from 19 embryo transfers (26%).     

Improved pregnancy outcome with gonadotropin releasing hormone agonist (GnRH-a) stimulation is due to the improvement in oocyte quantity rather than quality

The impact of gonadotropin releasing hormone agonist (GnRH-a) on the quality and quantity of oocytes harvested in in vitro fertilization—embryo transfer (IVF-ET) patients was studied by comparing the results for patients stimulated with gonadotropin alone and with gonadotropin plus GnRH-a. Adding GnRH-a significantly improved the viable pregnancies per transfer and reduced the spontaneous abortions, which seemed to improve oocyte quality. However, when oocyte quality was evaluated by the fertilization rate and the implantation and delivery rates per embryos transferred, there were no significant difference in the results, indicating that GnRH-a did not improve the oocyte quality. On the other hand, GnRH-a significantly increased the average number of oocytes harvested, fertilized, and transferred, and this increased number of oocytes transferred has been demonstrated to increase pregnancy and multiple-pregnancy rates. Multiple pregnancy with more embryos implanted would significantly reduce the abortion rate. Abortion rates decreased inversely to the number of embryos implanted. Our data strongly suggest that the efficacy of GnRH-a on IVF-ET patients was due more to the quantity increase than the quality of embryos transferred.This article was partly presented at the 7th World Congress on In Vitro Fertilization and Assisted Procreation, Paris, France, in June, 1991.     

Menotropin stimulation after prolonged gonadotropin releasing hormone agonist pretreatment for in vitro fertilization in patients with endometriosis

Two protocols were scheduled for in vitro fertilization and embryo transfer (IVF-ET) in patients with various stages of endometriosis who were resistant to conventional therapies. In the ultralong protocol (21 patients), gonadotropin releasing hormone agonist (Gn-RHa) was administered for at least 60 days prior to ovarian stimulation along with menotropin until human chorionic gonadotropin was injected. In the long protocol (11 patients), Gn-RHa was started at the midluteal phase and exogenous gonadotropin was commenced between the third and the seventh day of the menstrual cycle after pituitary suppression. The estradiol response and the number of retrieved oocytes, fertilized oocytes, cleaved oocytes, and transferred embryos were similar in both groups but the clinical pregnancy rate per transfer was superior in the ultralong protocol (67 vs 27%). The miscarriage rate was 14% (2/14) in the ultralong protocol. Prolonged Gn-RHa suppression of ovarian function before superovulation may overcome some causes of infertility in patients with endometriosis.     

The in vitro fertilization program in Helsinki

Summary In the in vitro fertilization program at Departments I and II of Gynecology and Obstetrics, University of Helsinki, 57 patients were stimulated with clomiphene and hMG. Follicular growth was monitored by ultrasound and serum estradiol measurements. Laparoscopic follicular puncture was performed 36h after hCG injection. Three hundred seventy-five follicles were punctured and 227 oocytes recovered, representing an oocyte recovery rate of 61%. A total of 130 oocytes (57%) showed evidence of fertilization and 71% of the fertilized oocytes cleaved. Fifty-seven embryo transfers were carried out at the two-to eight-cell stage. Multiple embryos were transferred to 24 patients. Biochemical pregnancies were encountered in two cases; early abortions, 3–5 weeks after implantation, in two cases. One normal ongoing single pregnancy occurred from a transfer of three four-cell embryos.     

Human in vitro fertilization employing individualized ovulation induction by human menopausal gonadotropins

One hundred six women suffering from obstructive tubal disease not corrected by previous surgery were treated in an in vitro fertilization (IVF) program. Ovulation was induced by 3 amps of human menopausal gonadotropin (HMG)/day starting on the third day of the cycle for 5 days. In most of the patients the regmmen was continued for another 1–3 days, depending on the individual's ovarian response (means, 20±5 amps/cycle). Monitoring consisted of daily follicular ultrasonography and serum estradiol measurements. Human chorionic gonadotropin (HCG), 10,000 IU, was administered when more than two large (1.5 to 1.8 cm in diameter) follicles were visualized. Using this regimen, a mean of five follicles per woman was aspirated, from which a mean of 3.9 over was recovered. The oocytes were pre-incuted for 8 or 24 hr. according to the morphological degree of inucification and dispersal of the oocyte-corona-cumulus complex. Following exposure to washed spermatozoa for 16 hr, a 68% fertilization rate was obtained. Oocytes were transferred into the uterus 48 hr after laparoscopy. Ninety-nine transfers (93% of the women) of 1–8 embryos (mean, 2.9/woman) were performed and resulted in 16 clinical pregnancies. No pregnancies occurred in 14 women transferred with one to three oocytes in the pronuclear stage and only one pregnancy (7.1%) was obtained in 14 women transferred with one cleaved oocyte. Over 70% of the women were transferred with two or more cleaved oocytes: in this group the pregnancyl transfer rate was 21%. Of thee pregnant women 5 of 16 (31%) aborted between 6 and 10 weeks of gestation and 1 (6%) had an ectopic pregnancy. The individualized regimen of HMG is valuable in increasing the number of fertilized oocytes and compensates with multiple-embryo transfers for the high early embryonic loss occurring in IVF.     

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.     

Correlation of human menopausal gonadotropin/human chorionic gonadotropin stimulation and oocyte quality in an in vitro fertilization program

One hundred forty-seven cycles in normal ovulatory patients are reported. All were stimulated with human menopausal/human chorionic gonadotropin. Three estrogen responses were identified: normal, high, and low. Patients who achieved pregnancy formed a fourth category, the pregnancy group. The number of preovulatory and immature oocytes, the preovulatory and immature oocytes that fertilized normally or abnormally, the ones that cleaved in culture, and the ones that were transferred were used as parameters to compare quality of the oocytes in each of the estrogen responders. No significant differences were found in any of them. Abnormal zonae pellucidae are described as possibly due to overmaturation of the follicle. No significant difference in the proportion of abnormal zonae in the different categories was found.     

In vitro fertilization and embryo transfer program in Clamart,France

Our in vitro fertilization and embryo transfer program really began in September 1980. Yet attempts to collect oocytes had been performed since 1978, and the first in vitro fertilizations were obtained in May 1979. The first pregnancy was obtained in April 1981, but it ended on the 12th week by a spontaneous abortion of a 45,X fetus. We have distinguished two periods in our program: The initial phase was from September 1980 until November 1982: ovulation monitoring of 365 cycles, spontaneous or stimulated, 276 laparoscopies, and 121 embryos transfers were performed, and 12 early pregnancies obtained (4.3% per laparoscopy and 9.9% per embryo transfer). Seven normal healthy infants were born (five boys and two girls); four cases were limited to biochemical pregnancies and one spontaneous abortion (yet described) was observed. The second and actual phase, December 1982–June 1983, is described more precisely: ovulation monitoring of 329 cycles, after stimulation protocols with clomiphene citrate and human menopausal gonadotropin, 230 laparoscopies, and 162 embryos transfers have been performed and have led to 34 pregnancies (14.8% per laparoscopy and 20.9% per embryo transfer). Eighteen of these 34 pregnancies are actually in progress (more than 12 weeks), 9 were limited to an increase in plasma human chorionic gonadotropin, and 7 cases ended in spontaneous abortions between 6 and 12 weeks.     

Clomiphene-HMG ovarian stimulation in human in vitro fertilization and embryo transfer

In a program for in vitro fertilization and embryo transfer, laparoscopies for oocyte aspiration were performed in 40 cycles in 36 normally menstruating women with irreparable tubal diseases (IVF patients) who received clomiphene citrate (CC) and human menopausal gonadotropin (hMG). An intramuscular injection of human chorionic gonadotropin (hCG) was given to all patients after completion of follicular maturation. Fourteen cycles in 13 spontaneously ovulating women (control patients), also stimulated with CC and hMG, were adequately monitored to identify the appearance of the spontaneous luteinizing hormone (LH) surge. The follicular maturation was followed by daily ovarian ultrasonographic examination and serum estradiol estimations. Just before the LH surge the diameter of the leading follicle was 20.2 +/- 0.7 (mean +/- S.E.) mm and the serum estradiol concentration per follicle was 384.1 +/- 16.3pg/ml in the control patients. In the IVF patients the former was 20.6 +/- 0.3mm and the latter was 305.8 +/- 13.3pg/ml prior to hCG administration. When the relationship of follicular size to the rates of oocytes recovery, maturation, fertilization and cleavage was examined, larger follicles (3ml less than or equal to follicular fluid volume) showed good results. Of the 152 oocytes that were recovered from these IVF patients, 96 (63.2%) were fertilized and 79 (52.0%) cleaved. Three pregnancies resulted from 35 embryo transfers.     

Personal experience with in vitro fertilization and embryo transfer

The causes of sterility could be better characterized in 49 so called complex laparoscopies with estimation of sperm ascension and extraction of oocytes following hormonal stimulation. Oocytes could be obtained in sterility operations. They have been fertilized and transferred into the tubes, with the result of 2 pregnancies after 49 such procedures. Up to now there is no late pregnancy after 115 in vitro fertilizations and 53 embryo transfer into the uterus.     

Relationship between gonadotropin releasing hormone agonist dosage and in vitro fertilization outcome.

A prospective study in 132 women undergoing in vitro fertilization was performed in order to assess whether lower doses of gonadotropin releasing hormone agonists (GnRH-a) may ensure adequate oocyte retrieval and pregnancy rate, without pituitary oversuppression. Forty-five patients received subcutaneous tryptorelin depot (Decapeptyl 3.75, IPSEN SpA), 41 received subcutaneous tryptorelin acetate daily (Decapeptyl 0.1 mg, IPSEN SpA) and 46 received 0.05 mg tryptorelin acetate daily from day 21 of the cycle. From day 3 of the new cycle, if the estradiol levels were < 30 pg/ml, patients received two or three ampules of gonadotropin daily. In the group receiving subcutaneous tryptorelin acetate depot, the mean number of total gonadotropin ampules was significantly higher (p < 0.05), otherwise estradiol levels and the number of oocytes retrieved, fertilized and cleaved were significantly lower (p < 0.05). Pituitary oversuppression induced by GnRH-a causes an increase in the gonadotropin requirement for assisted reproductive techniques (ART) and a reduction in the number of oocytes retrieved and fertilized. There is a high risk of oversuppression in normal-weight or underweight women, because there is greater bioavailability of the peptide, hence elevated circulating levels of GnRH-a. Thus, ovarian stimulation in ART cycles depends on many factors, not least the identification of the best GnRH-a dose.     

The use of high-dose human menopausal gonadotropin in an in vitro fertilization program

Sixty-three normal ovulatory women suffering from obstructive tubal disease not corrected by previous surgery were enrolled in an in vitro fertilization (IVF) program. To achieve a large number of mature follicles, a relatively high dose of human menopausal gonadotropin (hMG) was administered (19 +/- 4 ampules/cycle). Monitoring consisted of daily follicular ultrasonography and serum estradiol measurements. Human chorionic gonadotropin (10,000 IU) was administered when more than two large follicles (1.6 to 1.8 cm in diameter) were visualized. Fifty-five laparoscopies for oocyte retrieval were performed. A mean of 4.3 follicles per woman were aspirated, and 3.2 oocytes per woman were recovered. The oocytes were preincubated for 8 or 24 hours according to the morphologic degree of mucification and dispersal of the oocyte-corona-cumulus complex. Seventy-seven percent of the oocytes were fertilized and were transferred into the uterus 38 to 40 hours after insemination. Fifty-two women received one to eight embryos (mean, 3.5 +/- 1.9), and 9 (17%) conceived. This regimen of high-dose hMG precludes the need for serum or urine luteinizing hormone monitoring, because the occurrence of spontaneous ovulation is low. It is valuable in increasing the number of fertilizable oocytes, the percentage of women undergoing embryo transfer, and compensates with multiple oocyte transfer for the high embryonic loss involved in IVF.     

A prospective study comparing the outcome of oocytes retrieved in the aspirate with those retrieved in the flush during transvaginal ultrasound directed oocyte recovery for in-vitro fertilization.

OBJECTIVE: To study prospectively the fate of oocytes collected from the follicular aspirate and subsequent flushes during transvaginal ultrasound directed oocyte recovery for in-vitro fertilization (IVF). SETTING: A tertiary referral assisted conception centre. SUBJECTS: 100 consecutive patients undergoing 100 cycles of IVF. Four patients were withdrawn because their embryos were electively cryopreserved. Therefore 96 cycles were studied. MAIN OUTCOME MEASURES: The oocyte recovery rate, viability, fertilization and cleavage rates and outcome of embryos generated from oocytes that were obtained from either the initial aspirate (A1), dead space in the collecting system (A2) or the first two 2 ml flushes (F1 and F2) were compared. RESULTS: The overall oocyte recovery rate was 87.8%. Of the 1046 oocytes collected, 40.3% were from A1, 41.3% from A2, 13.7% from F1 and 4.7% from F2. There were comparable numbers of viable and fertilized oocytes and cleaved, transferred and frozen embryos in tubes A1 and A2 but all these parameters were significantly lower in tubes F1 and F2 (P < 0.0001). All these parameters were also significantly higher in F1 compared with F2 (P < 0.001), except for the number of embryos frozen, in which there was no difference. The overall pregnancy rate per cycle was 28.1% and the pregnancy rate per embryo transfer was 31.0%. There were no pregnancies in any of the cycles in which embryos originating from F2 were transferred, nor were there pregnancies in cycles in which only embryos from F1 were transferred. CONCLUSION: Follicular aspiration together with one 2 ml flush maximises the recovery of oocytes that will result in pregnancies.     

Dose of human menopausal gonadotropin influences the outcome of an in vitro fertilization program

This study compares outcomes of in vitro fertilization (IVF) in two groups of 57 patients when either 2 (group 1) or 3 (group 2) ampules of human menopausal gonadotropin (hMG) were administered daily. Treatment began on day 3 of the cycle and was discontinued when at least 2 follicles attained diameters greater than or equal to 1.5 cm. Human chorionic gonadotropin (hCG) was given either 24 or 48 hours after the last dose of hMG. Although serum estradiol levels were lower in group 1, the average number of oocytes retrieved (3.2 versus 2.9), fertilized (1.9 versus 2.0), and cleaved (1.7 versus 1.8) per completed cycle did not differ between groups 1 and 2. Likewise, the number of oocytes that fertilized abnormally was similar in both groups (0.5 versus 0.3/cycle). However, the number of atretic oocytes (0.03 versus 0.5/cycle) and the percent of oocytes recovered from the cul-de-sac (0 versus 7.2%) were significantly (P less than 0.05) lower in group 1. In group 1, administration of hCG 48 hours after the last dose of hMG was associated with a higher number of cleaving embryos (2.1 versus 1.5/cycle) and a higher pregnancy rate (34.8 versus 14.7%; P less than 0.05) when compared with injection at 24 hours. In group 2, the interval between hMG and hCG did not influence these results. Together, the associations between fewer oocytes that were atretic or recovered from the cul-de-sac, and a trend toward a higher pregnancy rate, suggest that follicular recruitment with 2 ampules of hMG is more appropriate than 3 ampules in an IVF program.     

The relative success of gonadotropin-releasing hormone analogue, clomiphene citrate, and gonadotropin in 1,099 cycles of in vitro fertilization.

OBJECTIVES: To evaluate the effectiveness of and analyze the factors influencing the outcome of three ovarian stimulation protocols used during in vitro fertilization (IVF) in a large population. DESIGN: Retrospective file review. SETTING: In vitro fertilization program in one center during the years 1985 to 1990. PATIENTS AND PROTOCOLS: Three hundred forty-one patients received clomiphene citrate (CC) and human menopausal gonadotropin (hMG), 365 received hMG alone, and 393 received gonadotropin-releasing hormone analogue (GnRH-a) for pituitary suppression followed by hMG stimulation. MAIN OUTCOME MEASURE: Rates of cancellation, total pregnancies, and ongoing pregnancies, with breakdown by age of patients. RESULTS: The cancellation rate because of early luteinization following GnRH-a/hMG was significantly reduced compared with the other two protocols: 3.6% versus 9.4% and 13.7% for CC/hMG and hMG, respectively. However, in women over 40 years of age, GnRH-a/hMG resulted in the highest rate of poor ovarian response. Significantly more oocytes were retrieved, fertilized, and cleaved after the use of GnRH-a/hMG compared with the other two protocols. Despite this, clinical pregnancy rate (PR) was the highest with CC/hMG compared with GnRH-a/hMG and hMG:31.4% versus 16.9% and 15.7%, respectively. Ongoing PRs were 20.5%, 9.7%, and 11.6%, respectively. CONCLUSIONS: Although the use of GnRH-a for pituitary suppression before ovarian stimulation for IVF reduced the cancellation rate and increased the number of retrieved oocytes, it was not found to result in higher PRs than those achieved by stimulation with CC/hMG. This suggests that treatment by GnRH-a/hMG should be reserved mainly for the prevention of early luteinization.     

培养液中添加不同促性腺激素对卵母细胞体外成熟的影响

目的:比较卵母细胞体外成熟培养液中添加不同促性腺激素对未成熟卵母细胞体外成熟结局的影响。方法:将行卵母细胞体外成熟(IVM)的35例患者共42个新鲜取卵周期,随机分成A组:22个取卵周期将重组人促卵泡激素(果纳芬,rFSH)和重组人绒毛膜促性腺激素(艾泽,hCG)按1∶1的比例混合添加,终浓度为75 mIU/ml;B组:20个取卵周期添加终浓度为75 mIU/ml的尿源性促性腺激素(hMG),进行未成熟卵母细胞体外成熟培养。35例患者中新鲜取卵周期未移植或移植后未孕者行解冻胚胎移植。比较组间患者的卵母细胞成熟率、受精率、卵裂率、优质胚胎率、累计临床妊娠率及胚胎着床率。结果:取卵均于月经周期第12日或最大卵泡发育至10￣12 mm时进行,故所获卵均为未成熟卵。A组获卵181枚,经培养后成熟84枚,行卵胞浆内单精子注射(ICSI)84枚,受精60枚,卵裂55枚,优质胚胎20枚;新鲜胚胎移植9例,获1例临床妊娠,解冻胚胎移植5例,获1例临床妊娠,累计临床妊娠率为14.29%,胚胎着床率为7.14%。B组获卵176枚,经培养后成熟120枚,行ICSI 120枚,受精97枚,卵裂90枚,优质胚胎41枚,新鲜胚胎移植6例,获4例临床妊娠,解冻胚胎移植9例,获3例临床妊娠,累计临床妊娠率为46.67%,胚胎着床率为33.33%。结论:卵母细胞体外成熟培养液中添加尿源性促性腺激素可获得较添加重组人促卵泡激素和重组人绒毛膜促性腺激素高的卵母细胞成熟率、临床妊娠率及胚胎着床率。     

The predictive value of hCG beta subunit levels in pregnancies achieved by in vitro fertilization and embryo transfer: an international collaborative study

Serial human chorionic gonadotropin (hCG) beta subunit measurements of 300 pregnancies achieved by in vitro fertilization (IVF) were obtained by 15 IVF centers worldwide. Hormonal curves were established for 164 normal singleton pregnancies, 25 normal multiple gestations, 60 chemical pregnancies, 41 first-trimester spontaneous abortions, and 10 ectopic pregnancies. In comparison to the normal singleton pregnancy curve, chemical pregnancies and spontaneous abortions showed statistically lower hCG levels. hCG levels of ectopic pregnancies, compared with normal singleton gestations, were lower from days 7 to 14. It is concluded that beta-hCG determinations of in vitro fertilized pregnancies allow pregnancy diagnosis as early as 7 to 9 days after embryo transfer (ET) and will permit early discrimination between normal and abnormal IVF pregnancies. A single beta-hCG determination on day 9 after ET may discriminate chemical, ectopic pregnancy or impending miscarriage from a normal gestation. An hCG determination on day 17 will predict early normal development of an IVF pregnancy.     

Vital initiation of pregnancy (VIP) using human menopausal gonadotropin and human chorionic gonadotropin ovulation induction: Phase I--1981

Laparoscopies for oocyte aspiration in 31 cycles were performed on 25 patients receiving human menopausal gonadotropin and human chorionic gonadotropin. Sixty oocytes were aspirated, of which 48 were considered preovulatory. Ninety-seven percent (58 of 60) of the oocytes were found in the original aspirate, and the remaining oocytes were found in either the first or second follicle wash. The fertilization rate per preovulatory oocyte was 33% (16 of 48), whereas on a per cycle basis it was 39% (12 of 31). A total of 15 conceptuses (2-cell = 5; 3-cell = 3; 4-cell = 7) were transferred to 12 patients, and two pregnancies were established. These pregnancies were established by transfers of 3-cell and 4-cell conceptuses at approximately 47 hours after insemination. Both pregnancies resulted in term deliveries of normal infants.     

In vitro fertilization and embryo transfer: two-year experience

Between February 1983 and January 1985, 206 laparoscopies were performed on 172 women following controlled ovarian hyperstimulation with human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG). Sixty-four clinical pregnancies advanced beyond the sixth week of gestation and were confirmed by ultrasound; and 37.2% of the patients conceived after in vitro fertilization and embryo transfer. The clinical pregnancy rate was 31.1% when based on the number of laparoscopies performed and 33.9% when based on the number of embryo transfers. There were 12 multiple pregnancies (18.8%), 11 miscarriages (17.2%), and one ectopic (tubal) pregnancy (1.6%). The most important factors contributing toward the success of this program were the establishment of specific criteria for patient selection, rigid adherence to clinical and laboratory protocols, and the maintenance of strict quality control.     

The clinical outcome of reinsemination of human oocytes fertilized in vitro

To assess the value of reinseminating human oocytes, the results of 1,662 embryo transfers were analyzed. In 1,460 transfers embryos arose from oocytes that had fertilized and cleaved after initial insemination. The pregnancy rate was significantly higher than in transfers of embryos (n = 76) resulting solely from reinseminated oocytes (27% versus 3%). Adding reinseminated embryos to those fertilizing on initial insemination at transfer failed to raise the pregnancy rate. Only 2 of 158 (1.3%) reinseminated embryos implanted compared with 540 of 4,181 (12.9%) fertilized and cleaved on initial insemination (P less than 0.001). Reinseminated embryos do occasionally produce viable pregnancies. It is therefore worth considering replacement of these embryos if initial fertilization has entirely failed. Patients should be counseled as to the low chance of implantation with these embryos.