Transcatheter occlusion of ruptured sinus of Valsalva aneurysm guided by three-dimensional transesophageal echocardiography.

Transcatheter occlusion of ruptured sinus of Valsalva aneurysm (RSVA) is an alternative strategy to traditional conventional surgical repair. Three-dimensional (3D) transesophageal echocardiography (TEE) may provide more accurate measurement of the defect size and position and expedite closure of the defect in this difficult procedure. A 47-year-old woman with RSVA was successfully treated by transcatheter occlusion technique. Two-dimensional (2D) and 3D TEE was performed during the procedure. Under 2D and 3D TEE and fluoroscopic guidance, the Amplatzer duct occluder was deployed successfully and without complications of the aortic valve.     

经胸超声心动图在继发孔型房间隔缺损介入治疗中的作用

目的研究经胸超声心动图(TTE)在继发孔型房间隔缺损(ASD)介入治疗的病例筛选及封堵器选择方面的应用价值。 方法回顾分析2002-03—2006-03于山东大学山东省立医院小儿心脏科行介入治疗的54例继发孔型ASD患儿，统计其术前TTE所测的ASD的形态、大 小、边缘情况等，对术前TTE测得的ASD最大径、X线测得的球囊腰径及TTE测得的球囊径分别与所用封堵器型号大小进行统计学分析比较，并进 行TTE测得的ASD最大径与封堵器型号大小的相关性分析，计算回归方程。 结果54例均成功封堵，手术时间20~145(57.64±24.89)min，曝光时间3.1~31.5(9.22±7.41)min，住院天数3~10(5.74±1.72)d。其中有15例患 儿存在ASD单一边缘不够标准，均封堵成功。术前TTE测得的ASD最大径［4~33mm,(16.31±7.34)mm］、术中X线测球囊腰径［6.7~28mm,(19.80± 7.24)mm］及TTE测球囊径［9.6~24.8mm,(19.92±6.38)mm］与封堵器大小［5~36mm,(18.85±7.89)mm］差异均无显著性意义(P>0.05)。且术前 TTE测得的ASD最大径与封堵器型号有良好的线性相关(r=0.945，P<0.05)，计算回归方程为：封堵器型号=1.015×(TTE测得的ASD最大径)+2.3mm 。 结论TTE的应用，使ASD介入治疗病例的筛选得到了保证。作为一种无创性影像学诊断方法，对ASD封堵器选择的评估有重要的应用价值。     

Amplatzer septal occluder-induced transient complete atrioventricular block.

Percutaneous transcatheter atrial septal defect (ASD) closure is a widely used technique that has replaced open-heart surgical closure in many centers. The most common implant is the Amplatzer septal occluder which seems to be a highly effective and safe device. However, there are reports of complications associated with its implantation. We report a 9-year-old boy who presented with complete atrioventricular block after undergoing percutaneous closure of a large secundum ASD with an Amplatzer septal occluder. We treated the patient with oral prednisolone. The patients atrioventricular conduction improved to second-degree Mobitz type 1 block on post-procedure day 24 and first-degree block on day 35. We conclude that patients with Amplatzer septal occluder-induced complete atrioventricular block generally have a good outcome, although it may take several weeks for improvement.     

封堵器介入治疗儿童继发孔房间隔缺损术后房室传导阻滞分析

探讨应用Amplatzer封堵器 （ASO）介入治疗儿童继发孔房间隔缺损（ASD）术后房室传导阻滞（AVB）的发生率、危险因素及防治措施。方法　1998年3月至2005年12月在广东心血管病研究所心儿科450例继发孔ASD患儿接受ASO封堵术。对术前及术后随访的心电图资料进行回顾性分析,统计AVB的发生率及类型,并分析与AVB发生有关的危险因素及防治措施。结果　共有14例发生各种类型的AVB,发生率为3.1%,分别为Ⅰ度AVB 6例,Ⅱ度AVB 4例,Ⅲ度AVB 4例。所有AVB均发生于术后1～2 d内。14例中12例为术后新出现的AVB,2例术前为Ⅰ度AVB术后发展为Ⅱ度和Ⅲ度AVB（各1例）。统计学分析显示,使用过大ASO及小年龄与术后AVB的发生密切相关。AVB发生后常规应用激素等治疗,4例Ⅲ度AVB实施外科手术取出ASO。AVB绝大多数于短期随访内恢复或好转,未见复发。结论　AVB是应用ASO介入治疗儿童继发孔ASD术后的严重并发症。对年龄较小患儿避免置入过大ASO是降低术后AVB的关键。AVB发生后及早给予内科或外科干预,多可于短期内恢复,术后长期随访十分重要。     

第二代动脉导管未闭封堵器封堵 特殊类型室间隔缺损2例报告

目的　总结分析应用第二代动脉导管未闭封堵器（ADO-Ⅱ）对特殊类型室间隔缺损（VSD）封堵的技巧。方法　研究对象为2011年8月至9月在上海交通大学医学院附属上海儿童医学中心行介入治疗的患儿2例,因应用常规VSD封堵器封堵困难,遂选取ADO-Ⅱ进行治疗。常规建立动静脉轨迹后,采用主动脉内释放,然后行左室、升主动脉造影和心脏超声检查,如封堵器位置好,无残余分流、瓣膜反流则释放。结果　例1左室造影显示为膜周VSD,左室面7.6 mm,较大假性室隔瘤形成,右室分流口弥散,最大约2.3 mm,缺损上缘距主动脉为6.1 mm。导丝建轨后,7 F长鞘无法通过分流口,最后选用5F长鞘,“6 mm×4 mm”的ADO-Ⅱ封堵成功,术后心脏超声三尖瓣轻微分流。例2心室造影为肌部VSD,左室面6.3 mm,右室分流口为2 mm,上缘距主动脉16 mm。因VSD走行异常且分流口小,最终选冠脉导丝建轨成功,应用4 F长鞘,“4 mm×4 mm”ADO-Ⅱ封堵成功。2例患儿术后1d复查心脏超声和心电图,无异常,观察5 d后出院随访,并口服阿司匹林［3～5 mg/（kg·d）］。结论　对于一些形态较特殊的VSD,常规VSD封堵器无法成功封堵时,可选择ADO-Ⅱ进行封堵,手术操作简单、安全、可靠而并发症少。     

小儿经皮室间隔缺损封堵术后非阵发性 室性心动过速临床意义分析

目的　总结小儿经皮室间隔缺损（VSD）封堵术后非阵发性室性心动过速（AIVR）的发生情况,探讨其临床意义及可能的发生机制。方法　2002年10月至2011年5月,1179例VSD患儿在广东省心血管病研究所心儿科行经皮VSD封堵术（室缺封堵组）,术后检出AIVR 17例。在我院门诊进行动态心电图检查的1392例非介入治疗患儿（非介入组）以及在我院行房间隔缺损封堵术的患儿988例（房缺封堵组）作为对照。比较室缺封堵组与对照组间AIVR的检出情况。对室缺封堵组9例患儿进行治疗,并对17例患儿进行随访。结果　室缺封堵组术后动态心电图AIVR检出率高于非介入组,差异有统计学意义（P < 0.05）;次日常规心电图AIVR检出率高于房缺封堵组（P < 0.05）。室缺封堵组所有AIVR患儿封堵术后1个月动态心电图均无AIVR,随访中无不良事件发生,随访心电图无AIVR。结论　室缺封堵组封堵术后AIVR检出率高于对照组,其发生与VSD封堵有关。该病多无自觉症状,预后良好,可能无须治疗。     

经导管室间隔缺损封堵术后传导阻滞的处理及随访

目的随访经导管室间隔缺损(VSD)封堵术后并发的传导阻滞，探讨其发生机制及预后。 方法2002 06—2005 07山东省立医院小儿心脏科经导管介入治疗89例VSD患儿，对临床资料、心电图、心脏超声、心血管造影资料及随访结果进行分析。 结果89例患儿应用Amplatzer膜部VSD封堵器67例，国产对称型VSD封堵器20例，Amplatzer导管封堵器1例，pfm弹簧圈1例。术后出现间歇性完全性房室传导阻滞2例次，其中1例应用临时起搏器治疗，分别于术后第10天、第20天恢复窦性心律；完全性左束支阻滞3例次，完全性右束支阻滞3例次，左前半分支阻滞2例次，不完全性右束支阻滞5例次，加速性交界性心律合并完全性左束支阻滞1例次。 结论传导阻滞是VSD介入治疗术后的常见并发症，经治疗预后良好，及时发现、及时处理是诊疗的关键，对心内传导系统远期的影响仍需进一步评价。     

国产房间隔缺损封堵器乳猪模型实验观察

目的评价国产房间隔缺损封堵器的相容性和内皮化程度。 方法选用乳猪6头，应用房隔穿刺和Rashkind球囊房隔造口术，建立可控大小房间隔缺损(ASD)动物模型；在X线引导下，用测量球囊测定ASD最大伸展直径，并结合超声心动图选择适当大小的国产房间隔缺损封堵器进行猪的房间隔缺损堵塞；术后1个月、3个月和6个月分别将小猪处死(每次2只)，对标本进行肉眼、光镜和扫描电镜检查。 结果所有封堵装置表面均没有发现赘生物、血栓形成、支架发生断裂及被腐蚀；术后1个月，封堵装置表面被胶原纤维和散在内皮细胞所覆盖，大量炎症细胞浸润，封堵装置边缘有小灶性炎症细胞浸润；术后3个月，封堵装置表面几乎被内皮细胞所覆盖，炎症细胞较1个月时明显减少，封堵装置内见纤维化，封堵装置边缘心肌细胞浸入；术后6个月，封堵装置表面完全被心内膜和纤维组织所覆盖，伞尖表面光滑并有内皮细胞上爬，炎症反应明显消散，但仍有少量慢性炎症细胞存在，装置内有新生的血管、淋巴管长入。 结论国产房间隔缺损封堵器具有良好的生物相容性，置入动物体内3个月几乎完全内皮化，6个月已完全内皮化。     

Atrial and ventricular septal defects - epidemiology and spontaneous closure.

OBJECTIVE: To present data on the epidemiology and spontaneous closure for septal defects (secundum atrial septal defect (ASD) and/or ventricular septal defect (VSD)). METHODS: Data from the EUROCAT Registry of Congenital Malformations for Funen County, Denmark were analyzed. All infants born from 1986 to 1998, diagnosed with a secundum ASD and/or a VSD as the only cardiac malformation, were included. RESULTS: There were 78 infants with an ASD, 195 with a VSD, and 19 had both an ASD and a VSD. The overall prevalence of septal defects was 4.1 per 1000 livebirths. Among the VSDs 45% were perimembranous and 55% were muscular defects. Associated non-cardiac malformations, syndromes, or karyotype anomalies were present in 54 cases (19% of total) but with a significantly lower proportion among cases with muscular VSDs (7%, p < 0.05). Eighty-one percent of the cases had an isolated cardiac malformation. Five of 61 cases (8%) with isolated ASD were closed surgically before five years of age and 43 (70%) closed spontaneously within the first five years of life. Of the 65 cases with isolated perimembranous VSDs, 13 were closed surgically (20%) and 13 closed spontaneously (20%). Of the 99 cases with isolated muscular VSDs no defects were closed by surgery and 64 (65%) closed spontaneously. The rate of spontaneous closure for perimembranous and muscular VSDs were significantly different (p < 0.0001). CONCLUSIONS: Secundum ASD has a high rate of spontaneous closure. Perimembranous and muscular VSDs seem to be two different diseases with different epidemiology and natural history.     

Transcatheter arterial embolization in the management of postpartum hemorrhage due to genital tract injury

Six patients with uncontrollable postpartum hemorrhage due to genital tract injury were treated with transcatheter arterial embolization. The causes of hemorrhage were laceration of the cervix and vagina in five cases and rupture of the uterus in one. Four cases included a large hematoma in the paravaginal and/or retroperitoneal space. Two women had a hysterectomy before arterial embolization. Angiography revealed extravasation in five cases. All six subjects had their hemorrhage arrested dramatically using transcatheter arterial embolization with gelatin sponge particles. No major complication was encountered in any case. Normal menstruation resumed in the women who did not undergo a hysterectomy. Transcatheter arterial embolization therapy seems to be the treatment of choice in patients with uncontrollable hemorrhage.     

Atrial and ventricular septal defects – epidemiology and spontaneous closure

Objective.?To present data on the epidemiology and spontaneous closure for septal defects (secundum atrial septal defect (ASD) and/or ventricular septal defect (VSD)).

Methods.?Data from the EUROCAT Registry of Congenital Malformations for Funen County, Denmark were analyzed. All infants born from 1986 to 1998, diagnosed with a secundum ASD and/or a VSD as the only cardiac malformation, were included.

Results.?There were 78 infants with an ASD, 195 with a VSD, and 19 had both an ASD and a VSD. The overall prevalence of septal defects was 4.1 per 1000 livebirths. Among the VSDs 45% were perimembranous and 55% were muscular defects. Associated non-cardiac malformations, syndromes, or karyotype anomalies were present in 54 cases (19% of total) but with a significantly lower proportion among cases with muscular VSDs (7%, p < 0.05). Eighty-one percent of the cases had an isolated cardiac malformation. Five of 61 cases (8%) with isolated ASD were closed surgically before five years of age and 43 (70%) closed spontaneously within the first five years of life. Of the 65 cases with isolated perimembranous VSDs, 13 were closed surgically (20%) and 13 closed spontaneously (20%). Of the 99 cases with isolated muscular VSDs no defects were closed by surgery and 64 (65%) closed spontaneously. The rate of spontaneous closure for perimembranous and muscular VSDs were significantly different (p < 0.0001).

Conclusions.?Secundum ASD has a high rate of spontaneous closure. Perimembranous and muscular VSDs seem to be two different diseases with different epidemiology and natural history.     

经导管膜周部室间隔缺损封堵术并发三尖瓣损伤8例临床分析

摘要：目的　分析经导管膜周部室间隔缺损（PMVSDs）封堵术并发三尖瓣损伤原因，探讨其预防及处理措施。 方法　2002年10月至2009年12月广东省心血管病研究所825例PMVSDs患儿，均进行了经导管介入封堵，其中8例出现三尖瓣损伤。8例患儿中男4例，女4例；年龄3.5～8.0岁。8例三尖瓣损伤患儿中4例出现三尖瓣狭窄，其中2例严重狭窄者行外科手术治疗，术中见封堵器右室盘与三尖瓣腱索缠绕，予松开缠绕、取出封堵器并修补室间隔缺损；2例轻度狭窄者予随诊观察。8例中其余4例出现三尖瓣关闭不全，其中3例反流严重予外科手术治疗，术中见三尖瓣腱索断裂1例，腱索断裂并瓣膜撕裂1例，三尖瓣隔瓣腱索被封堵器牵拉1例。术中将断裂的腱索缝合，取出封堵器并修补室缺，合并三尖瓣撕裂者行三尖瓣整形。余1例三尖瓣隔瓣脱垂并轻至中度反流的病例予随诊。结果　5例外科手术治疗者中，4例三尖瓣功能恢复良好，1例三尖瓣血流速度稍增快。三尖瓣损伤不重未行外科处理的3例病例随诊1月至2年，三尖瓣病变无加重，患儿无明显临床症状。结论　经导管PMVSDS封堵术并发三尖瓣损伤有多方面原因。操作中应避免轨道钢丝穿过三尖瓣腱索，出现腱索与封堵器或输送钢缆缠绕时切勿使用暴力牵拉。三尖瓣损伤严重时应外科手术治疗。     

Transcatheter intervention in the neonate with congenital heart disease

Over the past 30 years, interventional cardiology has developed as a distinct subspecialty, playing a major role in the management of infants with CHD. In the neonatal period, a wide variety of transcatheter interventions are performed routinely, either as palliation or therapy, as adjunct to surgery, or in place of surgical intervention. Among these are creation or enlargement of ASDs to allow atrial mixing; balloon valvotomy to treat congenital valvar stenoses; balloon angioplasty or stenting of stenotic vessels (pulmonary arteries, coarctation of aorta, or systemic or pulmonary veins) or postoperative anastomoses; closure of [figure: see text] unwanted vessels (congenital fistulae or collaterals); and other miscellaneous interventions. A wide variety of patients are candidates for these procedures, including those with transposition of the great arteries or other defects with transposition physiology, left atrial outlet obstruction and hypertension, severe valvar pulmonary or aortic stenosis, hypoplastic stenotic pulmonary arteries with severe symptomatology, severe coarctation of aorta and high surgical risks, large aortopulmonary collaterals or other hemodynamically significant unwanted vessels, acute thrombosis of certain surgical anastomoses, and many more. In experienced hands, these procedures are highly successful and safe, with a low morbidity and mortality (less than 1%).     

Difficult obstetric vesicovaginal fistula: a report on 12 cases.

In each of the 12 cases presented, the fistula was the result of obstructed labor. Common features to each case were: (a) a large retropubic defect involving the anterior vaginal wall, bladder and urethra, (b) total or partial urethral rupture, and (c) marked vaginal wall scarring with vaginal stenosis. Primary repair was performed by the vaginal route, and two patients were cured by the first operation. Six patients required two or more vaginal procedures for successful closure. Following repeated failure of vaginal closure, two patients had a successful transvesical closure and two require ureterosigmoidostomy.     

Minilaparotomy myomectomy: a minimally invasive alternative for the large fibroid uterus

STUDY OBJECTIVE: To assess the efficacy of performing myomectomies through 3- to 6-cm incisions for the removal of myomas up to 14 cm in diameter. DESIGN: A retrospective analysis of 139 myomectomies performed at our center from January 1995 through December 2003 (Canadian Task Force classification II-3). SETTING: A suburban medical center, part of a large prepaid health maintenance organization. PATIENTS: One hundred thirty-nine women. INTERVENTIONS: Myomectomies were performed through 3- to 6-cm suprapubic cruciate incisions using atraumatic elastic retractors with or without laparoscopic assist. Myomas were morcellated with a scalpel before being enucleated. The uterus was repaired in a classic three-layered closure in all cases. All procedures were performed in the ambulatory surgery unit of our hospital, which is part of the main operating room. MEASUREMENTS AND MAIN RESULTS: The median age of the patients in this series was 30.0 years (range 23-56 years). The median weight of the myomas removed was 275.0 g (range of 30-975 g). One hundred thirty-seven (98.5%) of 139 patients were discharged in 23 hours or less, with 24 patients leaving within 4 hours and 61 within 8 hours. The median length of stay was 6.0 hours, with two patients remaining hospitalized for 48 hours. The median operating time was 110 minutes (range 44-260 min). Estimated blood loss ranged from 50 to 2000 mL, with a median of 300 mL. Three hysterectomies were performed: one as an emergency for hemorrhage and two for recurrent myomas. Three patients developed wound seromas, and one developed a wound infection. CONCLUSIONS: Minilaparotomy myomectomy is a safe, effective minimally invasive alternative to laparoscopic myomectomy. Early discharge and return to normal activities is comparable to laparoscopy and is far more cost effective. It affords the ability to palpate the uterus and close the myometrial defect easily with a standard three-layered closure making it particularly suitable for gynecologists with limited laparoscopic suturing skills.     

Ventriculomegaly without dysraphic malformations--retrospective analysis fetuses diagnosed in the Department of Gynecology & Obstetrics of the Postgraduate Center of Medical Education in Warsaw,between 1997-2002

OBJECTIVES: Our objective was to determine if ventriculomegaly not related to the open neural tube defects is associated with other anomalies and aneuploidy. What we should do after such diagnosis. We also analyzed gestational age at the first examination. DESIGN: We retrospectively studied ultrasound reports of the fetuses with this type of ventriculomegaly. MATERIALS AND METHODS: We analyzed 71 cases diagnosed between September 1997 and March 2002. Ventriculomegaly was a assumed to be present when atrial width was equal or greater than 10 mm. Antenatal karyotyping was performed in all fetuses. RESULTS: 21 cases were concomitant with other CNS malformations, in 50 cases ventriculomegaly was the only one brain anomaly. The incidence of chromosomal abnormalities was 8.5% and it was strongly related to the presence of multisystem malformations. The median gestational age at diagnosis was 27.6 weeks. CONCLUSIONS: Our results suggest that in fetuses with ventriculomegaly not related to the open neural tube defects a detailed ultrasonographic survey and karyotyping should be done. Furthermore, every pregnant woman should undergo ultrasound screening before the 24th gestational week.     

Changes in myometrial thickness during hysteroscopic resection of deeply invasive submucous myomas.

STUDY OBJECTIVE: To evaluate the efficacy of hysteroscopy in resecting submucous myomas with deep intramural invasion. DESIGN: Prospective, observational study (Canadian Task Force classification II-2). SETTING: Department of gynecology at a general hospital. PATIENTS: Sixteen women with a solitary submucous myoma, in which myometrial thickness between the outer edge of the myoma and inner edge of the serosa was between 5 and 10 mm. INTERVENTION: One-step hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Median myoma diameter and weight were 3.3 cm and 30 g, respectively. Myometrial thickness between the myoma and serosa increased gradually and significantly from 6.7 mm before, to 8.9 mm during, to 16.1 mm immediately after hysteroscopic myomectomy (p <0.001). The thickness of the opposite uterine wall increased from 10.1 mm before, to 11.4 mm during, to 18.8 mm after operation (p <0.001). CONCLUSION: One-step hysteroscopic myomectomy may be performed to remove deeply infiltrating submucous myomas when myometrial thickness at the implantation site is as thin as 5 mm.     

经食管超声心动图在小儿先天性心脏病围术期的应用价值

目的 评价经食管超声心动图(TEE)对指导小儿先天性心脏病(先心病)外科手术和介入治疗的应用价值及其安全性。方法 2000年11月至2005年1月，在上海市复旦大学附属儿科医院心血管中心接受外科开胸手术或经导管介入治疗的先心病患儿中有317例进行了TEE检查，年龄2个月至17岁6个月(平均4.7岁)。采用HP/SONOS2500超声诊断仪，频率5.5~7.5MHz双平面经食管探头，全麻状态下进行。结果 与术前经胸超声心动图(TTE)比较，术前TEE检查对诊断作出修正或补充者51例(16.1%)，其中因此而修正了手术治疗方案25例(7.9%)。术后TEE检查发现有并发症或残余问题57例(18.0%)，其中8例(2.5%)因此立即再次手术。所有病例均未因TEE检查而引起并发症。结论 TEE可安全地应用于小儿先心病围术期检查，对术前诊断做出修正或补充，术后可及时发现并发症或残余问题。 Abstract Objective To evaluate the utility of transesophageal echocardiography (TEE) for surgical and interventional repairs in children with congenital heart disease (CHD) and its safety as well.Methods 317 patients with CHD underwent TEE examinations at the age of 2 months~17 years and 6 months(mean 4.7 years).HP/SONOS2500 ultrasonic instrument with transesophageal biplane probe of 5.5~7.5MHz was used to perform TEE under general anesthesia.Results Compared with preoperative transthoracic echocardiography(TTE),TEE had new findings or made revision of the diagnoses in 51 cases(16.1%) before operations,which led to the changes of surgical or interventional precedure in 25 cases(7.9%).TEE had found residual problems or evolving situations in 57 cases(18.0%) after operations,which led to a second immediate surgical intervention in 8 cases(2.5%).There were no detectable complications due to TEE in all cases.Conclusion TEE is valuable in providing meaningful preoperative emendations or additions and finding residual problems after operations. The technique is safe in children. Key words Transesophageal echocardiography (TEE);Congenital heart disease (CHD);Perioperative period;Children     

A prospective study of thimerosal-containing Rho(D)-immune globulin administration as a risk factor for autistic disorders.

BACKGROUND: This study evaluated the relationship between prenatal mercury exposure from thimerosal (49.55% mercury by weight)-containing Rho(D)-immune globulins (TCRs) and autism spectrum disorders (ASDs). METHODS: The Institutional Review Board of the Institute for Chronic Illnesses approved the present study. A total of 53 consecutive non-Jewish Caucasian patients with ASDs (Diagnostic and statistical manual of mental disorders, fourth ed. - DSM IV) born between 1987 and 2001 who presented to the Genetic Centers of America for outpatient genetic/developmental evaluations were prospectively collected from June 1, 2005 through March 31, 2006. Imaging and laboratory testing were conducted on each patient to rule out other causal factors for their ASDs. As race-matched controls, the frequency of Rh negativity was determined from 926 non-Jewish Caucasian pregnant women who had presented for outpatient prenatal genetics care to the Genetic Centers of America between 1980 and 1989. RESULTS: Children with ASDs (28.30%) were significantly more likely (odds ratio 2.35, 95% confidence interval 1.17-4.52, p < 0.01) to have Rh-negative mothers than controls (14.36%). Each ASD patient's mother was determined to have been administered a TCR during her pregnancy. CONCLUSION: The results provide insights into the potential role prenatal mercury exposure may play in some children with ASDs.     

Minimal precycle testing and ongoing cycle monitoring for in vitro fertilization and fresh pre-embryo transfer do not compromise fertilization, implantation, or ongoing pregnancy rates

OBJECTIVE: We sought to assess the fertilization, implantation, and ongoing pregnancy rates with a minimal precycle and ongoing cycle monitoring protocol for in vitro fertilization and embryo transfer. STUDY DESIGN: Retrospective review was conducted of 103 consecutive cycles of fresh in vitro fertilization and embryo transfer from 1996 to 1998. Precycle screening included semen analysis without strict morphologic analysis, and hysterosalpingography-sonohysterography within the last year. Serum prolactin, serum thyroid-stimulating hormone, reactive plasma reagin, human immunodeficiency virus, rubella titer, blood type, hepatitis B surface antigen, and hepatitis C antibody testing was performed on all patients within 3 months of cycle initiation. Women > or =37 years old underwent clomiphene challenge testing. The monitoring protocol included the following: baseline transvaginal ultrasonography after 12 to 14 days of midluteal gonadotropin-releasing hormone agonist down-regulation to assess endometrial thickness and adnexal appearance, transvaginal ultrasonography for follicle evaluation at 7 and 10 days, serum estradiol assay if > or =20 follicles, quantitative beta-human chorionic gonadotropin 12 to 14 days after pre-embryo transfer, repeat quantitative beta-human chorionic gonadotropin 3 to 5 days later, and transvaginal ultrasonography for intrauterine gestational sac confirmation 7 to 9 days after the initial positive pregnancy test result. The dose of gonadotropin used remained constant unless the sonogram obtained on day 7 indicated a suboptimal response (<3 follicles each, with an average diameter of 10 to 12 mm) or hyperresponse (> or =15 follicles with an average diameter of 10 to 12 mm). RESULTS: The per embryo implantation rate (fetal cardiac activity) was 13.1%, and the live birth rate per 100 pre-embryo transfers was 31.5 for patients < or =40 years old. The average number of pre-embryos transferred was 3.1. The singleton pregnancy rate was 71%, and there were no multiple gestations greater than twins. The mean number of oocytes fertilized was 66%. There was 1 case of failed fertilization with intracytoplasmic sperm injection. There were two other cases of failed fertilization. One case of severe ovarian hyperstimulation occurred in spite of cryopreservation of all embryos. CONCLUSIONS: In vitro fertilization and embryo transfer can be accomplished with minimal precycle testing and ongoing cycle monitoring without compromising fertilization, implantation, and ongoing pregnancy rates. This results in reduced overall costs for couples.