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Biomedical subjects

A A Milki

Publications and source records attributed to A A Milki.

At least 19 recordsLinked to original sources
PubMed2006

Comparison of GnRH antagonist cycles with and without oral contraceptive pretreatment in potential poor prognosis patients.

PURPOSE: To evaluate the effect of oral contraceptive pill (OCP) pretreatment in patients undergoing IVF cycles with an antagonist. METHODS: In this retrospective study, 194 cycles of women with diminished ovarian reserve undergoing IVF with a protocol using GnRH antagonists were evaluated. Oral contraceptive pretreatment was used in 146 cycles. RESULTS: Pregnancy rates were the same in both groups. Patients using OCPs required more gonadotropins (5,890 IU) compared to patients not undergoing OCP pretreatment (4,410 IU). CONCLUSIONS: Pregnancy outcomes were the same whether or not OCP pretreatment was implemented in poor responders using an antagonist protocol. While OCP pretreatment may help with scheduling flexibility, the higher dose of gonadotropins needed for ovarian stimulation should be considered.

Adult↗
PubMed2004

Uterine position at real embryo transfer compared with mock embryo transfer.

BACKGROUND: The purpose of this study was to determine the consistency in the uterine position between mock and real embryo transfer. METHODS: We reviewed 996 consecutive embryo transfer cycles (585 patients); 74% of patients had an anteverted (AV) uterus and 26% had a retroverted (RV) uterus at mock embryo transfer. All mock and real embryo transfers were performed under abdominal ultrasound guidance. RESULTS: Of 623 fresh embryo transfers in patients with an AV uterus at mock embryo transfer, only 2% became RV, while 55% of 213 embryo transfers in patients with an RV uterus on mock embryo transfer converted to AV at real embryo transfer (P < 0.0001). For frozen-thawed embryo transfer, 12% of AV uteri at mock embryo transfer became RV, while 33% of RV uteri became AV (P = 0.01). CONCLUSIONS: Our data suggest that an RV uterus at mock embryo transfer will often change position at real embryo transfer. Misdirecting the embryo transfer catheter can be avoided by accurate knowledge of the uterine position at the time of embryo transfer, which can be more accurately assessed by routine ultrasound guidance. Additionally, patients with an RV uterus at mock embryo transfer should still present with a full bladder for embryo transfer, since a significant number will convert to an AV position.

Cryopreservation↗
PubMed2003

Exercise-induced ovarian torsion in the cycle following gonadotrophin therapy: case report.

The incidence of ovarian torsion has been reported to be increased during controlled ovarian hyperstimulation. In this report we describe exercise-induced ovarian torsion in an ovary with a persistent cyst, following a failed gonadotrophin-stimulated intra-uterine insemination cycle. This report suggests that the risk of ovarian torsion persists beyond the treatment cycle and that patients should be instructed to refrain from exercise or strenuous activity if regression to normal ovarian size has not been documented. Ovarian torsion should be high in the differential diagnosis in patients experiencing abdominal pain with a history of recent gonadotrophin stimulation.

Adult↗
PubMed2002

Endometrioma of uterine serosa in a woman with mosaic Turner's syndrome receiving hormone replacement therapy: case report.

Endometriosis in Turner's syndrome patients has only been reported in five isolated cases. We present here an endometrioma on the uterine serosa and pelvic endometriosis arising in a mosaic Turner's patient receiving hormone replacement therapy (HRT). The 24 year old patient with mosaic Turner's syndrome [45,X; 46,X pseudo dicentric Y (q11.23)], on cyclic HRT after laparoscopic gonadectomy 5 years previously, was found to have an adnexal mass on routine examination. Given her history, due to the fear of a malignant process arising from a potential gonadal remnant, she underwent a laparoscopy and was found to have a 5 cm serosal endometrioma arising on a stalk from the uterine fundal surface as well as pelvic endometriosis. De-novo endometrioma and endometriosis occurred in a mosaic Turner's patient after gonadectomy on cyclic HRT. The presentation was also unusual with a pedunculated endometrioma arising from the uterine serosa. Due to the fact that the patient did have cyclic menstrual flow, her endometriosis may have arisen from retrograde menstruation or coelomic metaplasia induced by exogenous hormones.

Adult↗
PubMed2001

Concurrent IVF and spontaneous conception resulting in a quadruplet pregnancy.

Blastocyst transfer of just one or two embryos has been used to help limit the number of high-order gestations. In this case report we describe the occurrence of a quadruplet pregnancy after the transfer of only two blastocysts during IVF. Sonographic examination showed four fetuses and what appeared to be quadriamniotic/quadrichorionic sacs, suggesting that a concomitant spontaneous conception had occurred. Definite confirmation of zygosity was obtained by genetic testing using DNA microsatellite polymorphism determinations after the birth of one boy and three girls at 32 weeks gestation. Although this event has not been reported previously, the possibility of its occurrence should be kept in mind. IVF patients with patent Fallopian tubes should be cautioned against intercourse late in their controlled ovarian stimulation, especially if they would decline multifetal reduction.

Adult↗
PubMed2001

Vascular endothelial growth factor (VEGF) mRNA splice variants are differentially expressed in human blastocysts.

The aim of our study was to detect and characterize mRNA expression of VEGF isoforms VEGF(121), VEGF(145), VEGF(165), VEGF(189), and VEGF(206) in human blastocysts. We recently demonstrated VEGF mRNA expression during human preimplantation embryo development, and further information regarding the alternatively spliced mRNAs resulting in freely secreted proteins or proteins bound to cell surface heparan-sulphate proteoglycans is needed to better understand the process of angiogenesis during implantation. Human blastocysts unsuitable for transfer obtained from the IVF programme at Stanford University were examined by reverse transcription/hemi-nested polymerase chain reaction for their expression of VEGF mRNA splice variants. VEGF mRNA was expressed in 17 out of 19 (89%) blastocysts. Of the 17 blastocysts, VEGF(121) mRNA was detected in 88%, VEGF(145) mRNA in 100%, VEGF(165) mRNA in 71%, and VEGF(189) mRNA in 24% of blastocysts. There was co-expression of mRNA for VEGF(121) and VEGF(145) only in 29% blastocysts, of mRNA for VEGF(165) and VEGF(145) only in 12%, and of mRNA for VEGF(121), VEGF(145) and VEGF(165) in 59% blastocysts. VEGF(206) mRNA could not be detected. In conclusion, we demonstrated that blastocysts express the mRNAs encoding for the free VEGF proteins, enabling the implanting embryo to immediately induce angiogenesis at the implantation site.

Actins↗
PubMed2001

Recombinant gonadotropins.

Recombinant DNA technology makes it possible to produce large amounts of human gene products for pharmacologic applications, supplanting the need for human tissues. The genes for the alpha and beta subunits of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and human chorionic gonadotropin (hCG) have been characterized and cloned. Recombinant FSH (rFSH) has been shown to be safe and effective in the treatment of fertility disorders. In comparison with the urinary gonadotropin products, human menopausal gonadotropins (HMG), and urinary follitropins (uFSH), rFSH is more potent and better tolerated by patients. Recombinant HCG appears to be as efficacious as urinary HCG with the benefit of improved local tolerance. Recombinant LH (rLH) is likely to be recommended as a supplement to rFSH for ovulation induction in hypogonadotropic women. It may also benefit in vitro fertilization patients undergoing controlled ovarian hyperstimulation with rFSH combined with pituitary suppression, with a gonadotropin-releasing hormone agonist or antagonist.

Adult↗
PubMed2000

Expression of vascular endothelial growth factor mRNA in human preimplantation embryos derived from tripronuclear zygotes.

OBJECTIVE: To detect the expression of vascular endothelial growth factor (VEGF) mRNA and/or secretion of VEGF protein by human preimplantation embryos. DESIGN: Human preimplantation embryos not suitable for uterine transfer were examined for beta-actin and VEGF mRNA expression. Culture media from normally fertilized and developing preimplantation embryos were assessed for VEGF protein secretion. SETTING: Clinics and academic research laboratories at the Departments of Obstetrics and Gynecology at the Stanford University, Palo Alto, California and the Heinrich-Heine-University, Düsseldorf, Germany. PATIENT(S): Couples undergoing IVF by intracytoplasmic sperm injection for various reasons. INTERVENTION(S): Six unfertilized oocytes and 33 pathologically fertilized (tripronucleic, 3PN) preimplantation embryos were examined for VEGF mRNA expression, and 16 embryos were examined for VEGF protein secretion. MAIN OUTCOME MEASURE(S): Embryonic expression of VEGF mRNA and VEGF protein as determined by reverse transcription (RT)/nested polymerase chain reaction (PCR) and ELISA. RESULT(S): VEGF mRNA and protein could not be detected in unfertilized oocytes. However, 30/33 preimplantation embryos did express VEGF mRNA (11/12 10-to-16-cell embryos, 3/4 morulae, 11/12 early blastocysts, 5/5 hatched blastocysts). The VEGF protein level was below the sensitivity of the ELISA. CONCLUSION(S): Production of VEGF may give the embryo the ability to induce neoangiogenesis at the implantation site, thus creating an environment necessary for its survival.

Cell Nucleus↗
PubMed2000

Comparison of blastocyst transfer with day 3 embryo transfer in similar patient populations.

OBJECTIVE: To compare implantation and pregnancy rates (PRs) achieved with blastocyst transfer (BT) and day 3 ET in similar patient populations. DESIGN: Retrospective analysis. SETTING: Academic infertility center. PATIENT(S): One hundred consecutive patients <40 years undergoing IVF, each with more than three eight-cell embryos on day 3. INTERVENTION(S): Patients used their own eggs for IVF or IVF and intracytoplasmic sperm injection. Embryos were cultured in P1 medium (Irvine Scientific, Santa Ana, CA) until day 3, when they were either transferred or, in the case of embryos for BT, incubated in Blastocyst Medium (Irvine Scientific), followed by transferring on day 5. MAIN OUTCOME MEASURE(S): Implantation and PRs. RESULT(S): There were no statistically significant differences in patient age, FSH level, or number of oocytes or zygotes. The BT group had fewer embryos transferred (mean, 2.4) compared with the day 3-ET group (mean, 4.6). The viable PR (cardiac activity at 6-7 weeks was considered indicative of a viable pregnancy) was higher with BT (68%, 34/50) than with day 3 ET (46%, 23/50). The implantation rate was increased with BT (47%, 56 sacs/120 embryos) compared with day 3 ET (20%, 46 sacs/231 embryos). CONCLUSION(S): The BT group in our study had higher implantation and PRs compared with the day 3-ET group. Better embryo selection, improved embryo-uterine synchrony, and decreased cervical mucus on day 5 may have accounted for the enhanced outcome. Our data support the use of BT to limit the number of embryos transferred while improving PRs.

Adult↗
PubMed2000

Blastocyst-ET and monozygotic twinning.

PURPOSE: To examine the rate of monozygotic twinning associated with blastocyst transfer using commercially available, cell-free culture systems with unmanipulated blastocysts. METHODS: A retrospective analysis was conducted in multiple private and academic infertility centers throughout the United States, of 199 pregnant patients following in vitro fertilization (IVF) blastocyst embryo transfer (ET). Human embryos obtained through standard IVF stimulation protocols were cultured in commercially available, cell-free media systems and transferred as blastocysts. The main outcome measure was the rate of monozygotic twinning. RESULTS: A total of 199 blastocyst-ET pregnancies were achieved during the study period at the fertility centers examined. Monozygotic twinning was noted in 10/199 (5%) of these pregnancies. All were monochorionic diamnionic. CONCLUSIONS: Monozygotic twinning previously has been reported following IVF, especially in relation to assisted hatching. While blastocyst transfer has been available for many years using coculture, there have been no published multicenter reports of monozygotic twinning associated with unmanipulated blastocysts. In a multicenter analysis, a definite increase in monozygotic twinning was seen following blastocyst-ET. We believe this phenomenon is real and that this information should be considered when counseling patients for treatment.

Cell-Free System↗
PubMed1999

Sibling embryo blastocyst development correlates with the in vitro fertilization day 3 embryo transfer pregnancy rate in patients under age 40.

OBJECTIVE: To examine the IVF day 3-ET pregnancy rate in patients under 40 with sibling embryo blastocyst development, compared with similar patients without blastocyst formation. DESIGN: Retrospective analysis. SETTING: Academic infertility center. PATIENT(S): One hundred twenty-five IVF day 3-ET patients under 40 with sibling embryos for extended culture. INTERVENTION(S): Extended culture of nontransferred sibling embryos for blastocyst development. MAIN OUTCOME MEASURE(S): Pregnancy and multiple gestation rates, number of oocytes, embryos formed, and embryos transferred. RESULT(S): Thirty-eight percent of patients became pregnant. Forty-eight percent of patients had sibling embryos develop to blastocyst. The blastocyst group had more oocytes retrieved (17.4+/-6.6 versus 14.4+/-5.6), more embryos formed (11.2+/-4.2 versus 8.8+/-3.2), and a higher clinical pregnancy rate (60% versus 18%) than the group without blastocyst development. CONCLUSION(S): Blastocyst transfer has been shown to improve implantation rates and reduce the risk of multiple gestations from assisted reproductive technology. Sibling embryo blastocyst development may reflect superior embryo quality, as manifested by increased IVF-ET pregnancy rates. In addition to predicting pregnancy in the current cycle, sibling embryo blastocyst development may provide information about the potential for fresh blastocyst transfer in subsequent cycles and help to identify patients at risk for multiple gestations.

Adult↗
PubMed1999

Aspiration of a single dominant follicle leads to improved cohort development and pregnancy in a patient with poor response to in vitro fertilization treatment.

OBJECTIVE: To report improved follicular cohort development and a healthy ongoing pregnancy after midcycle aspiration of a single dominant ovarian follicle in a patient with poor response to IVF treatment. DESIGN: Case report. SETTING: University-based infertility center. PATIENT(S): A 39-year-old woman (gravida 1, para 0) with a borderline FSH level and four previous unsuccessful IVF attempts. INTERVENTION(S): A single 27-mm follicular cyst was aspirated after 13 days of treatment, while controlled ovarian hyperstimulation was continued. MAIN OUTCOME MEASURE(S): Number of follicles developed, number of oocytes retrieved, development of a clinical pregnancy. RESULT(S): In previous attempts, the patient had no more than two dominant follicles and a maximum of three oocytes retrieved. After midcycle aspiration of the single lead follicle, a new cohort of seven follicles developed and seven oocytes were recovered. Six embryos were replaced by tubal ET and an ongoing singleton gestation resulted. CONCLUSION(S): Midcycle aspiration of a single lead follicle in a patient with poor response to IVF treatment allowed the development of a larger secondary cohort of follicles during the same cycle and ultimately led to a viable pregnancy. This intervention may have future implications for the treatment of poor responders.

Adult↗
PubMed1999

Two-blastocyst transfer has similar pregnancy rates and a decreased multiple gestation rate compared with three-blastocyst transfer.

OBJECTIVE: To examine the effect of the number of blastocysts transferred on pregnancy and multiple gestation rates. DESIGN: Retrospective study. SETTING: Academic infertility center. PATIENT(S): Patients < 40 years undergoing IVF, with FSH levels of < 15 mIU/mL and more than three eight-cell embryos. INTERVENTION(S): Embryos were cultured in P1 until day 3 and then transferred to blastocyst medium. A maximum of three blastocysts were transferred. MAIN OUTCOME MEASURE(S): Pregnancy, multiple gestation, and implantation rates. RESULT(S): All 55 patients developed blastocysts and underwent ET. Twenty-four patients had three embryos transferred and 29 patients had two embryos transferred. Two patients had only one embryo each for transfer. There was no difference in the viable pregnancy rate between the two-blastocyst transfer and three-blastocyst transfer groups (62% vs. 58%). In the two-blastocyst transfer group, 39% of pregnancies were multiple gestations (all twin gestations), compared with 79% of pregnancies in the three-blastocyst transfer group (50% twin gestations, 29% triplet gestations). The implantation rate was 47% in both groups. CONCLUSION(S): A commercially available, sequential culture system is highly effective for producing viable blastocysts. Two-blastocyst transfer eliminated the risk of triplets while maintaining the same high success rates seen with three-blastocyst ET.

Adult↗
PubMed1999

Preliminary clinical experience with human blastocyst development in vitro without co-culture.

This preliminary analysis was designed to quantify blastocyst development of supernumerary embryos without the use of feeder cells, conditioned medium or whole serum. Embryos derived from in-vitro fertilization (IVF) that were not transferred or cryopreserved were included in this study. Ova were harvested for IVF after a standard ovarian stimulation with gonadotrophin-releasing hormone agonist/ human menopausal gonadotrophin (GnRHa/HMG) or follicle-stimulating hormone (FSH). Ova were collected and culture in 150 microliters droplets of P1 medium under mineral oil, in groups at 37 degrees C under 5% CO2, 5% O2, 90% N2 (group A) or under 5% CO2 in air (group B) environment. Embryo transfer was performed 72 h post-harvest. Viable embryos not transferred or cryopreserved were placed in blastocyst medium and cultured for an additional 48 h in 5% CO2 in air. Embryos that exhibited an expanded blastocoelic cavity and well-defined inner cell mass at 120 h were counted. Of 838 supernumerary embryos cultured, 448 (53.5%) reached the expanded blastocyst stage by 120 h of culture. Patients were given the option of cryopreservation at that time. The embryos were cryopreserved using a standard protocol with serial addition of glycerol. Embryos reaching the blastocyst stage after more than 120 h of culture were not included. There was no difference in the proportions of blastocyst development between group A, 217/410 (53.5%) and group B, 231/428 (54%). To date, 16 patients have each had up to three thawed blastocysts transferred, out of whom seven became pregnant. This report demonstrates that a simple system of sequential culture generated acceptable, viable blastocyst development (54%) with supernumerary embryos, without the use of feeder cells, conditioned medium or whole serum. Recognizing the differential metabolic requirements of early and late cleavage stage embryos has enabled the application of a glucose/phosphate-free simple culture medium (P1) for up to 72 h of culture and a complex, glucose-containing medium (blastocyst medium) for subsequent blastocyst development.

Blastocyst↗
PubMed1998

Comparison of carbon dioxide and air pneumoperitoneum for gamete intrafallopian transfer under conscious sedation and local anesthesia.

OBJECTIVE: To compare patient tolerance and pregnancy rates (PRs) between two cohorts that underwent GIFT under local anesthesia with air versus carbon dioxide (CO2) pneumoperitoneum. DESIGN: Retrospective study. SETTING: University clinic. PATIENT(S): Eighty-five patients who underwent 125 laparoscopies under conscious sedation for GIFT using air pneumoperitoneum were compared with 42 patients who had 70 GIFT procedures with CO2 pneumoperitoneum. INTERVENTION(S): Transvaginal ultrasound-guided egg retrieval followed by GIFT with compressed air or CO2 for pneumoperitoneum under local anesthesia and i.v. sedation. MAIN OUTCOME MEASURE(S): Patient tolerance and viable PR. RESULT(S): The percentage of patients scoring "very good" was lower in the CO2 group (73% for air versus 57% for CO2), but the combined percentage of those scoring "very good" or "good" was comparable at 89% and 87%. The difference in the viable PRs between the two groups (43% versus 37%) for patients < 40 years old was not statistically significant. CONCLUSION(S): Patient tolerance and PRs are similar for air and CO2 pneumoperitoneum during GIFT under local anesthesia. Given the theoretical risk of air embolus and lack of detrimental effect of CO2 on patient tolerance and success rate, it seems prudent to use CO2 in such a setting.

Adult↗
PubMed1998

Vaginal ultrasound probe cover leakage: implications for patient care.

OBJECTIVE: To assess the risk of probe contamination following transvaginal ultrasonography. DESIGN: Prospective cohort study. SETTING: University Infertility Center. PATIENT(S): Women undergoing transvaginal ultrasonography. INTERVENTION(S): One physician obtained 840 consecutive transvaginal ultrasonograms over nine months. Latex condoms were used to cover the probe. Following examination, the condoms were removed and the probe was wiped with a germicidal disposable cloth and left to air dry for 5 minutes. Condoms were filled with water and examined for leaks. MAIN OUTCOME MEASURE(S): Number of perforations and distance from condom tip. RESULT(S): Seventeen (2%) of 840 condoms leaked. The mean distance from the tip to the point of leakage was 10.6 cm +/- 2.8 (mean +/- SD; range, 7-14). Sixty-five percent of the leaks were < or = 10 cm from the tip. In several instances, two leaking condoms were found within a few examinations of each other. No visual contamination of the probe was noted. CONCLUSION(S): Although only 2% of condoms leaked, 65% were at distances that could have led to probe soiling intravaginally. While no body fluids were grossly visible, microscopic contamination was still possible. Since perforations were noted in close, and even consecutive scans, this study underscores the need for routine probe disinfection between examinations.

Body Fluids↗
PubMed1997

Office laparoscopy under local anesthesia for gamete intrafallopian transfer: technique and tolerance.

OBJECTIVE: To describe our technique for laparoscopic GIFT under local anesthesia and to evaluate patient tolerance and surgeon satisfaction in 175 consecutive procedures. DESIGN: Prospective cohort study. SETTING: University infertility practice. PATIENT(S): All GIFT candidates from 1992 to 1996 were offered the procedure. Of 119 patients, 119 chose local anesthesia for 175 procedures and 1 patient elected to have general anesthesia. INTERVENTION(S): Transvaginal ultrasound-guided egg retrieval followed by GIFT in the clinic procedure room with a 5-mm laparoscope and two accessory 3-mm trocars with local anesthesia and i.v. sedation. MAIN OUTCOME MEASURE(S): Patient tolerance and acceptance, duration of the procedure, amount of analgesics, surgeon satisfaction, and pregnancy rate (PR). RESULT(S): The laparoscopic portion lasted an average of 27 minutes, with a mean dose of 1.41 mg of midazolam and 68 micrograms of fentanyl used. Sixty-nine percent of the patients scored "very good," 20% "good," 9% "acceptable," and 2% "poor." All 38 patients undergoing 97 repeat procedures selected local anesthesia again. For women < 40 years of age, clinical PR and delivery rate were 43% and 38%, respectively. CONCLUSION(S): Routine office GIFT under local anesthesia is effective and well accepted by the surgeon and is preferred by patients. It offers a significant cost containment and scheduling flexibility in addition to high success rates.

Adult↗