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In this study, GIFT resulted in a 44% pregnancy rate. When excess oocytes fertilized and developed to the blastocyst stage, the pregnancy rate was 78%. The continuing pregnancy rate was increased from 31% to 55% when sibling blastocysts developed.
When both fallopian tubes appear normal, tubal selection for GIFT is left to the surgeon's discretion. We were interested to learn whether pregnancy rates were influenced by the choice of tubal transfer in relation to ovarian dominance. Ovarian dominance was defined sonographically as the ovary containing the greater number of follicles having a mean diameter > 16 mm. In a retrospective analysis of 144 GIFT procedures, the clinical pregnancy rate for transfers performed to the tube ipsilateral to the dominant ovary was significantly higher than that of transfers made to the contralateral tube (0.414 versus 0.228, P = 0.042). This difference could not be attributed to either patient characteristics or cycle performance. We suggest that gamete transfer be performed ipsilateral to the side with the greater number of dominant follicles to optimize pregnancy rates.
Forty-six patients with endometriosis-associated infertility underwent 59 GIFT cycles. The pregnancy rate per cycle was 30.5%. The presence of endometriomas in 11 patients did not affect this rate adversely. We conclude that, provided at least one fallopian tube is patent, GIFT compensates effectively for the possible causes of infertility in these patients.
BACKGROUND: Gonadotropin releasing hormone agonists (GnRHa) are used in assisted reproduction cycles to reversibly block pituitary function and prevent a luteinizing hormone surge. In the short and ultrashort protocols of GnRHa administration, injection of gonadotropins is commenced a few days after the start of GnRHa. In the long protocols (with GnRHa started either in the midluteal phase or in the early follicular phase) gonadotropin administration is delayed until pituitary desensitization has been achieved, usually 2-3 weeks. OBJECTIVES: To conduct a systematic overview of available data comparing short or ultrashort and long GnRHa protocols for pituitary desensitization in in vitro fertilization (IVF) and gamete intra-fallopian transfer (GIFT) treatment cycles. SEARCH STRATEGY: Search strategies included on-line searching of the MEDLINE and EMBASE data bases and the Cochrane Menstrual Disorders and Subfertility Group's Specialised Register from 1982 to 1998, and hand searching of bibliographies of relevant publications and reviews, and abstracts of scientific meetings. SELECTION CRITERIA: Randomized trials of short or ultrashort versus long (follicular or luteal phase start) GnRHa protocols in IVF or GIFT treatment cycles. DATA COLLECTION AND ANALYSIS: Data were extracted into 2 x 2 tables. For the primary outcome, clinical pregnancy per cycle started, the overall common odds ratio (OR) and the risk difference with 95% confidence interval (CI) were calculated after verifying the presence of homogeneity of treatment effect across all trials. The following subgroup comparisons were performed: ultrashort versus long protocols, short versus long protocols and, within each of these comparisons, subgroups of studies which used the long protocol with follicular phase start or the long protocol with luteal phase start. Secondary outcomes considered were clinical pregnancy per oocyte retrieval and per embryo transfer, spontaneous abortion, ongoing/delivered pregnancy per cycle started, number of ampoules of gonadotropin used, number of oocytes retrieved, and fertilization rate. MAIN RESULTS: Twenty-six trials met the inclusion criteria. The common OR for clinical pregnancy per cycle started was 1.32 (95% CI, 1.10 - 1.57) in favour of the long GnRHa protocol. The studies were subgrouped, depending on whether, in the long protocol, the GnRHa was commenced in the follicular phase (8 trials) or luteal phase (16 trials). The respective ORs were 1.54 (95% CI, 1.11 - 2. 13) and 1.21 (95% CI, 0.98 - 1.51). After excluding the four trials using the ultrashort protocol, the OR for long versus short protocols (22 trials) was 1.27 (95% CI, 1.04 - 1.56). A comparison of long versus ultrashort protocols (4 trials) produced an OR of 1. 47 (95% CI, 1.02 - 2.12). REVIEWER'S CONCLUSIONS: On the basis of clinical pregnancy rate per cycle started, this meta-analysis demonstrates the superiority of the long protocol over the short and ultrashort protocols for GnRHa use in IVF and GIFT cycles.
This case report describes the use of GIFT to achieve pregnancy for a man with Kallmann's syndrome who obtained only marginal sperm counts with both the pulsatile GnRH infusion pump and gonadotropin injections. Failure of this man to achieve a pregnancy with hormonal therapy alone and in combination with IUI suggests that assisted reproductive technologies should be considered in male patients with Kallmann's syndrome when suboptimal sperm concentrations are achieved despite exogenous hormonal stimulation.
Human spermatozoa that were incubated overnight at room temperature before intrafallopian transfer with freshly collected oocytes gave rise to successful pregnancies and normal live births. The resulting pregnancy rate per transfer of 50% (4 of 8) compared favorably with the average pregnancy rate of 41.8% (38 of 91), achieved by our standard spermatozoal preparation procedure that prepared the spermatozoa approximately 2 hours before the GIFT operation. This new approach for the preparation of human spermatozoa would be applicable to oligospermic patients and some GIFT patients whose partners may have difficulties in producing a semen specimen immediately before the GIFT operation.
OBJECTIVE: To evaluate if the previously reported increased implantation rates in hormonally replaced egg donation cycles relative to hyperstimulated IVF-ET cycles apply when GIFT is used. The increased implantation rates in the recipients have been attributed to the absence of the negative effects of hyperstimulation on endometrial receptivity. DESIGN: A prospective comparison of implantation rates in hyperstimulated and hormonally replaced cycles when GIFT was used in both the egg donors and their corresponding recipients. PATIENTS: Excess mature oocytes from 35 women undergoing GIFT after controlled ovarian hyperstimulation (COH) were transferred into the fallopian tubes of 35 hormonally replaced women. RESULTS: The male partners of all donors and recipients had normal semen parameters. The two groups did not differ significantly in the mean age, duration of infertility, and quality of eggs transferred. There was no statistically significant difference in the mean number of oocytes transferred per cycle between the donors and the recipients. The mean implantation rate per mature oocyte transferred was significantly higher in the donors (19.3%) than in the recipients (6.6%). CONCLUSION: Our results with GIFT show higher implantation rates in hyperstimulated cycles than in hormonally replaced cycles. These results differ from those reported in IVF-ET that suggest an adverse effect of COH on implantation rates.
OBJECTIVES: To evaluate prospectively the impact of subtle tubal disorders on GIFT pregnancy rates in women with pelvic endometriosis. DESIGN: A prospective comparison of pregnancy rates in different stages of endometriosis while controlling for the presence of tubal abnormalities. INTERVENTIONS: A total of 146 patients with endometriosis underwent 201 GIFT procedures. During laparoscopy special attention was brought to the fallopian tubes and any anatomical disorders were recorded. Tubal abnormalities included tubal sacculations, diverticulae, convolutions, phimosis, fimbrial agglutination, and peritubal adhesions. Best tube was considered in the final analysis. RESULTS: The presence of tubal abnormalities significantly lowered the pregnancy rates in all stages of endometriosis. When we controlled for age, semen characteristics, number of mature oocytes transferred, and tubal status, the extent of anatomical tubal disorders was the most important prognostic factor in determining pregnancy outcome. CONCLUSION: The extent of tubal abnormalities rather than the stage of endometriosis seems to be an important prognostic factor in determining GIFT pregnancy rates. Couples should be counseled accordingly and accurate prognostic parameters should be explained before enrollment in a GIFT program.
The influence of antisperm antibodies in the female serum on fertilization and pregnancy rate in patients undergoing GIFT was assessed. A study group of 52 couples (69 cycles) with significant levels of antisperm antibodies in the female serum were compared to a control group of 749 couples (1185 cycles). Maternal serum or donor serum was used as growth medium supplement. The TAT test was performed for the detection of antisperm antibodies in the serum. Antisperm-antibody presence in female serum was associated with similar fertilization and pregnancy rates in a GIFT program compared to the control group. The type of serum used as growth medium supplement did not affect statistically the fertilization or pregnancy rate.
This report summarises the result of the GIFT program at Ramathibodi Hospital during 1990-1991. There were 35 treatment cycles in 34 infertile couples. The age of the females varied from 29 to 41 years. Duration of infertility was 3 to 10 years. GIFT was performed during diagnostic laparoscopy in 26 cycles (78%). Other indications were endometriosis (5 cycles), concurrent with myomectomy (3 cycles) and unexplained infertility (1 cycle). Two cases received CC+HMG for superovulation, the others had GnRHa+HMG. Transvaginal ultrasound guided oocyte pick up yielded 2 to 10 oocytes (mean 5.8 oocytes per cycle). Two to 8 oocytes were transferred. All patients received progesterone or HCG for luteal support. In cases of diagnostic laparoscopy, the findings were normal (10 cases), endometriosis (7 cases), pelvic adhesion (6 cases) and myoma uteri 3 cases). No pregnancy was achieved among 18 GIFT cycles performed in 1990. In 1991, after changing some instruments and methods, there were 5 pregnancies out of 17 GIFT cycles (29%). The factors that influenced the outcome were good selection of instruments and method, maturity of oocytes and semen parameters.
The aim of the study was to compare the ability to prevent endogenous luteinizing hormone interferences, ovarian response, and success rate between two groups of patients undergoing GIFT procedures and treated with the same stimulatory protocol but with a different timing in the administration of the gonadotropin hormone-releasing hormone analogue (GnRH-a). The former underwent a concomitant administration of gonadotropin and analogue; the latter started stimulation only after the achievement of complete hypogonadotropinism. The analogue was always given intranasally and stimulation was identical in the two groups. Our results showed that (1) prevention of premature luteinization is obtained with both approaches and (2) no significant difference in terms of length of stimulation, gonadotropin doses, ovarian response, and success rate was recorded between the two groups.
OBJECTIVE: To test the efficiency and overall acceptability of hysteroscopic GIFT when compared with laparoscopic GIFT. DESIGN: We performed a randomized comparison between these techniques as regards pregnancy rate (PR), implantation rate, miscarriage rate, and ectopic pregnancy rate (ectopic PR). SETTING: All patients were enrolled for GIFT procedures in our Reproductive Medicine Unit. PATIENTS: We enrolled 133 patients showing documented tubal patency at a previous diagnostic laparoscopy. INTERVENTIONS: Gonadotropin-releasing hormone analog and FSH were administered to induce superovulation in all patients, who were then randomized for hysteroscopic GIFT or laparoscopic GIFT. Laparoscopic GIFT was performed under general anesthesia while, during hysteroscopic GIFT, oocyte retrievals were transvaginal ultrasound guided and transfers were performed by cannulating tubal ostia after hysteroscopic visualization. MAIN OUTCOME MEASURE: The efficacy was evaluated comparing PR, implantation rate, miscarriage rate, and ectopic PR. RESULTS: Pregnancy rate and implantation rate of hysteroscopic GIFT procedures (29.8% and 9%, respectively) are not significantly different from those obtained with laparoscopic GIFT (43.3% and 14%). CONCLUSIONS: Hysteroscopic GIFT is safe and easy and quick to perform. Moreover, it does not require hospital admission, general anesthesia, or the operating theater, reducing costs and assuring advantages in terms of low psychophysical involvement and repeatability.
OBJECTIVE: To compare GIFT, intrauterine insemination (IUI) with, and without, ovarian hyperstimulation in the treatment of unexplained infertility. DESIGN: Women randomly allocated to one of three treatment protocols. SETTING: Northern Regional Fertility Centre. SUBJECTS: 59 couples with unexplained infertility of more than 3 years duration. INTERVENTIONS: Three cycles of either GIFT, IUI after ovarian hyperstimulation or IUI in a spontaneous cycle. MAIN OUTCOME MEASURES: Pregnancy resulting in a live birth. RESULTS: Fecundabilities were 0.12 after GIFT, 0.018 after ovarian hyperstimulation and IUI, and 0.018 after IUI in a spontaneous cycle. The fecundability after IUI was no different from that which would be expected without treatment in these couples but fecundability was significantly better (P greater than 0.02) after GIFT. CONCLUSIONS: This trial does not support the use of IUI in the treatment of unexplained infertility but confirms the value of GIFT.
OBJECTIVE: To determine the length of procedure, length of recovery, patient tolerance, complications, and pregnancy rate (PR) of laparoscopically assisted GIFT performed during local anesthesia with i.v. sedation. DESIGN: A retrospective study. SETTING: Freestanding private ambulatory surgical center. PATIENTS: Thirty-one consecutive couples with infertility. INTERVENTIONS: Laparoscopically assisted GIFT during local anesthesia with i.v. sedation. MAIN OUTCOME MEASURES: Surgery time, recovery time, patient tolerance, PR, miscarriage rate, and complications. RESULTS: Cannulation of at least one fallopian tube was achieved successfully in all patients. The average surgery time was 64 +/- 12 minutes (mean +/- SD). The average recovery time was 92 +/- 30 minutes. The PR was 39% with an ongoing PR of 32%. There were no intraoperative or postoperative complications. CONCLUSION: Local anesthesia with IV sedation for GIFT using a two-puncture laparoscopic technique was well tolerated by the patients. Our ongoing PR of 32% compares very favorably with other series using general anesthesia.
This report contains details of what is the first group of patients with nontubal infertility to undergo fallopian replacement of eggs with delayed intrauterine insemination (FREDI). Twenty-three patients suffering from idiopathic or immune infertility, polycystic ovarian disease (PCOD), or mild endometriosis underwent follicular stimulation with human menopausal gonadotropin and/or pure follicle-stimulating hormone plus human chorionic gonadotropin prior to laparoscopic pickup of eggs of varying maturity. Eggs without spermatozoa were transferred at the time of laparoscopy. Subsequent high intrauterine insemination (IUI) of washed spermatozoa at a time when egg maturation within the tubes was judged to be complete enabled a cohort of fully capacitated spermatozoa to meet fully mature eggs in a totally physiological manner. Eight clinical pregnancies arose from this group, one healthy, male infant has been delivered, and four pregnancies remain ongoing. Although based on a small population of patients, it does seem that in vivo egg maturation following replacement in the fallopian tube is an effective alternative to in vitro maturation and, with the increased control over timing of egg insemination, leads us to propose FREDI as a flexible new therapeutic approach for the treatment of nontubal infertility.
A randomized controlled study of luteal support therapy (using intramuscular injections of progesterone and/or human chorionic gonadotropin) was conducted in a trial designed to minimize variables that might adversely affect the change of pregnancy. After applying rigid selection criteria, 207 women were recruited into one of four groups. Mathematical modeling was applied to the results to determine if there were degrees of improvement in uterine receptivity relative to various grades of embryo quality ("E" factor). Although the trial size was insufficient to enable the detection of significant improvements in the pregnancy rates that ranged from 27.5% for non-treatment to 41.2% for those receiving combined treatment, the birth rates were significantly better with luteal support (11.8% versus 29.4%). Similarly, the overall implantation rate just failed to reach statistical significance for luteal support, but the ongoing implantations were significantly better (3.6% versus 9.0%). Data modeling indicated that luteal support, particularly with the combined regimen, could improve the ongoing implantation rate by up to 2.5-fold when the E factor was poorest.
OBJECTIVE: To determine incidence of hypospadias in infants born as a result of assisted reproductive technology (ART). DESIGN: Prospective data collection. SETTING: Parents with various forms of infertility attended an in-hospital in vitro fertilization program. PATIENTS: Two of the 53 male infants, conceived as a result of ART over a 3-year period, were born with hypospadias. INTERVENTIONS: Patient no. 1 underwent follicular stimulation (17 ampules of human menopausal gonadotropin (hMG), followed by 10,000 IU of human chorionic gonadotropin (hCG) 60 hours after the last hMG). Patient no. 2 underwent follicular stimulation with clomiphene citrate 100 mg/d from days 3 to 7, followed by 14 ampules of hMG starting day 6, and 10,000 IU of hCG 30 hours after her last hMG. MAIN OUTCOME MEASURES: All infants were examined in the immediate postpartum period for congenital anomalies. RESULTS: Infant no. 1, one of a set of dizygotic twins, had penoscrotal hypospadias, with normal renal sonogram and chromosomal studies. Infant no. 2 had glandular hypospadias with the urinary meatus displaced to the border of the glans. CONCLUSION: This high incidence raises concern about possible links between assisted reproduction and hypospadias.
About 30% of the ovulation induction cycles in GIFT and FIVET programmes are cancelled due to an inadequate response of patients to gonadotropins and/or clomiphene citrate. GnRH agonist-gonadotropins and/or "pure" FSH combination has been successful in inducing ovulation in patients with a previous history of cycle cancellation and/or alterations in the menstrual cycles. In order to reduce the number of cycle cancellations and obtain more homogeneous oocytes, GnRH agonist-gonadotropins and/or "pure" FSH combination in all candidates for GIFT and FIVET has been recently hypothesised. The Authors report results obtained from GnRH agonist-"pure" FSH combination in 30 normally menstruating patients of the GIFT programme: in 93% of cases the harvested oocytes were preovulatory, in 27.6% of cycles and in 28.6% of the GIFTs respectively an ongoing pregnancy was obtained. While the results obtained must be considered preliminary, they nevertheless suggest that the use of a combination of GnRH-agonist "pure" FSH in all patients in the GIFT programme may be of real clinical validity.