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The ethics of the new reproductive technologies.
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Operative laparoscopy in assisted reproduction.
After the introduction of transvaginal ultrasound guided recovery of oocyte, the use of laparoscopy in Assisted Reproductive Technology is limited to GIFT and ZIFT or TET method and to the selection of patients. In this paper the Authors discuss about these methods, the advantages of tubal gametes or embryos transfer versus uterine transfer.
Active management of infertility.
Management of infertility is slow, time consuming and, paradoxically, costly. It needs to be streamlined so that diagnosis and management go hand in hand with proper division between primary physicians at district level and highly trained specialists at regional level. Incorporation of assisted conception techniques is the key to the success of such an approach.
Advances in clinical micromanipulation of gametes and embryos. Assisted fertilization and hatching.
Several methods for micromanipulation of human gametes have been proposed to enhance fertilization in cases of male infertility. Of these methods, two have been successful in producing pregnancies and live births worldwide; these include partial zona dissection and subzonal sperm insertion. During the period between October 1989 and July 1991, 251 patients with male infertility due to impaired sperm function were treated with in vitro fertilization in conjunction with gamete micromanipulation at our center. Sixty pregnancies (24% per cycle, 42% per replacement) resulted in 144 patients. The details of these treatments are discussed. In another study, in an attempt to increase the incidence of implantation, we have conducted three clinical trials of assisted hatching and selected assisted hatching. The combined results of the trials indicate a clinical pregnancy rate of 51% in the control group and 60% in the micromanipulated group (P less than .05). Moreover, while 20% of the embryos replaced in the control group implanted the implantation rate was increased to 28% in the experimental group (P less than .05). Methodologies and possible implications of these treatments are discussed.
Recent advances in medically assisted conception. Report of a WHO Scientific Group.
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[Current possibilities in reproduction medicine. 2. Spectrum of therapeutic procedures].
As measures of assisted conception, GIFT, ZIFT, TV test and insemination require patent Fallopian tubes. In the majority of cases, intra-uterine insemination is attempted before the invasive methods. Intratubal gamete transfer is employed in particular in the case of infertility that has resisted treatment for years, some forms of male subfertility, and in patients with endometriosis or other forms of genital pathology. In addition, ZIFT and the TV test permit an assessment of in vitro fertilization. In the case of IVF, the classical indication of microscopically non-treatable tubal occlusion has been expanded considerably. Although GIFT is associated with a pregnancy rate of between 30 and 40%, IVF is increasingly being used in women in whom GIFT is indicated, thus avoiding the need for laparoscopy. The alternative techniques of transvaginal GIFT or transvaginal embryo transfer cannot yet be definitively evaluated for clinical routine use. In view of the wide range of therapeutic possibilities, individual counselling of the patient is an essential requirement.
[Combined treatment with a GnRH-analog and gonadotropins in IVF-ET/GIFT patients after previously unsuccessful pure HMG stimulation].
Clinical results of a combined GnRH-analogue (buserelin, long protocol) + HMG stimulation of 44 IVF-ET or GIFT patients with previously failed pure HMG stimulation have been analysed. The cancellation rate and the incidence of premature LH surge was found to be lower in the buserelin + HMG group than in the control HMG group (30% vs. 40% and 16% vs. 51%). There was no significant difference between the buserelin + HMG and the control HMG group, neither in the number of retrieved and fertilized oocytes and transferred embryos nor in the fertilization and pregnancy rate. The combined GnRH-analogue and gonadotropin therapy led to a decrease of the cancellation rate and of premature LH surge in patients with previously failed pure HMG stimulation. In this group of patients the use of buserelin leads to treatment results comparable to results of pure HMG stimulated patients without previously failed stimulation cycles. Thus the GnRH-analogue + HMG stimulation is recommended for patients with previously unsuccessful pure HMG stimulation.
Complications of pregnancy in infertile couples: routine treatment versus assisted reproduction.
Ninety pregnancies conceived by infertile couples using assisted reproductive technologies and 86 pregnancies conceived by infertile couples with routine infertility treatment were analyzed to determine the outcome of and the complications experienced during the pregnancies. Pregnancies ending after 24 weeks' gestation were evaluated for the following complications: pregnancy-induced hypertension, diabetes mellitus, preterm labor, premature rupture of membranes, placenta previa, and fetal growth retardation. A matched control group of normal fertile patients admitted to the obstetric service at Vanderbilt University Medical Center was used to compare the incidence of pregnancy complications among the groups. In the group treated by assisted reproduction, 81 pregnancies were singleton and nine were multiple gestations, whereas in the routine group, 84 were singleton and two were multiple gestations. In the group treated by assisted reproduction, 29 of 90 gestations (32%) ended before 24 weeks, compared with 18 of 86 (21%) in the routine group, a nonsignificant difference. Mean birth weight and gestational age were similar among the three groups for singleton gestations. Among multiple gestations, the mean (+/- standard error of the mean [SEM]) birth weights were 2513 +/- 115, 724 +/- 57, and 2282 +/- 132 g in the group treated by assisted reproduction, the group receiving routine methods, and the control group, respectively (P less than .001 when those treated by routine methods were compared with the other two groups). The mean (+/- SEM) gestational ages were 36 +/- 1.2, 26.5 +/- 2.0, and 35.5 +/- 1.2 weeks, respectively (P less than .01 comparing those treated by routine methods and the other two groups).(ABSTRACT TRUNCATED AT 250 WORDS)
[Indications for and results of in-vitro fertilization (IVF), intratubal gamete- (GIFT) and embryo transfer (EIFT)].
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[Research in reproduction medicine].
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[Indications of fertilization in vitro (FIV) and intratubal transfer].
Initially developed to treat tubal infertility, in vitro fertilization (IVF) has acquired wider indications when the pregnancy rates have improved. IVF is now offered to couples as the ultimate solution in case of tubal infertility (with Fallopian tubes that are altered or definitively out of action), in case of unexplained infertility or in case of male infertility. In addition, it has been used in endometriosis, in cervical mucus problems or after failure of donor insemination. If at least one tube is healthy (unexplained or male infertility), a gamete intra-Fallopian transfer (GIFT) may be proposed. At the moment, IVF is not only the ultimate therapy but also the ultimate diagnostic test for infertile couples.
[Spermatocyte antibodies in serum and follicular fluid of IVF and GIFT patients].
With a new SPAK-ELISA test system (Seratec GmbH) we determined sperm antibodies in sera of 60 IVF, 11 GIFT patients and their husbands. We evaluated sperm antibodies in sera of 12 IVF (20.0%), 3 GIFT (27%) and 3 males with normozoospermia parameters (4.2%). Compared to seronegative patients either the number of oocytes and their quality as the fertilization- and embryo transfer rate during the IVF/GIFT procedure were not affected. No intact pregnancy occurred in cases of sperm antibodies in sera. In 16.6% of all seropositive IVF patients the detection of sperm antibodies in the follicular fluids correspond to sera. We recommend to remove autologous serum for the oocyte culture in cases of sperm antibodies in serum of IVF patients.
Selective continuation in quadruplets pregnancy following treatment of GIFT plus IVF and ET.
In this report, we present the selective reduction of quadruplets to triplets by transabdominal ultrasound guided cardiac puncture and injection of 1% xylocaine and air. This treatment resulted in the successful continuation of pregnancy until premature labor developed at the 33th week. Alive births of a normal male and a normal female infant, and a dead female infant were delivered.
Assisted reproductive technology. A clinical appraisal.
With the various types of reproductive technology now available, the overall pregnancy rates still are less than 25%. An increase in those rates would permit physicians to provide relief from infertility to a much larger population.
[Psychosocial responses of infertile couples attending an assisted reproduction program].
The purpose of this study was to evaluate gender differences in the psychosocial responses of 85 couples who attended the assisted reproduction program at Chung Shan Medical & Dental College Hospital from September 1991 to February 1992. The infertile couples were investigated by a self-administered structured questionnaire about demographic data, infertility history, and psychosocial responses and 75 couples completed the questionnaire. The average age of husbands was 35.0 years/and wives, 31.6 years. The average duration of infertility and treatment was 52.7 and 34.6 months, respectively. Parental expectation was the leading source of stress for men, while women counted being unable to meet childbearing demands as the main source of stress. Infertile women showed a higher psychosocial distress than their partners on the global measures and all the subscales of the infertility questionnaire and psychiatric symptoms test. Except for hostility, the differences between couples in subscales of self-esteem/body image, guilty, and all psychiatric symptoms reached statistical significance (p < 0.05). Among varied psychosocial responses of infertile couples, concordant response was demonstrated only in response to sexuality and physical condition. We consistently conclude with previous reports that infertile women showed a higher level of distress than their spouses, and that men and women displayed different psychosocial responses to infertility.
Second time around: a study of patients seeking second assisted reproduction pregnancies.
OBJECTIVE: To investigate the outcomes of subsequent cycles of IVF-ET, GIFT, and frozen ET in patients who have already achieved at least one assisted reproductive technology (ART) pregnancy. DESIGN: Retrospective cohort. SETTING: Private infertility clinic, Brisbane, Queensland, Australia. PATIENTS: From 1985 to 1992, 4,680 patients underwent 13,106 ART oocyte retrieval cycles. One thousand nine hundred twenty-two patients achieved a pregnancy, and 784 returned for a second pregnancy. These 784 return patients were divided into two subgroups: group A (288 patients) took home at least one baby from their first pregnancy; group B (496 patients) had an unsuccessful first pregnancy. MAIN OUTCOME MEASURES: Pregnancy rate (PR), cumulative PR, pregnancy outcome. RESULTS: Patients returning for second and third ART pregnancies had an increased chance of success. Pregnancy rates increased from 31.0% per transfer for patients attempting their first GIFT pregnancy, to 34.7% and 42.7% per transfer for patients attempting their second and third GIFT pregnancy. Cumulative PRs increased with subsequent pregnancy attempts. Groups A and B did not differ in PR, age, or indication of infertility but had significantly different live birth rates. The pregnancy outcomes of frozen ETs depended on the outcomes of the original cycle from which the embryos were derived. CONCLUSIONS: This study has important implications for the counseling of patients returning for subsequent ART pregnancies.
[Progress in vitro fertilization research on mainland China].
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