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[Elective single embryo transfer in assisted reproduction].

BACKGROUND: In Norway, assisted reproduction has been regulated by law since 1987, but the in vitro fertilization (IVF)-clinics are free to decide the number of embryos transferred. During the 1990ies, the number of embryos replaced was reduced from three to two. Triplets almost disappeared, but the twinning rate remained unchanged. According to the latest national data, 27.5 % of the deliveries following IVF and intracytoplasmic sperm injection (ICSI) in 2002 were multiple births. In our hospital, 23.9 % of the deliveries following IVF/ICSI in 2003 were multiple births. To reduce the multiple pregnancy rate, eSET was introduced as a routine in patients with a high probability to become pregnant in November 2004. MATERIAL AND METHODS: The results of eSET from the beginning of November 2004 until July 2005 are presented. All three inclusion criteria for eSET had to be fulfilled: 1) age <or= 35 years, 2) first or second treatment, 3) at least one top quality embryo. RESULTS AND INTERPRETATION: 163 out of 644 treatment cycles fulfilled all three criteria for eSET. For 54 (33 %) of the treated women, the treatment has resulted in live births or ongoing pregnancies, compared to 23 % of the treatments with two transferred embryos. The overall pregnancy rate was only slightly decreased (32.4 %) compared to before implementation of eSET (34 %). In the eSET group, 60 % of the patients had embryos available for cryopreservation. The cumulative pregnancy rate per started treatment cycle is expected to increase when pregnancies following transfer of frozen-thawed embryos are included. The overall twinning rate was reduced to 18.1 %. It should be possible to reduce the twinning rate further by for example raising the age-limit for eSET. An optimal trade-off between cumulative ongoing pregnancy rate and twinning rate could more easily be obtained if the Norwegian IVF-clinics and authorities establish an eSET policy.

Embryo Transfer↗

Children conceived by in vitro fertilisation after fresh embryo transfer.

AIMS: To compare the outcome in in vitro fertilisation (IVF) children (after fresh embryo transfer) from multiple and singleton births with one another, and with normally conceived control children. METHODS: A cohort of 278 children (150 singletons, 100 twins, 24 triplets and four quadruplets), conceived by IVF after three fresh embryos had been transferred, born between October 1984 and December 1991, and 278 normally conceived control children (all singletons), were followed up for four years after birth. They were assessed for neonatal conditions, minor congenital anomalies, major congenital malformations, cerebral palsy and other disabilities. Control children, all born at term, were matched for age, sex and social class. RESULTS: The ratio of male:female births was 1.03. Forty six per cent of IVF children were from multiple births; 34.9% were from preterm deliveries; and 43.2% weighed less than 2500 g at birth. The IVF singletons were on average born one week earlier than the controls, weighed 400 g less, and had a threefold greater chance of being born by caesarean section. The higher percentage of preterm deliveries was largely due to multiple births and they contributed to neonatal conditions in 45.0% of all IVF children. The types of congenital abnormalities varied: 3.6% of IVF children and 2.5% of controls had minor congenital anomalies, and 2.5% of IVF children and none of the controls had major congenital malformations. The numbers of each specific type of congenital abnormality were small and were not significantly related to multiple births. IVF children (2.1%) and 0.4% of the controls had mild/moderate disabilities. They were all from multiple births, including two children with cerebral palsy who were triplets. CONCLUSIONS: The outcome of IVF treatment leading to multiple births is less satisfactory than that in singletons because of neonatal conditions associated with preterm delivery and disabilities in later childhood. A reduction of multiple pregnancies by limiting the transfer of embryos to two instead of three remains a high priority.

Cerebral Palsy↗

Developmental competence of somatic cell nuclear transfer embryos reconstructed from oocytes matured in vitro with follicle shells in miniature pig.

The developmental competence of domestic pig oocytes that were transferred to somatic cell nuclei of miniature pig was examined. A co-culture system of oocytes with follicle shells was used for the maturation of domestic pig oocytes in vitro. Co-cultured oocytes progressed to the metaphase II stage of meiosis more quickly and more synchronously than non co-cultured oocytes. Oocytes were enucleated and fused with fibroblast cells of Potbelly miniature pig at 48 h of maturation. The blastocyst formation rate of nuclear transfer (NT) embryos using cocultured oocytes (24%) was significantly higher (p < 0.05) than that of non-co-cultured oocytes (13%). Cleaved embryos at 48 h after nuclear transfer using co-cultured oocytes were transferred to the oviducts of 14 Göttingen miniature pigs and four Meishan pigs. Estrus of all Göttingens returned at around 20-31 days of pregnancy. Two of the four Meishans became pregnant. Three and two cloned piglets were born after modest number of embryo transfer (15 and 29 embryos transferred), respectively. These results indicated that oocytes co-cultured with follicle shells have a high developmental competence after nuclear transfer and result in full-term development after embryo transfer.

Animals↗

Perinatal outcome after embryo transfer in ovum recipients. A comparison with standard in vitro fertilization.

OBJECTIVE: To compare perinatal outcome after embryo transfer vs. standard in vitro fertilization (IVF) in ovum recipients. STUDY DESIGN: We reviewed 22 consecutive ovum donor pregnancies delivered at Mount Sinai Hospital between July 1989 and November 1992 and matched them for age, parity and order of gestation to a control group who underwent standard IVF-embryo transfer (ET) during that period. RESULTS: The two groups showed similar rates of maternal complications, including hypertensive disorders, gestational diabetes and puerperal complications. When compared to patients undergoing autologous IVF-ET, ovum recipients had a lower rate of preterm labor (22.7% vs. 54.6%, P < .05), a higher mean gestational age at delivery (38.7 vs. 36.1 weeks, P < .01) and increased mean birth weight of neonates (2,924 vs. 2,374 g, P < .005). Though infants born through traditional IVF-ET were more likely to be preterm, Apgar scores were similar at one and five minutes. Our data support the generally favorable outcome seen in pregnancies conceived through ovum donation despite the fact that many of these patients had prior poor prenatal outcomes, long intervals until conception, and coexisting medical conditions. CONCLUSION: Ovum donation in women of comparable ages has obstetric outcomes equal to or better than patients undergoing traditional IVF-ET. Obstetric and perinatal outcome do not seem to be impaired in patients receiving donated oocytes.

Adult↗

Cigarette smoking and outcomes of in-vitro fertilization and embryo transfer: a prospective cohort study.

A prospective cohort study of 222 consecutive couples undergoing 297 cycles of in-vitro fertilization and embryo transfer (IVF-ET) was conducted to evaluate the impact of cigarette smoking in males and females. Compared with non-smokers, females smoking at the time of treatment had more previous pregnancies (1.16 versus 0.63, P less than 0.001), consumed more coffee per day (3.29 versus 1.85 cups, P = 0.001) and were less likely to hold a professional or skilled job (41% versus 66%). There was no difference in the response to ovarian stimulation in terms of the duration and dose of human menopausal gonadotrophin, peak oestradiol level or number of oocytes retrieved. The fertilization rate was actually higher in heavy smokers than in non-smokers (79.3% versus 61.3%, P = 0.007). The rate of embryo cleavage was retarded in a dose-dependent fashion. In smokers of 1-14 cigarettes/day, the likelihood of transferring an embryo at greater than or equal to 4-cell stage was 0.87 [95% confidence limits (CL) 0.56-1.4] and in smokers of greater than or equal to 15 cigarettes/day, the likelihood was 0.52 (95% CL 0.31-0.88). However, evaluation of interrelated factors using logistic regression suggested that a low socioeconomic status had a greater detrimental effect on embryo cleavage rate than female smoking. No significant difference was noted in the clinical outcome following embryo transfer. A study of larger sample size is required to evaluate whether the effects of cigarette smoking are independent of socioeconomic status and other related factors and whether they result in reduced ongoing clinical pregnancy and live birth rates.

Coffee↗

Ultrasound guided embryo transfer significantly improves pregnancy rates in women undergoing oocyte donation.

OBJECTIVES: Recent reports suggest ultrasound (US) guided embryo transfer (ET) improves pregnancy rates. Using the ovum donation model to eliminate confounding variables, we assessed the impact of US guided ET on pregnancy rates, implantation rates, and multiple gestation rates. METHODS: All women who underwent IVF-ET cycles using donated oocytes from November 1997 to September 1998 (n = 137) were evaluated retrospectively. ET from November 1997 to April 1998 were performed without US, while all ET from May 1998 to September 1998 were performed using transvaginal or transabdominal US. ET was further categorized as easy or difficult. Difficult ET was defined as requiring at least two attempts and/or the presence of blood on the catheter and/or > 5 min. RESULTS: Pregnant patients (n = 73) were similar with respect to the number and morphology of the embryos transferred compared to non-pregnant patients (n = 65). US guidance significantly improved implantation and pregnancy rates in cycles with easy transfers [28.8 vs. 18.4% and 63.1 vs. 36.1%, respectively (P < 0.05)] without impacting multiple pregnancy rates. CONCLUSION: US guided ET is simple and reassuring and appears to significantly improve pregnancy outcomes in ovum donation cycles by optimizing the placement of embryos.

Adult↗

Simultaneous bilateral tubal pregnancies after in vitro fertilization and embryo transfer: report of a case.

Ectopic pregnancies continue to be a major complication of in vitro fertilization and embryo transfer (IVF-ET). A case of bilateral simultaneous tubal pregnancy after IVF-ET is described. The patient underwent ovum pick-up (OPU) through a laparotomy with concomitant pelvic surgery. Embryo transfer (ET) was performed two days after OPU; this resulted in bilateral tubal pregnancies, diagnosed and treated one month apart. There are several possible causal mechanisms for the increased rate of ectopic pregnancies following IVF-ET. It is important to recognize that care in the transfer technique, with respect to the catheter position and limiting the volume of transfer medium to 20 microL, and an awareness of previous occlusion of the tubal ostia, or of a salpingectomy before IVF-ET, can help to minimize this complication rate. Two important points are the possibility of a simultaneous bilateral tubal pregnancy after IVF-ET, and the necessity of carefully examining both adnexa at the time of surgery for an ectopic pregnancy. Early and accurate diagnosis of a simultaneous bilateral ectopic pregnancy can prevent the necessity of a second operation and reduce maternal morbidity and mortality.

Adult↗

Is there any difference in pregnancy and implantation rates when nurses perform embryo transfer in an IVF-ET program?

A retrospective analysis of fresh in vitro fertilization treatment cycles and frozen embryo transfer (FET) cycles from mid-1995 to December 31, 1998, was undertaken. Nurses performed embryo transfer (ET) for government-funded cycles, whereas doctors performed ET for self-funded cycles. During the study period, fresh ET was performed in 1,165 treatment cycles. There were no significant differences in demographic data, ovarian responses and the number of embryos replaced between ET cycles performed by nurses and doctors. Pregnancy rates for ETs performed by nurses and doctors were 16.7 and 15.8% per transfer, respectively, whereas the corresponding implantation rates were 8.3 and 6.9%, respectively. Similar pregnancy and implantation rates were encountered in FET cycles whether ET was performed by nurses or doctors.

Adult↗

Serum free beta-HCG and alpha-fetoprotein levels in IVF, ICSI and frozen embryo transfer pregnancies in maternal mid-trimester serum screening for Down's syndrome.

BACKGROUND: The aim of this study was to compare the maternal mid-trimester free beta-HCG and alpha-fetoprotein (AFP) levels in pregnancies conceived by assisted reproduction technology and spontaneous pregnancies in Down's syndrome screening. The influence of the number of embryos transferred and the amount of gonadotrophins used on the marker levels was also evaluated. METHODS: The study population consisted of 58 IVF, 32 ICSI and 26 frozen embryo transfer (FET) singleton pregnancies. The levels of beta-HCG and AFP were compared with the control group of 6548 singleton spontaneous pregnancies. RESULTS: The false positive rate (FPR) in the Down's syndrome screening was 19% overall in assisted reproductive technology pregnancies, being highest (30.8%) in the FET group. The free beta-HCG multiples of the median (MoM) values were statistically significantly elevated only in the FET group (1.33 MoM; P = 0.012). A positive correlation between the number of embryos transferred and the marker levels was observed in the IVF group. No correlation was found between the amount of gonadotrophin medication used and the marker levels. CONCLUSIONS: The present data confirm that the overall FPR in the serum screening for Down's syndrome in assisted reproduction pregnancies is high, resulting in unnecessary invasive procedures.

Adult↗

Pregnancies following the interval double-transfer technique in an in vitro fertilization-embryo transfer program.

In 16 women undergoing IVF-ET, with more than four embryos available, two transfers were performed (24 hr apart), instead of one. The pregnancy rate was 25%, as compared with a pregnancy rate of 6.2% in 16 women having fewer than four embryos available and in whom one conventional transfer was performed. Since in our IVF-ET program, we do not freeze the extra embryos available, the purpose of the double transfer was to use all the embryos available and to improve the chances of finding the "implantation window" open. It is our feeling that multiple transfers may be beneficial to improve the pregnancy rate in an IVF-ET program without freezing facilities. However, a larger controlled clinical trial is necessary, in order to establish the advantages of multiple transfers in terms of pregnancy rate in comparison with the potential disadvantages.

Embryo Transfer↗

Blastocyst stage transfer: the real benefits compared with early embryo transfer.

With the development of commercially available sequential media it is now possible to grow human embryos to the blastocyst stage without feeder cells. The transfer of blastocysts offers several advantages, the most important being synchronization of the embryos with the uterine endometrium and selection of the best quality embryos with a high implantation potential. This study was conducted to compare the efficiency of day 2 and day 5 transfer in a prospective randomized trial involving patients for whom embryo selection was possible (i.e. those with more than three embryos on day 2 following insemination). We obtained equivalent clinical pregnancy rates per cycle for day 2 (41.7%) and day 5 (38.8%) transfer, but fewer embryos were transferred on day 5 (2.24 versus 3.03). The implantation rates were 18.9% on day 2 and 24.1% on day 5. Selected patients with a good response to gonadotrophins (at least eight good quality metaphase II oocytes) may therefore benefit from blastocyst transfer by a reduction in the multiple pregnancy rate, provided no more than two (or even one) blastocyst is transferred.

Adult↗

Pathologic features of placentas from singleton pregnancies obtained by in vitro fertilization and embryo transfer.

Fifty placentas were collected at term from singleton pregnancies resulting from in vitro fertilization (IVF) and intrauterine embryo transfer. Their pathologic features were compared with those of a control group composed of 50 placentas obtained from spontaneous singleton pregnancies. The mean maternal age, mean gestational age, mean fetal weight, sex ratio, and rate of pregnancy complications did not differ. There was also no significant difference between the groups in the mean placental weight and in the incidence of placental pathologic lesions, including extended infarcts, massive perivillous fibrin depositions, chorioangiomas, and placental inflammatory lesions. The incidence of abnormal placental shapes was significantly (P less than .05) greater in the IVF group (22%) compared with the control group (6%). A significant (P less than .025) difference was observed between the groups in the distribution of umbilical cord insertions. The mean distance between the cord insertion and the closest placental margin was significantly (P less than .005) shorter in the group conceived by IVF (3.23 +/- 1.91 cm) than in the control group (4.54 +/- 2.42 cm). A relationship between these placental morphologic features and the superficial implantation and/or inadequate orientation of the blastocyst after IVF and intrauterine embryo transfer is proposed.

Adult↗

Successful pregnancy by transmyometrial and transtubal embryo transfer after IVF in a patient with congenital cervical atresia who underwent uterovaginal canalization during Caesarean section: case report.

Successful pregnancy in a patient with congenital cervical atresia is a great challenge for assisted reproductive techniques and reproductive medicine. We report a case of successful pregnancy by transmyometrial and transtubal embryo transfer simultaneously after in-vitro fertilization (IVF) in a 33 year-old patient with congenital cervical atresia diagnosed at the age of 18 years. The patient had experienced cyclic abdominal pain and amenorrhoea since she was 13 years old. She had had two unsuccessful attempts to create a new uterovaginal canal in another hospital. At the age of 32 years, she was referred to our unit and had a successful pregnancy after transmyometrial and transtubal embryo transfer. Caesarean section was performed at 36 weeks gestation due to progressive pre-eclampsia and gestational diabetes. A healthy male baby weighing 2812 g was safely delivered. Uterovaginal canalization with amniotic membrane for the covering of the neo-endocervical wall was performed during Caesarean section. Normal menstrual outflow and symptomatic relief have continued for 5 months after the operation. To the best of our knowledge, this is the first reported case of successful pregnancy by transmyometrial and transtubal embryo transfer as well as uterovaginal canalization performed during Caesarean section in a patient with congenital cervical atresia.

Amnion↗

Production of interferon by red deer (Cervus elaphus) conceptuses and the effects of roIFN-tau on the timing of luteolysis and the success of asynchronous embryo transfer.

The role of interferon in early pregnancy in red deer was investigated by (a) measuring production of interferon by the conceptus, (b) testing the anti-luteolytic effect of recombinant interferon-tau in non-pregnant hinds, and (c) treatment of hinds with interferon after asynchronous embryo transfer. Blastocysts were collected from 34 hinds by uterine flushing 14 (n = 2), 16 (n = 2), 18 (n = 8), 20 (n = 13) or 22 (n = 9) days after synchronization of oestrus with progesterone withdrawal. Interferon anti-viral activity was detectable in uterine flushings from day 16 to day 22, and increased with duration of gestation (P < 0.01) and developmental stage (P < 0.01). When interferon-tau was administered daily between day 14 and day 20 to non-pregnant hinds to mimic natural blastocyst production, luteolysis was delayed by a dose of 0.2 mg day(-1) (27.3 +/- 1.3 days after synchronization, n = 4 versus 21 +/- 0 days in control hinds, n = 3; P < 0.05). Interferon-tau was administered to hinds after asynchronous embryo transfer to determine whether it protects the conceptus against early pregnancy loss. Embryos (n = 24) collected on day 6 from naturally mated, superovulated donors (n = 15) were transferred into synchronized recipients on day 10 or day 11. Interferon-tau treatment (0.2 mg daily from day 14 to 20) increased calving rate from 0 to 64% in all recipients (0/11 versus 7/11, P < 0.005), and from 0 to 67% in day 10 recipients (0/8 versus 6/9, P < 0.01). The increased success rate of asynchronous embryo transfer after interferon-tau treatment in cervids may be of benefit where mismatched embryo-maternal signalling leads to failure in the establishment of pregnancy.

Animals↗

Hypothalamic-pituitary suppression with oral contraceptive pills does not improve outcome in poor responder patients undergoing in vitro fertilization-embryo transfer cycles.

PURPOSE: To evaluate and compare the use of OCP with GnRHa for hypothalamic-pituitary suppression in poor responder IVF patients. METHODS: Retrospective analysis of IVF-ET cycles of poor responders. Hypothalamic-pituitary suppression with OCP (Group I, n = 29) or GnRHa (Group II, n = 52), followed by stimulation with gonadotropin, oocyte retrieval, and embryo transfer. Baseline characteristics and cycle outcomes were compared. RESULTS: 73 women underwent 81 cycles from 1/1/1999 to 1/1/2000. Baseline characteristics were similar. 31/81 (38%) cycles were cancelled (Group I, 14/29 (48%) vs. Group II, 17/52 (33%), NS). Cycle outcomes including amount of gonadotropin, number of eggs retrieved, number of embryos transferred, and embryo quality were similar. Patients in Group I required fewer days of stimulation to reach oocyte retrieval. Pregnancy outcomes were similar in the two groups. CONCLUSION: Our retrospective analysis revealed no improvement in IVF cycle outcomes in poor responders who received OCPs to achieve hypothalamic-pituitary suppression instead of GnRHa.

Adult↗

The effect of clomid induced superovulation on human follicular and luteal function for extracorporeal fertilization and embryo transfer.

The administration of clomiphene citrate (Clomid) 150 mg/day from days 5-9 of the menstrual cycle to spontaneously ovulatory women in order to induce adequate multiple follicular development followed by timed laparoscopic aspiration of mature oocytes does not appear to impair luteal phase length or the steroid pattern of oestradiol-17 beta (E2) or progesterone (P) production as reflected by their peripheral blood concentrations. In Clomid stimulated cycles where preovular oocyte pickup (OPU) and embryo transfer (ET) occurred but no recognizable pregnancy resulted, the cycle length was 30.0 (s.e.m. = 0.3) days, the follicular phase length was 15.6 (s.e.m. = 0.3) days and the luteal phase length was 14.4 (s.e.m. = 0.3) days, which did not differ from a group of women having spontaneous ovular cycles. Following Clomid stimulation the dominant follicle was similar in size to the pre-ovulatory follicle in spontaneous uniovular cycles, but the second, third, fourth and fifth order follicles were significantly larger (P less than 0.0001). The ultimate test of luteal competence was the successful implantation of 11 concepti in 7 women (4 sets of twins) from 49 laparoscopies (14%) or 33 embryo transfers (21%). Comparisons between conceptual and non-conceptual embryo transfers following identical Clomid regimes showed no difference between plasma E2 concentrations at the time of hCG administration or the start of an endogenous LH rise; follicle volume, follicular fluid E2, P and testosterone concentrations were also not different. However, there was a trend for follicular P to be higher in the non-conceptual group indicating that advanced luteinization may hinder successful implantation. The follicular fluid androstenedione (A4) concentration was significantly lower in the conceptual group and the total androgen concentration (A4 + T) was also lower which was indicative of active aromatase activity in these follicles. It was concluded from this study that there was no indication to give exogenous hormonal support to the luteal phase, provided there was both optimal follicular growth and steroidogenic function following Clomid stimulation and that exogenous hCG was administered very close to the expected rise of LH. This observation was supported by the finding that timing of OPU based on a knowledge of the start of the LH surge was associated with a higher pregnancy rate than when hCG was administered and indicates that the endogenous mid-cycle events may permit superior maturation of the oocyte and/or permit better synchronization of endometrial maturation for implantation.

Adult↗

The outcome of in vitro fertilization and embryo transfer therapy in women with endometriosis failing to conceive after laparoscopic conservative surgery.

STUDY OBJECTIVE: To compare the outcome of in vitro fertilization and embryo transfer (IVF-ET) after laparoscopic surgery in women with endometriosis with that of patients with tubal factor infertility. DESIGN: Retrospective survey of hospital and office charts using a computerized worksheet. SETTING: Lin-Kou medical center of Chang Gung Memorial Hospital. PATIENTS: Sixty-seven women with minimal to mild or moderate to severe endometriosis. Women with tubal factor infertility without other associated disorders (60 cycles) made up the control group. INTERVENTIONS: Seventy-five consecutive cycles of IVF-ET were performed in these patients who failed to conceive after laparoscopic conservative surgery. MEASUREMENTS AND MAIN RESULTS: The concentration of serum estradiol on the day of human chorionic gonadotropin (hCG) injection, the day of hCG injection, clinical pregnancy rates per transfer, number of follicles larger than 14 mm, number of embryos transferred, and implantation rate were not significantly different between women with endometriosis and those with tubal factor infertility. The number of oocytes retrieved and number fertilized were decreased, and the basal level of follicle-stimulating hormone on cycle day 3 was higher in women with both degrees of endometriosis. Women in both endometriosis groups received more follicle-stimulating hormone and human menopausal gonadotropin than those with tubal factor infertility. CONCLUSIONS: The outcome of IVF-ET in patients with endometriosis after laparoscopic surgery did not differ from that in the group with tubal factor infertility, but the former required more ampules of gonadotropin to achieve the same response. The advantages of laparoscopic surgery in women with endometriosis should be probably correlated with success of IVF-ET.

Adult↗

The effect of smoking on the outcome of in-vitro fertilization--embryo transfer.

This study investigated the influence of cigarette smoking on the outcome of in-vitro fertilization-embryo transfer. Forty-one women under the age of 37 years, suffering from mechanical infertility, were suppressed with gonadotrophin releasing analogue from day 21 of the cycle. Twenty women were smokers and 21 women were non-smokers. Gonadotrophin releasing analogue was injected daily before ovarian stimulation with gonadotrophin was begun. The follicular phase was longer and the number of human menopausal gonadotrophin ampoules required to reach adequate stimulation were higher in smokers. The peak serum oestradiol level was not significantly different in smokers compared to non-smokers. However, follicular fluid levels of oestradiol were significantly lower in smokers than in non-smokers (657 +/- 367 versus 1077 +/- 786 ng/ml) respectively. Furthermore, the fertilization rate was also lower in smokers than in non-smokers (40.9 versus 61.7%) respectively. Four pregnancies were achieved in the non-smokers group, while only one ectopic pregnancy was diagnosed in the smokers group. These findings suggest that cigarette smoking has a detrimental effect on the outcome of in-vitro fertilization and embryo transfer.

Adult↗