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PubMed2003

Spontaneous abortion among pregnancies conceived using assisted reproductive technology in the United States.

OBJECTIVE: To examine rates and risk factors for spontaneous abortion among pregnancies conceived using assisted reproductive technology (ART). METHODS: Subjects were 62,228 clinical pregnancies resulting from ART procedures initiated in 1996-1998 in US clinics. Spontaneous abortion was based on ART clinic report and was defined as loss of the entire pregnancy. Spontaneous abortion rates for ART pregnancies were compared with spontaneous abortion rates from the National Survey of Family Growth, a population-based survey of US women 15-44 years. RESULTS: The spontaneous abortion rate among ART pregnancies was 14.7%. This was similar to rates among pregnancies reported in the National Survey of Family Growth. Among pregnancies conceived with the patient's oocytes and freshly fertilized embryos, the spontaneous abortion risk ranged from 10.1% among women 20-29 years to 39.3% among women older than 43. Spontaneous abortion risk among pregnancies conceived with donor eggs was 13.1% with little variation by patient age. Spontaneous abortion risk was increased for pregnancies conceived with frozen and thawed embryos and decreased among multiple-gestation pregnancies. Spontaneous abortion risk was increased among women reporting previous spontaneous abortions and ART attempts, and among women who used clomiphene or zygote intrafallopian transfer. Pregnancies conceived by young women, but gestated by a surrogate, were at increased risk for spontaneous abortion in comparison with young women who gestated their own pregnancies. CONCLUSION: These findings suggest that ART does not pose a risk for spontaneous abortion. Factors related to oocyte or embryo quality are of primary importance in assessing spontaneous abortion risk.

Abortion, Spontaneous↗
PubMed1992

Recent advances in female infertility care.

The causes of infertility in the female may be ovulatory dysfunction; tubal, uterine, and cervical factors; endocrinopathies; and unexplained infertility. Recent advances in female infertility care include the use of medications to induce ovulation combined with intrauterine insemination, laparoscopic treatment of ectopic pregnancy and uterine leiomyomata, transcervical balloon tuboplasty, and leuprolide acetate depot treatment for uterine leiomyomata and endometriosis. For in vitro fertilization (IVF) and related procedures, developments include the use of gonadotropin-releasing hormone agonist (GnRH-a) in IVF, serum follicle stimulating hormone (FSH) levels to predict outcomes, oocyte donation, and zygote intrafallopian transfer (ZIFT). Nurses, as coordinators and counselors, play an important role in infertility treatment.

Catheterization↗
PubMed1993

Iatrogenic multiple pregnancies in East Flanders, Belgium.

OBJECTIVE: To evaluate the specific contribution of artificial induction of ovulation to the increasing number of multiple gestations in East Flanders and the effects of this treatment on the frequencies of monozygotic and dizygotic twinning. DESIGN: Since 1976 the East Flanders Prospective Twin Study has collected data on artificial induction of ovulation for all the multiple births listed in its registry. SETTING: East Flanders Prospective Twin Survey. PATIENTS: Between 1976 and 1992, 458 twin and 78 triplet pregnancies resulting from artificial induction of ovulation were analyzed. MAIN OUTCOME MEASURES: Zygosity and frequency of iatrogenic multiple births. RESULTS: Since 1985 there is an explosive increase in twin and triplet births in East Flanders. This increase has been caused mainly by the sole use of fertility-enhancing drugs and in the last few years by resorting to other technologies of assisted reproduction, such as IVF-ET, GIFT, or zygote intrafallopian transfer. CONCLUSION: In view of the elevated risk inherent to multiple pregnancies in terms of perinatal mortality and morbidity, the over enthusiastic or improper use of fertility drugs should be curtailed.

Belgium↗
PubMed1994

A randomized study of transcervical intrafallopian transfer of pronucleate embryos controlled by ultrasound versus intrauterine transfer of four- to eight-cell embryos.

OBJECTIVE: To establish the value of transcervical intrafallopian transfer of zygotes and the accuracy of fallopian cannulation. DESIGN: A prospective randomized study, comparing ultrasonically controlled transcervical intrafallopian transfer of zygotes with intrauterine transfer of cleaved embryos. SETTING: Department of IVF of the Rotterdam Academic Hospital. PATIENTS: One hundred forty-five patients with patent tubes entered the IVF program. MAIN OUTCOME MEASURE: Pregnancy rates in both groups and ultrasound (US) assessment during fallopian cannulation and ET. RESULTS: Transvaginal cannulation of the tube appears not to be sufficiently accurate when performed without US guidance. Catheter damage occurred in many cases. The previously reported superior implantation rate after intrafallopian transfer in comparison with intrauterine transfer could not be confirmed. CONCLUSIONS: Intrauterine transfer of cleaved embryos remains the method of choice in IVF.

Adult↗
PubMed1997

Cost of assisted reproductive technologies for a health maintenance organization.

OBJECTIVE: To calculate the cost of assisted reproductive technologies (ART) for a health maintenance organization (HMO), assess factors that contribute to the cost per delivery and to analyze how utilization rates can be controlled by the use of clinical criteria. STUDY DESIGN: Pregnancy outcome and a cost analysis of all ART cycles at an HMO in a state with mandated coverage for these procedures was performed. All patients (n = 148) undergoing ART cycles insured by the HMO performed at one in vitro fertilization (IVF) center during 1990-1995 were studied. RESULTS: ART cycle outcomes and a cost analysis, including global cycle and cancellation charges, medication costs, obstetric costs and neonatal care costs, were assessed. ART cycles (n = 375) included IVF (n = 278), gamete intrafallopian transfer (n = 46), cryopreserved embryo transfer (ET) (n = 42), zygote intrafallopian transfer/tubal embryo transfer (n = 7) and donor oocyte (n = 2). Pregnancy outcome with IVF was 18.3% deliveries per retrieval, for gamete intrafallopian transfer 27.8% deliveries per retrieval and for frozen ET 19% per procedure. Overall, 62/148 (41.9%) of the patients delivered. There were 35 singletons, 22 twin sets and 5 triplet sets. This resulted in an average cycle cost per delivery of $36,417. The mean obstetric and neonatal charges were $9,329 for a singleton delivery, $20,318 for twins and $153,335 for triplets. If these charges are expressed in terms of the number of infants born, a twin pregnancy would cost $10,159 per infant and a triplet pregnancy, $51,112. The ART cycle cost per HMO plan member was $2.49 per annum. Our IVF utilization was 295 cycles per million population. CONCLUSION: An HMO can control the cost of ART services by establishing preauthorization clinical criteria. Our utilization rates might be used as a benchmark for other insurers considering ART coverage. The cost of ART ($2.49 per annum) would be only a small fraction of the typical annual insurance premium.

Abortion, Spontaneous↗
PubMed1992

Local anesthesia with conscious sedation for laparoscopic intrafallopian transfer.

Local anesthesia with conscious sedation is well accepted by patients and provides scheduling flexibility, cost containment, patient safety, and ease of recovery. We believe the technique should be offered to selected patients undergoing intrafallopian transfer. By adhering to specific guidelines for surgical technique and monitoring, the procedure is a safe and acceptable alternative to general anesthesia for laparoscopic intrafallopian transfers.

Adult↗
PubMed1997

Assisted reproductive technology: the state of the ART.

At least one in ten couples of reproductive age is affected by infertility. Tubal disease, ovulatory defects, endometrosis and abnormal sperm physiology are the most common causes of failure to conceive. Many of these disorders can be treated successfully with surgery, ovulation induction or intrauterine insemination, but in selected cases, or where there is long-standing intractable infertility, assisted reproductive technology (ART) becomes the treatment of choice. We provide an overview of the techniques for assisted reproduction, including in vitro fertilization, gamete intrafallopian transfer and other related procedures. Indications for treatment, patient evaluation and advances in reproductive technology including embryo cryopreservation, micromanipulation and donor gametes are also reviewed.

Cryopreservation↗
PubMed1992

Patient selection for assisted reproduction.

Patient selection is a critical factor in influencing results in assisted reproduction. Patients should be assessed individually in terms of all relevant fertility factors including age, duration and aetiology of infertility and psycho-social attitudes so that an approximate prognosis of their management can be made. Restrictive criteria for patient selection will enhance a programme's results but at the expense of depriving some couples of their only chance of conception. The best overall management of each individual infertile couple should always remain the main criteria for selection into a particular assisted reproduction programme.

Adult↗
PubMed1992

Indications and outcomes of assisted reproduction.

Since 1978 many healthy children have been born after in vitro fertilization and embryo transfer, fulfilling the wishes of many previously childless couples. In vitro fertilization and subsequently developed methods (GIFT, intratubal embryo transfer) have contributed to progress in the diagnosis and treatment of unwanted childlessness. Furthermore these techniques have improved knowledge of ovarian function, fertilization and early embryo development.

Embryo Transfer↗
PubMedDate not supplied

Assisted reproductive technologies in severe male infertility.

The increasing incidence of male subfertility as an indication for ART is first discussed. The tendency to use assisted reproduction techniques in such cases is attributed to the disappointing results of classical treatments. The Authors deal with two problems: the choice of the best treatment methods of the sperm and the choice of the best technique of ART for treating male infertility. The analysis of 138 couples treated for male subfertility showed that the centrifugation on discontinuous Percoll gradients (CDPG) and especially on the mini-Percoll (mini CDPG) offers the best results if compared with pellet swim up and other techniques. With reference to the technique of choice, an accurate analysis of tubal (TET and ZIFT) and uterine (IVF/ET) transfers shows that no advantage seems to be obtained with the more sophisticated and exacting tubal transfer. This final conclusion is presently evaluated on the basis of a retrospective study.

Embryo Transfer↗
PubMed2002

Nuclear transfer technologies: between successes and doubts.

Cloning of mammals by nuclear transfer can lead to the birth of healthy adult animals but more often compromises the development of the reconstructed embryos. A high incidence of fetal and postnatal losses has been observed in several species, revealing the existence of long-lasting effects induced by the nuclear transfer procedures. Remodeling of donor chromatin by the recipient cytoplasm after nuclear transfer is frequently associated with the deregulation of specific genes, and recent observations point to the potential importance of time-dependent DNA methylation events in the occurrence of these alterations. Screening strategies to design nuclear transfer procedures that would mimic the epigenetic remodeling occurring in normal embryos are being designed, and improvement in the efficiency of procedures could imply a pre-conditioning of donor cells. Early mammalian development appears to be rather tolerant to epigenetic abnormalities, raising the possibility that even a fully functional reprogrammed genome may have been subjected to some epigenetic alterations. Bringing nuclear transfer to routine practice requires greater knowledge and understanding of the basic biological processes underlying epigenetic controls of nuclear activities. An important issue at present is to limit the production of those aberrant phenotypes that may result in significant insult to the nature and welfare of animals.

Animals↗
PubMed1992

Oocyte and embryo donation: evaluation of 412 consecutive trials.

A total of 199 patients (412 consecutive cycles) were treated by oocyte-embryo donation in 336 replacement cycles. Of these, 296 involved intra-uterine embryo transfers, 38 zygote intra-Fallopian transfers (ZIFT) and two gamete intra-Fallopian transfers (GIFT). Of the 336 replacements, 244 (73%) constituted transfers of fresh concepti and 92 (27%) of frozen-thawed ones. A total of 85 pregnancies were achieved of which 16 ended in preclinical abortions, giving a clinical pregnancy rate of 34.7% per patient, 20.5% per transfer and a take-home baby rate of 29.1% per patient. The pregnancy rate was significantly higher (P less than 0.05) following fresh gamete or embryo replacement (23%; 56/244) than following that of frozen-thawed embryos (14.1%; 13/92). No significant difference was observed when intra-Fallopian replacement was applied (27.5%; 11/40) as opposed to intra-uterine (19.6%; 58/296). Ovarian function was not found to be of significant importance to the achievement of pregnancies after oocyte donation since comparable pregnancy rates per replacement and per started cycle were obtained in patients with ovarian failure and in those with functional ovaries (19% and 15.4%; 24.2% and 20.2% respectively). Comparison of the implantation and abortion rates between these two groups did not reveal any significant difference (11.1% and 11.1% versus 14.8% and 16.6%). The highest pregnancy rate among patients with ovarian failure was observed in those with primary ovarian failure (26.4%; 14/53), while the lowest was among women who had received chemotherapy and/or radiotherapy (9%; 1/11).(ABSTRACT TRUNCATED AT 250 WORDS)

Embryo Transfer↗
PubMed1996

The effects of smoking on ovarian function and fertility during assisted reproduction cycles.

OBJECTIVE: To investigate the effects of cigarette smoking on ovarian function and fertility in women undergoing assisted reproduction cycles. METHODS: We assessed the effects of smoking on ovarian function and fertility in a cohort of 499 women. Questionnaires were designed to quantify past smoking exposure and to determine whether the woman was smoking during the treatment cycle. Ovarian function characteristics and pregnancy rates were compared among current smokers, past smokers, and nonsmokers. RESULTS: Compared with nonsmokers, both current and past smokers have reduced gonadotropin-stimulated ovarian function. A history of increasing tobacco exposure was associated with decreasing serum estradiol concentrations, numbers of retrieved oocytes, and numbers of embryos. On average, for every 10 pack-years of cigarette smoking, 2.5 fewer mature oocytes and 2.0 fewer embryos were obtained. Women who smoked during their treatment cycle had approximately a 50% reduction in implantation rate and ongoing pregnancy rate compared with women who had never smoked. Women who quit smoking before their treatment cycle had the same pregnancy rate as nonsmokers. CONCLUSION: Cigarette smoking is associated with a prolonged and dose-dependent adverse effect on ovarian function. Smoking appears to have a more transient toxic effect on fertility, because current smokers, but not past smokers, had a markedly reduced pregnancy rate after treatment cycles compared with nonsmokers. Women should quit smoking before assisted reproduction cycles.

Adult↗
PubMed1996

A randomized clinical trial to evaluate the clinical effects of split- versus single-dose human menopausal gonadotropins in an assisted reproductive technology program.

OBJECTIVE: To compare the effect of twice (split) versus once (single) daily administration of hMG on assisted reproductive technology (ART) cycle parameters. DESIGN: A randomized clinical trial. SETTING: Hospital-based academic ART program. PATIENTS: A total of 171 patients undergoing their initial ART cycle were enrolled. All patients received one of two hMG regimens and were excluded from the study if they were receiving medications other than leuprolide acetate (LA) and hMG for ovulation induction. INTERVENTIONS: Subjects were randomized to receive an initial dose of 300 IU/d of hMG in either split-dose (i.e., 150 IU twice daily) or single-dose fashion for four successive days after down-regulation with LA. Thereafter, their daily dose was individualized, maintaining a split-or single-dose schedule. All cycles were managed in accordance with our standard ART protocols. MAIN OUTCOME MEASURES: Cancellation rate, total hMG requirements, number of days treated with hMG, E2 and P responses, oocyte yield and maturity, fertilization rate, total number of embryos, embryo quality, number of embryos transferred, implantation rate, clinical and ongoing-delivered pregnancy rates. RESULTS: Split-dose hMG administration resulted in a significantly higher implantation rate, but significantly lower normal and polyspermic fertilization rates than single-dose hMG administration. No significant differences were noted between the two dosage protocols with respect to the other outcome measures. CONCLUSIONS: Split-dose hMG administration may be associated with significantly higher implantation rates; single-dose hMG with significantly higher fertilization rates. Although our data also demonstrate a trend toward higher clinical and ongoing-delivered pregnancy rates with split-dose therapy, demonstration of a significant difference would require a multicenter trial. Based on our data, clinicians may want to consider split-dose therapy for patients with repeated implantation failures.

Adult↗