Christine A. Kirby

Culture factors in relation to the success of human in vitro fertilization and embryo transfer

The development of 1-cell mouse zygotes to the blastocyst stage in vitro has been used as a quality control for the media employed for human in vitro fertilization and embryo transfer (IVF-ET). The following procedures were associated with high rates of mouse embryo development and human pregnancies following IVF-ET: adequate gassing and equilibration of the medium, double rinsing of pipettes and catheters used to handle embryos, use of a HEPES-buffered medium for manipulating embryos in the absence of an atmosphere containing 5% CO2, control of excessive temperature in the vicinity of the embryos, and ET using medium containing 50% patients serum. The institution of these procedures gave more consistent pregnancy rates. However, there was no obvious association between fertilization and cleavage of human oocytes and the quality of the medium ascertained by the mouse embryo development test.

INCIDENCE OF MULTIPLE PREGNANCY AFTER IN-VITRO FERTILISATION AND EMBRYO TRANSFER

7 multiple pregnancies occurred in a series of 20 pregnancies after oocyte recovery for in-vitro fertilisation and embryo transfer. After ovarian stimulation with clomiphene alone or with human menopausal gonadotropin, 102 laparoscopies were carried out in 62 women and the ongoing pregnancy rate beyond the first trimester was 17/102 laparoscopies (17%), including 5 sets of twins. 1 triplet and 1 twin pregnancy showed evidence of regression of two sacs and one sac, and both are progressing as singleton pregnancies at 16 and 34 weeks, respectively. 3 abortions occurred at 7, 8, and 9 weeks--a spontaneous abortion rate of 15%. The pregnancy and multiple pregnancy rates after stimulation with clomiphene alone or with human menopausal gonadotropin were comparable, but oocyte pickup based on a knowledge of the duration of the endogenous rise in luteinising hormone, rather than 36 h after administration of human chorionic gonadotropin, increased the pregnancy rate. As the quality and number of embryos transferred to the uterus increased, the risk of multiple pregnancy also rose. Consideration should therefore be given to restricting the number of embryos transferred to limit multiple pregnancies to twins.

In vitro fertilization and embryo transfer program, Department of Obstetrics and Gynecology, University of Adelaide at the Queen Elizabeth Hospital, Woodville, South Australia

A review is presented summarizing the in vitro fertilization experience at the University of Adelaide, Australia. Initial attempts utilizing the normal cycle were unsuccessful in obtaining a pregnancy. Since 1982 the overall ongoing pregnancy rate has been 21% per embryo transfer, 16% per laparoscopy, and 12% per treatment cycle. A detailed description of presently utilized methodology is presented.

Endocrinology of Ovarian Stimulation for In Vitro Fertilization

Summary: Understanding of the endocrinology of in vitro fertilization has advanced rapidly in the past 5 years. Despite a multitude of ovarian stimulation regimens a particular regimen has not demonstrated a marked superiority. In principle the achievement of high FSH levels during the early follicular phase to recruit a maximum number of follicles with a tolerable degree of asynchrony for final maturation is confined to a limited time span or ‘FSH window’ of about 3 to 4 days before negative E2 feedback induces below‐threshold FSH levels, thereby condemning all subsequent follicles in that cycle to atresia. It appears that one can widen and/or amplify the ‘FSH window’ too far from gross hyperstimulation resulting in the recruitment of many follicles with an intolerable degree of asynchrony. This may lead to a defective endocrine environment for the oocytes contained within these follicles or an abnormal luteal environment and an increased frequency of fertilization, cleavage and implantation failure.

A Prospective Trial of Intrauterine Insemination of Motile Spermatozoa Versus Timed Intercourse

STUDY OBJECTIVE The efficacy of intrauterine insemination (IUI) of selected motile sperm. DESIGN Prospective randomized sequential alternating cycle trial comparing IUI with luteinizing hormone (LH)-timed intercourse. SETTING Clinical infertility service. PATIENTS Couples selected included unexplained infertility (n = 73), cervical mucus hostility (n = 24), moderate semen defect (n = 110), and severe semen defect (n = 78). Two hundred eighty-five couples undertook 600 IUI cycles and 505 LH-timed intercourse. RESULTS Overall, IUI was slightly more effective than LH-timed intercourse with a pregnancy rate of 6.2% versus 3.4% per cycle. When individual categories were considered only, IUI for severe semen defect was significantly better (5.6% versus 1.3%, P less than 0.05). The first IUI cycle was more effective when compared with both subsequent IUI cycles and the initial LH-timed cycle. Overall, 74% (27/37) of IUI pregnancies occurred in the first cycle. CONCLUSIONS Compared with LH-timed intercourse, IUI provided little or no improved expectation of pregnancy but was beneficial in couples with severe semen defect. The occurrence of pregnancy was limited per cycle and confined essentially to the initial cycle of treatment. Continued IUI is considered to be unrewarding.

The Effect of Transferring Pronuclear Embryos on Pregnancy Outcome after in Vitro Fertilization

In a prospective clinical trial the pregnancy rate in patients matched for infertility status, degree of hyperstimulation, and number of oocytes recovered was unaffected by whether embryos were transferred while still pronuclear (day 1) or after they had undergone cleavage (day 2). The pregnancy rates per transfer were 27% and 22%, respectively, for the two transfer times. Unlike results of a previous study, no difference was detected in the outcome of pregnancies from the two groups.

Incidence of the luteinized unruptured follicle phenomenon in cycling women**Supported in part by National Health and Medical Research Council (NH&MRC) grant 810549.

A prospective study is presented in order to determine the frequency of the luteinized unruptured follicle (LUF) in a population of 66 regularly cycling women. They were monitored by daily ultrasound for a total of 183 cycles, and the LUF was detected in 9 cycles, giving an incidence of 4.9%. The results of daily changes of luteinizing hormone, estradiol, and progesterone provide support for the thesis that the LUF behaves steroidogenically as a corpus luteum and that the luteal phase duration is normal. Continued monitoring in 35 cycles revealed a recurrence in only one case during a fourth subsequent cycle. Thus, the findings indicate that the LUF is a sporadic and infrequent phenomenon. It is therefore an uncommon cause of infertile cycles in potentially fertile women and represents a biologic variable rather than a syndrome. Based on ultrasonic and endocrine observations, a mechanism is proposed for the resolution of the LUF.