David Molloy

Multiple-sited (heterotopic) pregnancy after in vitro fertilization and gamete intrafallopian transfer *

Pregnancies occurring simultaneously in different body sites (heterotopic pregnancies) are a rare condition thought to occur in 1 of 30,000 spontaneous pregnancies. Individual cases may occur after in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). In the past 4½ years, our unit has performed 6,204 IVF/GIFT or pronuclear stage transfer cycles of treatment. Ten such pregnancies proven by surgical, ultrasound, and histological diagnosis have occurred. In the same period 640 IVF, 355 GIFT, and 6 pronuclear stage transfer clinical pregnancies were achieved. This suggests that the incidence of heterotopic pregnancy after assisted reproduction is closer to 1 of 100 pregnancies. Clinicians managing early complications of IVF, GIFT, and/or pronuclear stage transfer pregnancies should be aware of this relatively high incidence of concomitant intrauterine and extrauterine pregnancy.

A laparoscopic approach to a program of gamete intrafallopian transfer

Gamete intrafallopian transfer (GIFT) provides an effective method of achieving pregnancy in infertile women with normal fallopian tubes. Laparoscopic approach to ovum pickup and tubal catheterization provides a simple and rapid means of performing the operation. Equipment used to facilitate this process is described, and techniques of tubal catheterization are discussed. A clinical pregnancy rate of 27% is reported in a series of 71 treatment cycles. The application of GIFT in conjunction with in vitro fertilization is discussed, especially the use of excess gametes to provide embryos for freezing. The use of GIFT as a research and investigative tool may provide further insight into the causes for idiopathic infertility.

Performance of patients with a “frozen pelvis” in an in vitro fertilization program

It is now possible to identify and study the performance of different subgroups of patients in in vitro fertilization (IVF) programs. Patients with severe pelvic adhesions due to pelvic inflammatory disease (PID) or endometriosis were classed as having a frozen pelvis if less than or equal to 20% of total ovarian surface was visible and if the rest of the ovary was bound down with significant adhesions. IVF offers the only hope of pregnancy for these patients. Fifty-one treatment cycles in 23 such patients were matched against 51 cycles in 48 patients with adhesion-free ovaries. The study group had a significantly higher number of cancelled oocyte retrievals because of poor estradiol (E2) response. They also had a significantly lower rate of E2 rise and a lower peak value of E2 before and after the administration of human chorionic gonadotropin. These patients took longer to respond to a hyperstimulation regime, and when a response occurred they formed fewer follicles, as measured with the use of ultrasound. Lower numbers of oocytes were obtained from this group, but the fertilization rate of oocytes was the same for both groups. One pregnancy occurred in the study group and 11 in the control group. It is possible that disruption of ovarian blood supply or mechanical factors due to the pressure of significant adhesions prevent a good follicular response in patients with a frozen pelvis.

The predictive value of idiopathic failure to fertilize on the first in vitro fertilization attempt

OBJECTIVE To investigate the subsequent performance of patients with idiopathic fertilization failure on the first in vitro fertilization (IVF) cycle. DESIGN A retrospective study of 2,322 consecutive patients undergoing their initial IVF cycle. SETTING Advanced infertility treatment in an IVF/general infertility clinic. PATIENTS In 5 years, 94 couples with unexplained failed oocyte fertilization had 270 cycles of treatment. Each couples performance was tracked through subsequent cycles of treatment. INTERVENTIONS In vitro fertilization with husband and donor sperm. MAIN OUTCOME MEASURE(S) Investigated retrospectively after 5 years of data collection. RESULTS Sixty-five couples of the original 94 had a second IVF attempt. Fifty of these successfully fertilized oocytes with husbands sperm and 4 with donor sperm. Nineteen of the 65 couples who continued treatment achieved a pregnancy, and only one couple had continuing fertilization failure. CONCLUSIONS The prognosis in the study group was surprisingly favorable despite the initial failed IVF treatment cycle.

Cross-over trial of superovulation protocols from two major in vitro fertilization centers

A study was undertaken as a controlled comparison of two different superovulation induction protocols currently in use in major Australian in vitro fertilization (IVF) clinics. Thirty patients each from the Monash University and the Royal Womens Hospital (RWH) IVF programs were stimulated for ovulation induction by the other program. Once timing for oocyte retrieval was scheduled, all care reverted to the program from which the patient first came. Results given as pregnancies per patient commencing stimulation were: RWH patients on Monash protocol, 27%; RWH control patients, 15%; Monash patients on RWH protocol, 7%; Monash control patients, 13%. In the year preceding the trial pregnancy rates were 16.9% at Monash and 10.6% at RWH. Stimulation protocols were also compared with respect to each of administration, cost, and patient stress. The results of this cross-over trial demonstrated major differences between the two ovulation induction protocols studied, although it was not possible to conclude that differences in pregnancy rate were due to stimulation alone.

Contribution of the assisted reproductive technologies to fertility in males suffering spinal cord injury.

Summary: This study reviews 19 couples referred between 1990 and 1997 for fertility treatment for anejaculatory infertility in the male partner following spinal injury. Using sperm obtained by assisted ejaculation procedures, 14 of the 19 patients (74%) achieved at least 1 pregnancy. Pregnancy rates per treatment cycle were 12.0% for timed intrauterine insemination, 38.9% for gamete intra‐Fallopian transfer and 19.2% for intracytoplasmic sperm injection followed by uterine embryo transfer. Choice of the appropriate assisted reproduction treatment to match the available semen quality results in a high level of success in such patients.

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.

The Establishment of a Successful Programme of Gamete Intra‐Fallopian Transfer (GIFT): Preliminary Results

Following the initial success of In Vitro Fertilization (IVF) in achieving pregnancy in patients with tubal disease, this technique has been applied successfully in patients with other causes of infertility, including those with completely normal tubes and unexplained infertility. Asch et al (1,2) have combined IVF-type ovarian hyperstimulation, sperm preparation and ovum retrieval with immediate transabdominal transfer of 2 ova and prepared sperm to each Fallopian tube of such patients. We have recently reported the first Australian pregnancy(3) using this procedure of Gamete Intra-Fallopian Transfer (GIFT). This paper reports the outcome in our first series of 57 patients so treated.

Incidence of transmissible diseases in a network of assisted reproduction clinics throughout Queensland

In assisted reproduction, knowledge of the presence of transmissible disease assists diagnosis and permits appropriate risk minimisation. The overall incidence was lowest in the Brisbane full‐cost clinic and highest in the Springwood low‐cost clinic. Male partners predominated over females, particularly in the low‐cost clinic. Hepatitis C was the most commonly detected infection with the highest incidence in the low‐cost clinic. HIV was the least commonly detected infection amongst those tested.

Multiple-sited (heterotopic) pregnancy after in vitro fertilization and gamete intrafallopian transfer

Pregnancies occurring simultaneously in different body sites (heterotopic pregnancies) are a rare condition thought to occur in 1 of 30,000 spontaneous pregnancies. Individual cases may occur after in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). In the past 4 1/2 years, our unit has performed 6,204 IVF/GIFT or pronuclear stage transfer cycles of treatment. Ten such pregnancies proven by surgical, ultrasound, and histological diagnosis have occurred. In the same period 640 IVF, 355 GIFT, and 6 pronuclear stage transfer clinical pregnancies were achieved. This suggests that the incidence of heterotopic pregnancy after assisted reproduction is closer to 1 of 100 pregnancies. Clinicians managing early complications of IVF, GIFT, and/or pronuclear stage transfer pregnancies should be aware of this relatively high incidence of concomitant intrauterine and extrauterine pregnancy.