Deborah Lurie

Increased endometrial thickness on the day of human chorionic gonadotropin injection does not adversely affect pregnancy or implantation rates following in vitro fertilization–embryo transfer

OBJECTIVES To investigate the controversy whether an increased endometrial thickness has an effect on pregnancy, implantation, or abortion rates in in vitro fertilization-embryo transfer (IVF-ET) cycles. DESIGN Retrospective analysis. SETTING A university-based IVF center. PATIENT(S) Five hundred seventy women under the age of 40. INTERVENTION(S) Measurements of endometrial thickness on day of human chorionic gonadotropin (hCG) administration. Cycles were compared by endometrial thickness of </=14 mm in 510 women to a thickness of >14 mm in 60 women. MAIN OUTCOME MEASURE(S) Implantation, pregnancy, and abortion rates. RESULT(S) Implantation, pregnancy, and abortion rates were similar in each group. In cycles where the endometrial thickness was </=14 mm, the rates were 20.9%, 43.1%, and 11.8% compared with 25.5%, 48.3%, and 13.8% in cycles >14 mm. CONCLUSION(S) No adverse effects of a thickened endometrium were demonstrated on implantation, pregnancy, or abortion rates in the first IVF-ET cycle. These findings fail to corroborate with those of Weissman et al. and support those of Yakin et al.

A matched study to determine whether low-dose aspirin without heparin improves pregnancy rates following frozen embryo transfer and/or affects endometrial sonographic parameters.

Purpose:The objective of the matched, controlled study was to determine whether low-dose aspirin therapy without heparin improves pregnancy rates following frozen embryo transfer.Methods:Thirty-six women who did not achieve a pregnancy following fresh embryo transfer and who had frozen embryos available for another transfer were included. Eighteen women were treated with 81 mg aspirin from day 2 of the cycle through pregnancy testing. If the β-human chorionic gonadotropin level was positive, aspirin was continued through the pregnancy. Eighteen women were not given aspirin. The mean outcome variables were pregnancy and implantation rates.Results:The clinical pregnancy rate in the aspirin group was 11.1%, compared with 33.3% for the controls, and implantation rates were 2.9 and 10.9%, respectively.Conclusions:No positive effects of low-dose aspirin therapy on pregnancy rates following frozen embryo transfer were observed.

Clinical outcome of cryopreserved human pronuclear stage embryos resulting from intracytoplasmic sperm injection

OBJECTIVE To compare the survival rate and pregnancy rate (PR) of embryos from intracytoplasmic sperm injection (ICSI) or conventional IVF, which were cryopreserved at the pronuclear stage in cycles where fresh transfer was deferred. DESIGN Comparative observational study. SETTING University-associated IVF center. PATIENT(S) Ninety-nine patients who deferred ET and had all their embryos cryopreserved at the pronuclear stage after 153 oocyte retrievals. Thirty-nine patients had their oocytes inseminated by ICSI and 60 patients had conventional IVF insemination. INTERVENTION(S) All embryos were frozen-thawed at the two pronuclear stage and allowed to cleave for 2 days before transfer. MAIN OUTCOME MEASURE(S) Survival rate (morphologically intact after thaw), cleavage rate (cleaved by time of transfer), and the clinical PR after frozen ET. RESULT(S) In the ICSI group, 205 embryos were thawed for use in 57 frozen ETs; in the IVF group, there were 527 embryos thawed for use in 149 frozen ETs. There was no significant difference in any of the outcome measures by insemination method: survival rates (ICSI, 93.2%; IVF, 94.8%); cleavage rates (ICSI, 95.2%; IVF, 94.7%), and clinical PR (ICSI, 14.0%; IVF, 17.4%). CONCLUSION(S) Pronuclear embryos resulting from ICSI can be cryopreserved successfully, thawed, and the survival rate and PR are comparable to conventional IVF.

Effect of Age on Pregnancy Outcome without Assisted Reproductive Technology in Women with Elevated Early Follicular Phase Serum Follicle-Stimulating Hormone Levels

There are data suggesting that patients with elevated early follicular phase serum follicle-stimulating hormone (FSH) levels have a poor fertility outcome. This has been attributed to a high rate of aneuploidy in the oocytes. It is not clear whether the spindle defects leading to nondisjunction are related to the high FSH levels or the age of the oocyte. The study presented herein retrospectively evaluated 6-month pregnancy rates in women with elevated early follicular phase serum FSH levels according to age. Only cases without in vitro fertilization were used, since the elevated FSH levels were deemed likely to interfere with multiple egg recruitment needed for assisted reproductive technology. The 6-month clinical and ongoing pregnancy rates were significantly higher in the women <40 years of age (46.1 and 34.6%, respectively) than in those aged 40 or older (10.5 and 5.3%). These data suggest that women with elevated follicular-phase serum FSH levels have a better fertility prognosis when they are younger.

Pregnancy achieved with pronuclear-stage embryos that were cryopreserved and thawed twice : A case report

AbstractPurpose: Our purpose was to determine if pronuclear-stage embryos (2PN) could be thawed, then frozen again with subsequent survival and cleavage after thawing. Methods: A simplified cryopreservation protocol was used in which a slow cooling program is started at the seeding temperature of −6°C in an alcohol-bath controlled-rate freezer. 1,2-Propanediol (1.5 M) was added to embryos before cooling. A fast thawing technique at room temperature was used. The cryoprotectant was removed in one step using a I M sucrose solution. Results: Three months after refreezing, the three 2PN embryos were thawed and all three cleaved after 24 hr in culture. Following embryo transfer a pregnancy was achieved and a healthy full-term baby girl was born. Conclusions: This is the third case reported of successful pregnancies after transfer of human embryos that were frozen twice before transfer and the first case where the second freeze occurred at the pronuclear stage. This is also the first successful refreezing of human embryos using a simplified freezing and thawing technique with one-step addition and removal of cryoprotectant.

Evaluation of a New Embryo-Grading System to Predict Pregnancy Rates following in vitro Fertilization

This study examines two descriptive parameters of embryo morphology to determine if either parameter correlates with subsequent pregnancy rates (PRs). The two parameters were the evenness (similarity in size) of the blastomeres and the degree of cellular fragmentation. A total of 242 embryo transfers in which 4 embryos were transferred were included. Sixty-nine (28.5%) clinical and 62 (25.6%) viable pregnancies resulted. In all cases 4 embryos were transferred, but the number of embryos with even round blastomeres (grade 1) varied from 0 to 4. Statistically, there was no correlation between PR and number of grade 1 embryos transferred. When 4 grade 1 embryos were transferred, the PR was 33.3 versus 28.1% when no grade 1 embryos were transferred. There was, however, a statistical difference in the implantation rate; a higher frequency of multiple gestations occurred when 3 or 4 of the embryos transferred were graded 1:12.7 as compared with 6.7% when < or = 2 embryos were grade 1. The significance of the degree of cellular fragmentation in the embryos was also assessed. There was no statistical difference in the PR according to the number (0-4) of embryos transferred that did not have fragments (grade A). When 4 grade A embryos were transferred, the PR was 18.2 versus 26.1% when there were no grade A embryos. Neither implantation nor multiple birth rates correlated with fragmentation.

Transfer of cryopreserved embryos improved pregnancy rates in patients with damage to the functional integrity of the sperm membrane as measured by the hypo-osmotic swelling test

OBJECTIVE To compare the pregnancy rates (PRs) after transfer of cryopreserved embryos in patients who have damage to the functional integrity of the sperm membrane as measured by the hypo-osmotic swelling test to those without this defect. DESIGN Prospective clinical study. SETTING University-associated IVF center. PATIENTS Fifty-four patients enrolled in a matched prospective study to evaluate the effects of low HOS scores (<50%) on PRs after IVF-ET were followed to determine the PR after transfer of cryopreserved embryos. MAIN OUTCOME MEASURE Clinical PRs and implantation rates. RESULTS Fourteen patients with low hypo-osmotic swelling test scores underwent 21 frozen ET cycles, achieved for clinical pregnancies for a PR per cycle of 19.0% and an implantation rate of 7.1%. Twelve patients with normal hypo-osmotic swelling test scores underwent 21 frozen ET cycles, achieved five preganancies for a clinical PR per cycle of 23.8% and an implantation rate of 9.3%. CONCLUSION Previous studies have demonstrated an adverse effect of low hypo-osmotic swelling test scores on PRs after IVF-ET despite normal fertilization. This adverse effect was not found in the transfer of cryopreserved embryos from males with hypo-osmotic swelling test scores. Further investigation is required to determine how cryopreservation improves the chances of implantation of these embryos.

The effect of consecutive cycles of clomiphene citrate therapy on endometrial thickness and echo pattern

Objective To determine whether successive cycles of clomiphene citrate affect endometrial thickness. Methods Thirty-four women presenting for treatment of anovulation, oligoovulation, or follicle maturation defects were given the smallest dose of clomiphene citrate necessary to attain a mature follicle. If no pregnancy ensued, the same dose was continued if a follicle 18–24 mm in diameter and a serum estradiol (E2) level greater than 200 pg/mL were achieved. Ethinyl E2 was supplemented for poor cervical mucus only. Endometrial thickness and echo patterns were measured each cycle at peak follicular maturation. Results There was no difference in mean endometrial thickness during the first six cycles of therapy, nor was there a trend for thickness to increase or decrease with successive cycles with or without the addition of ethinyl E2. There was no change in the distribution of echo patterns with successive cycles of clomiphene citrate. Post-treatment measures of thickness and echo pattern did not differ from baseline pre-treatment values. The homogeneous hyperechogenic pattern was the rarest. Mean serum E2 and progesterone levels at mid-cycle did not change with successive cycles. Conclusion One proposed mechanism for the dichotomy between ovulation and pregnancy rates after clomiphene citrate therapy is that the drug adversely affects the endometrium. If clomiphene citrate does affect implantation adversely, the mechanism does not seem to be related to thinning the endometrium or causing an echo pattern that indicates a poor prognosis. The data also suggest that estrogen supplementation does not influence endometrial thickness and would best be used exclusively for hostile cervical mucus.

Evaluation of a nonhomogeneous endometrial echo pattern in the midluteal phase as a potential factor associated with unexplained infertility

OBJECTIVE To determine whether the failure to develop a homogeneous hyperechogenic pattern in the midluteal phase is associated with decreased fecundity in infertile women who are not receiving follicle-maturing drugs. DESIGN Observational study. SETTING Outpatient infertility clinic of a University Medical Center. PATIENT(S) Two hundred ninety-six infertile women (> or =6 months) with regular menses, normal fallopian tubes and uterine cavity, and absence of severe male factor on their initial investigation cycle for follicular dynamic studies. INTERVENTION(S) Midluteal phase sonographic endometrial evaluation. MAIN OUTCOME MEASURE(S) Viable pregnancy rates (live fetus at end of first trimester) according to endometrial echo pattern in the midluteal phase. Other variables considered were age of patient, endometrial thickness and serum E(2) levels at midcycle and midluteal phase, midcycle echo pattern, and P levels in the midluteal phase. RESULT(S) The viable pregnancy rate was significantly higher in those women who exhibited a homogeneous hyperechogenic pattern (8.5%) compared to those women whose endometrium was found to be nonhomogenous (2.2%). No other confounding variables were found that could explain this outcome. CONCLUSION(S) A nonhomogeneous hyperechogenic sonographic endometrial echo pattern predicts lower fertility potential in women who are not receiving follicle-maturing drugs.

Intrauterine Insemination for Cervical and Male Factor without Superovulation

Intrauterine insemination (IUI) has been used for the treatment of various causes of infertility, including unexplained infertility, male factor, and cervical factor. Some centers frequently use superovulation combined with IUI. The study presented herein attempted to evaluate the efficacy of IUI without superovulation in cases where all causes of infertility other than cervical or male factors have been eliminated. However, in the case of poor or absent cervical mucus, the use of controlled ovarian hyperstimulation (COH) may obscure the actual importance of the IUI, since it is possible that the poor cervical mucus is related to poor timing, inadequate follicular maturation, or low estradiol levels, which if corrected will obviate the need for IUI. In this study IUI was targeted for 36-40 h following the sera luteinizing hormone surge. A total of 108 patients were enrolled in this study: 47 with male factor, 61 with cervical factor. Patients were followed for a maximum of three cycles unless a pregnancy occurred within 3 months of treatment. Comparison of pregnancy rates (PRs) were based on diagnosis. The cumulative PRs per cycle for each of the three cycles studied were as follows: cervical factor--19.7, 36.8, and 36.8%; male factor--12.8, 29.3, and 38.3%. Thus, PRs were comparable for both groups after three treatment cycles. These data demonstrate that IUI is an effective therapy for cervical and/or male factor, even without superovulation.