Efraim Zohav

The influence of estradiol/follicle and estradiol/oocyte ratios on the outcome of controlled ovarian stimulation for in vitro fertilization

Objective. The aim of the study was to evaluate the influence of the ratios of estradiol (E2) to either the number of follicles >14 mm on the day of human chorionic gonadotropin administration (E2/follicle) or the number of oocytes retrieved (E2/oocytes) during controlled ovarian hyperstimulation (COH) with gonadotropin-releasing hormone (GnRH)-agonist (agonist group) and GnRH-antagonist (antagonist group), on the outcome of in vitro fertilization (IVF) cycles. Patients and methods. All consecutive women aged <35 years admitted to our IVF unit during a 6-year period with normal to high response to COH were retrospectively studied. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryos transferred and pregnancy rate were assessed. Results. Six hundred and ninety consecutive IVF cycles were evaluated, 301 in the agonist group and 389 in the antagonist group. The ratios of E2/follicle and E2/oocyte were significantly higher in the agonist group (p < 0.001 for both). Moreover, while pregnancy rates within E2/oocyte ratio of 100–200 pg/ml were comparable between the agonist and antagonist groups, when E2/oocyte ratios were <100 pg/ml or >200 pg/ml, pregnancy rates were significantly higher in the agonist group. Furthermore, no difference in pregnancy rates was observed within the agonist group between different E2/oocytes ratios, while within the antagonist group, higher pregnancy rates were observed when comparing those with E2/oocyte ratio of 100–200 pg/ml with those with E2/oocyte ratio <100 pg/ml or >200 pg/ml. Conclusion. While E2/oocyte ratio cannot predict the success of GnRH-agonist protocol, patients undergoing GnRH-antagonist protocol should reach E2/oocyte ratio within the 100–200 pg/ml range in order to achieve the best IVF outcome.

Use of three-dimensional ultrasound in evaluating the intrauterine position of a levonorgestrel-releasing intrauterine system

This paper reports the first case of three-dimensional (3-D) transvaginal ultrasonography (TVS) imaging of malpositioned levonorgestrel-releasing intrauterine system (LNG-IUS). In patients carrying LNG-IUS, the application of 3-D TVS with the adjunctive volume contrast imaging in the coronal plane (VCI-C) and inversion rendering modes clearly display the correct spatial position of the LNG-IUS in relation to the uterine cavity much better than two-dimensional ultrasound.

Do stimulation characteristics of the first in vitro fertilization cycle predict pregnancy in women of 40 years old and over

The failure of tests of ovarian reserve to predict clinical pregnancy in women 40 years old and older prompted this study of the predictive value of information obtained during the first cycle of in vitro fertilization (IVF). Stimulation characteristics during the first IVF cycle attempt were unhelpful in predicting the possibility of clinical pregnancy within the first three consecutive IVF cycles.

P24.18: Centralization and U turn of uterine arteries demonstrated by three dimensional power Doppler flow are new imaging signs for diagnosis of complete uterine inversion

volume (FMBV). We aimed to evaluate the influence of 3 different persistence levels (smoothing) at the same region of interest. Methods: Anterior placentas were evaluated for placental perfusion assessment by time-averaged maximum perfusion (TAMP) on a 2D cine sequence in 16 normal pregnant women with singleton pregnancies. The power Doppler (PDU) color box was placed in a sagittal plane of the placenta with visualization of the site of insertion of the umbilical cord. The PDU color box was adjusted to the maximum placental length and height with the following settings: low-pass filter, pulse repetition frequency of 0.6 kHz, and normal quality image. A 4–5 seconds video sequence was saved in an AVI format without compression for off-line analysis. Three recordings from the same area were saved using 3 smoothing levels (1/1, 6/6, 12/12). Recordings were obtained without maternal and fetal movements. For analysis, in the first image of each video sequence the region of interest (ROI) was delineated and then all the images included in the video loop were automatically calculated, the final value was termed Time-Averaged Maximum Perfusion (TAMP). Difference between 3 smoothing levels was evaluated by the ANOVA test and the statistical significance accepted for p values was < 0.05. Results: The mean and range of values for the 3 levels of smoothing (1/1, 6/6, 12/12) were 10.6% (5.0–21.8%), 15.6% (7.9–24.6%) and 18.6% (13.4–26.5%) respectively. There was a significant difference between the 3 levels of smoothing (P = 0.01). Conclusions: There is a strong influence of the smoothing level when evaluating perfusion by TAMP method. The highest level of persistence is associated with higher FMBV values. For real blood perfusion evaluation, the lowest persistence might be used.

OP15.06: The use of 3D ultrasound for diagnosis of unicornuate and didelphys uteri with twins gestation during first trimester of pregnancy

Results: 438 consecutive FFTS cases were treated at 15 to 26 weeks. PABS developed in eight cases (1.8%). The affected twin was always the former recipient. The diagnosis was made prenatally in two of eight cases (25%). All cases survived the perinatal period. PABS affected fetal leg, arm or foot. In five (62.5%) and seven (87.5%) cases, PABS occurred following premature rupture of membranes and intrauterine demise of the donor, respectively. No maternal, fetal or peri-operative risk factor could be identified. Conclusions: This complication is related to invasive procedure and is probably different in the physiopathology from the intrinsic malformative theory, suggesting that the anomalies and the fibrous bands have a common origin, caused by an anomaly of the developing germinal disc of the early embryo. The sequence of events in our series involved rupture of the amnion (5/8), fetal demise of the donor after laser fetoscopy (7/8) and prematurity (7/8). The latter is consistent with a particular role of membranes in this condition. Awareness and targeted serial ultrasound evaluation in this high-risk group may improve prenatal diagnosis, counseling and management of PABS following FLS.

P19.03: 3D study of uterine and endometrial parameters in uteri with Mullerian anomalies versus normal uteri

Results: Saline infusion sonography-guided endometrial samples were obtained in all 21 patients with nondiagnostic EMBs and pathology diagnoses were obtained in 13 of 21 (62%) patients (p = 0.0001), including one diagnosis of endometrial adenocarcinoma. The combination of saline infusion sonography and guided sampling achieved clinical diagnoses in 20 of the 21 patients (P < 0.0001). Conclusions: Saline infusion sonography-guided endometrial sampling yielded a significant increase in pathologic diagnoses in patients with nondiagnostic EMBs.

Does gravidity influence the success of in vitro fertilization–embryo transfer cycles?

Objective. To evaluate the influence of gravidity on the results of in vitro fertilization (IVF)–embryo transfer (ET) cycles. Patients and methods. All consecutive women aged <35 years admitted to our IVF unit from January 2002 to December 2004 were enrolled in the study. Only patients undergoing one of their first three IVF cycle attempts were included. Gravidity, ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and clinical pregnancy rate were assessed. Results. Three hundred and forty-two consecutive IVF cycles were evaluated. One hundred and sixty-one cycles were from nulligravidas and 181 from women with a history of at least one previous clinical pregnancy. Forty-eight (29.8%) clinical pregnancies were observed in the nulligravida group and 56 (30.9%) in the gravida group. There were no differences between nulligravidas and gravidas in causes of infertility, length of ovarian stimulation, peak estradiol and progesterone levels, number of oocytes retrieved, fertilization rate and number of embryos transferred. Gravidas were significantly older (30.4 vs. 27.6 years, p < 0.001) and used more gonadotropin ampoules (36.1 vs. 31.8, p < 0.004) compared with the nulligravidas. Conclusions. Patient gravidity has no influence on the likelihood of achieving pregnancy in IVF–ET cycles.

P07.12: Early endometrial changes following successful implantation post embryo transfer, a three‐dimensional ultrasound study

Objective: To determine the prevalence of atypical hyperplasia, and endometrial cancer in asymptomatic postmenopausal women with endometrial polyps on atrophic endometrium, removed by hysteroscopic polypectomy. Methods: Asymptomatic postmenopausal women with standardized sonographic (endometrial thickness ≤ 4 mm), and/or hysteroscopic (visual diagnosis) diagnosis of endometrial polyp on atrophic endometrium, were retrospectively reviewed from 2000 to 2004. Patients on HRT and/or TMX treatment were excluded. All women underwent transvaginal sonography (TVS) with colorand/or powerDoppler evaluation, sonohysterography in selected cases, and/or diagnostic hysteroscopy (HYS). Hysteroscopic polypectomy was performed by using office operative hysteroscope or by resectoscope. Demographic, sonographic and hysteroscopic data were recorded. Histology of the removed polyp was the main outcome. Results: 637 consecutive patients were analysed among those so far included. Mean age (± sd) was 62 years ± 8. Mean years after menopause were 13 ± 13. Mean BMI was 26 ± 5. Mean diameter of endometrial polyp at TVS and/or HYS was 18 ± 15 mm. Typical, atypical hyperplasia, and cancer were 4.9%, 1.6%, and 0.2%, respectively. One polypoid cancer was found. Conclusions: This first ad interim analysis of a larger multicentre study observed one case of endometrial cancer in asymptomatic postmenopausal women with endometrial polyp on atrophic endometrium. This confirmed the reliability of endometrial thickness ≤ 4 mm and hysteroscopic visual diagnosis for the exclusion of endometrial disease. This retrospective study adds evidence to the feasibility of a conservative management of asymptomatic polyps. Monitoring criteria need to be established.