Gad Lavy

The role of office hysteroscopy in in vitro fertilization

Twenty-eight patients participated prospectively in a study to evaluate the impact of hysteroscopically detected uterine and cervical anomalies on the success rate of ET in an IVF-ET program. All participants had a normal intrauterine cavity by standard HSG. All the patients had a diagnostic office hysteroscopy under paracervical block before commencing COH. Because our IVF program does not include hysteroscopy as a requirement before undergoing IVF and because the significance of mild intrauterine abnormalities is not yet known, the hysteroscopic findings were not relayed to the personnel involved in the IVF-ET procedure. Sixteen patients (group I) had a normal hysteroscopic evaluation. Twelve patients (group II) had abnormal hysteroscopic findings including small uterine septa, small submucous fibroids, uterine hypoplasia and cervical ridges. Although no difference in patients or cycle characteristics was present, there was a significant difference in the clinical PR between patients in groups I and II. In conclusion, in an IVF-ET program patients with normal hysterography but abnormal hysteroscopic findings had a significantly lower clinical PR, demonstrating the importance of performing hysteroscopy before IVF-ET.

Human chorionic gonadotropin, estradiol, and progesterone profiles in conception and nonconception cycles in an in vitro fertilization program *

In 22 consecutive in vitro fertilization cycles stimulated with purified follicle-stimulating hormone, human chorionic gonadotropin (hCG), estradiol (E2), and progesterone (P) were measured every 3 days during the luteal phase. All serum measurements were normalized to the day of hCG administration (day 0). There was a total of nine pregnancies; two were biochemical pregnancies, whereas 7 of the 22 women had clinical pregnancies (31.8%). Of these, two miscarried and five had term pregnancies (three singleton, two twin). Conception cycles could be differentiated from nonconception cycles by serum E2 levels on day 8 (P = 0.035), by hCG levels on day 11 (P = 0.03), and by P levels on day 14 (P = 0.001). From days 8 to 11, hCG levels plateaued in conception cycles and decreased in nonconception cycles. However, during that period, E2 and P fell in both groups of women. This decline in sex steroids, which was observed in both conception and nonconception cycles, may well negatively influence endometrial development during the peri-implantation period and compromise conception, resulting in failure to conceive, biochemical pregnancy, and early miscarriage.

Preembryo biopsy and analysis of blastomeres by in situ hybridization

We developed a method for the biopsy of preimplantation mouse embryos (preembryos) at the four- to eight-cell stage, which uses partial zona pellucida dissection. The preembryos were collected in calcium- and magnesium-free phosphate-buffered saline solution with 0.01% ethylenediaminetetraacetic acid, 0.1 mol/L sucrose, and 4 mg/ml of bovine serum albumin to facilitate removal of blastomeres. This allows entry of a fine micropipette into the perivitelline cavity with subsequent removal of a single blastomere by gentle suction. The majority of embryos (75%) from which biopsy specimens were obtained in this fashion developed to the blastocyst stage. The blastomeres obtained were mainly intact and they were fixed to glass slides. After permeabilization, in situ hybridization was performed with chromosome X- and chromosome 3-specific probes. Human unfertilized eggs and blastomeres from human polyspermic embryos also have been analyzed by in situ hybridization with chromosome specific probes. The combination of nondestructive embryo biopsy and in situ hybridization is a possible approach for preimplantation genetic diagnosis.

Ectopic pregnancy: Its relationship to tubal reconstructive surgery

Ectopic pregnancy is the shady companion of tubal surgery. Among patients with ectopic pregnancy, relatively few have a history of tubal surgery as their underlying etiologic factor when compared with other etiologies such as PID. Nevertheless, a history of tubal surgery should place the patient at a higher-risk group for ectopic pregnancy; 3% to 20% of these patients will encounter an ectopic pregnancy after the corrective surgery. The incidence of ectopic pregnancy after tubal surgery is extremely variable and is closely linked to the degree of restoration of normal functional and anatomic integrity after the surgical procedure. This depends, to a large extent, on the amount of previous damage to the tube and its potential reversibility. Major improvements in surgical technique can, therefore, have reduced, but not eliminated, the occurrence of tubal pregnancy. The incidence of ectopic pregnancy associated with any given tubal surgical procedure should be taken into consideration when surgery is contemplated. When the risk of ectopic pregnancy is unacceptably high, or when the patient is reluctant to be exposed to a high risk of ectopic pregnancy, IVF-ET could be offered as an alternative. Table 11 represents the incidence of ectopic pregnancy associated with the various surgical procedures. The figures demonstrate the wide variation in outcome for the same procedure.

A paired analysis of in vitro fertilization and cleavage rates of first- versus last-recovered preovulatory human oocytes exposed to varying intervals of 100% CO2 pneumoperitoneum and general anesthesia.

This study compares the in vitro fertilization and cleavage rates of paired first- and last-recovered preovulatory human oocytes that were exposed to a 100% CO2 pneumoperitoneum and general anesthesia. In 305 consecutive cycles of laparoscopy, 1741 oocytes (5.7/cycle) were recovered. The exact time of aspiration (T) was recorded for each oocyte. The time interval (T1 to T2) between recovery of first and last oocytes ranged from 0 to 38 minutes and represented differences in the exposure time of first and last oocytes to the CO2 pneumoperitoneum and to general anesthesia. For all cycles (n = 305) without regard for T1 to T2, last-recovered oocytes fertilized less often than first-recovered eggs (P = 0.06; McNemars test). When T1 to T2 was short (less than or equal to 5 minutes), first- and last-recovered oocytes fertilized at comparable rates (70.8% and 74.0%). When only cycles with T1 to T2 greater than 5 minutes were considered (n = 209), the difference in fertilization rates between first and last oocytes (68.5% versus 56.4%) was highly significant (P less than 0.01; McNemars test). Pairing negated differences due to patient, cycle, or semen variables and first- and last-recovered oocytes had comparable maturity scores (4.0 +/- 0.5 versus 4.3 +/- 0.8). There were no significant differences in cleavage rates for first- and last-recovered oocytes that fertilized, regardless of the exposure interval (T1 to T2). We conclude that exposure to a 100% CO2 pneumoperitoneum and/or general anesthesia may adversely affect oocyte quality.

Interinstitutional variability of follicle-stimulating hormone and estradiol levels *

Objective To evaluate the variability of follicle stimulating hormone (FSH) and estradiol (E 2 ) results from different laboratories. Design Prospective analyses of sera separated and frozen, obtained from 15 female patients in the follicular phase. All kits used for radioimmunoassay (RIA) for FSH were from the Second International Reference Preparation (IRP). Four different kits were used for FSH and three for E 2 . Setting Sera obtained from each patient were separated into five test tubes and frozen. Analysis of all samples was done on the same day in each one of five participating hospital-based RIA laboratories (North Shore, Cornell, Yale, Mount Sinai, and Norfolk). Participants Fifteen consecutive patients from the assisted reproductive technology program at North Shore University Hospital participated in the study. Main Outcome Measures After FSH and E 2 levels were tabulated for each laboratory, mean levels were calculated. Results Using the Bonferroni adjusted pairwise multiple comparisons analysis, significant differences were found between three groups of laboratories within the FSH results and three different groups within the E 2 results. Conclusions [1] Different results may be obtained on the same sera for FSH and E 2 at different laboratories; [2] for FSH, even though the same IRP is used, different results are reached; [3] for E 2 even when the same kits are used, results may be significantly different. These results suggest that specific FSH and E 2 levels used to predict chances for achieving a viable pregnancy through in vitro fertilization should be interpreted with caution across institutions.

Heterogeneity in patient populations explains differences in in vitro fertilization programs.

OBJECTIVE To evaluate the efficacy of in vitro fertilization and embryo transfer (IVF-ET). DESIGN Two different models for pregnancy rates in IVF-ET have been developed: a beta-geometric model and a split population model. SETTINGS All IVF cycles were performed at the Yale University School of Medicine in New Haven, Connecticut. PATIENTS, PARTICIPANTS All patients undergoing 1,257 IVF-ET cycles performed between the years 1983 through 1987. INTERVENTIONS None. MAIN OUTCOME MEASURE The probability of achieving a viable pregnancy per cycle. RESULTS Because both models provide excellent explanations for our data distribution, the decline in the conditional probability of achieving pregnancy after a given number of unsuccessful cycles may be inferred. CONCLUSIONS These findings question the justification of continuing IVF-ET treatment beyond some threshold number of cycles.

Ovarian stimulation for in vitro fertilization and embryo transfer, human menopausal gonadotropin versus pure human follicle stimulating hormone: a randomized prospective study

A randomized, prospective study was conducted to compare ovarian stimulation with human menopausal gonadotropin (hMG) and human follicle-stimulating hormone (hFSH) in an in vitro fertilization and embryo transfer (IVF-ET) program. Minimal inclusion criteria included age less than or equal to 37, tubal infertility, regular menstrual cycles before IVF, and a normal semen analysis. Equivalent doses (225 IU/day) of either hMG (N = 20) or hFSH (N = 20) were administered, and the patients followed by serum estradiol (E2) levels and pelvic ultrasound. Parameters related to the ovarian response to therapy, the number and quality of ova recovered, and the cycle outcome were compared in the two groups using the Students t-test and chi-square analysis. No difference was detected between the groups in peak E2 levels (828 +/- 78 versus 819 +/- 79 in the hMG and hFSH groups, respectively), day of human chorionic gonadotropin (hCG) administration (9.3 +/- 0.3 versus 9.7 +/- 1.01), occurrence of spontaneous luteinizing hormone (LH) surge (44% versus 27%, P greater than 0.05, chi square analysis), average number of ova recovered (5.0 +/- 0.7 versus 5.6 +/- 1), ova maturation (7.5% versus 12.7% rate of immature ova), rate of normal and abnormal fertilization (9.2% versus 8.1% polyspermic fertilization), cleavage stage at transfer (3.6 +/- 0.4 versus 3.4 +/- 0.7 cells per embryos), the number of embryos transferred (2.5 +/- 0.3 versus 2.6 +/- 0.3), or the occurrence of pregnancy (1 in the hMG group and 2 in the hFSH group).(ABSTRACT TRUNCATED AT 250 WORDS)

The role of ACTH in placental steroidogenesis

We have studied the possible function of the placental adrenocorticotrophic hormone-(ACTH-) like substance (PALS) in placental steroidogenesis by measuring oestradiol (E2) and progesterone (P4) in term human placental explants incubated with commercially available porcine ACTH I-39. There was a dose-dependent increase in the E2 and P4 released into the medium at 24 h as compared to controls. At 48 h, no significant effect was noted. Propranolol (10(-5) M) did not block the effect of ACTH on P4 release. The data suggest that ACTH may have a regulatory role on placental steroidogenesis. The possible mechanisms of action of PALS on the placenta and the adrenal are discussed, and the role of PALS in the maintenance of pregnancy and in maternal response to stress is suggested.

Manifestation of diabetes mellitus on mouse follicular and pre-embryo development: Effect of hyperglycemia per se

Animal models of diabetes mellitus during pregnancy have repeatedly suggested that maternal hyperglycemia was teratogenic during organogenesis, and thus may contribute to diabetic teratogenesis. However, little attention has been focused on the effects of hyperglycemia on pre-organogenic development. In this report, we examine the effect of hyperglycemia (950 mg glucose/dL) on the development of mouse pre-embryos in vitro. B6C3F1 mice were superovulated with 5 U pregnant mare serum gonadotropin (PMSG) followed by 5 U human chorionic gonadotropin (hCG) 48 hours later. Two cell pre-embryos were recovered 48 hours later, pooled together, and randomly assigned to different treatment groups. Cultures were performed in HAMs F-10 media (Gibco, Long Island, NY) with 0.1% bovine serum albumin (BSA; Sigma, St. Louis, MO) BSA at 37 degrees C in an atmosphere of 5% CO2, 5% O2, and 90% N2 with 15 to 30 embryos per milliliter of culture fluid. Cultures were viewed daily at 24, 48, and 72 hours after culturing, with recording of the development. Compared with control pre-embryos (n = 216), embryos cultured in elevated glucose levels (950 mg/dL) (n = 226) demonstrated marked growth retardation as assessed both by (1) distribution of developmental stages at each observation point (24 hours, P less than .001; 48 hours, P less than .006; 72 hours, P less than .001); and (2) a difference in the average rank sums indicating a delay in maturation (P less than .005). In a second protocol group, pre-embryos were cultured in an equivalent amount of L-glucose; no impairment in development compared with controls was noted.(ABSTRACT TRUNCATED AT 250 WORDS)