John A. Schnorr

Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile women: a prospective, randomized study ☆

OBJECTIVE To compare the diagnostic accuracy, pain scores, and procedure length of outpatient hysteroscopy (OHS), hysterosalpingography (HSG), and saline infusion hysterosonography (SIS) for evaluation of the uterine cavity of infertile women. DESIGN Prospective, randomized, investigator-blind study. SETTING Tertiary infertility clinic. PATIENT(S) Forty-six consecutive infertile women. INTERVENTION(S) Outpatient HSG, OHS, and SIS, followed by operative hysteroscopy (HS). MAIN OUTCOME MEASURE(S) Uterine abnormalities, procedure length, and subjective pain. RESULT(S) Fifty-nine percent of infertile subjects were found to have an abnormality on at least one of three outpatient uterine evaluations. When compared with the case of definitive operative HS, 60% of abnormalities were correctly classified by HSG, 72% by OHS, and 52% by SIS (P: NS). When comparing all combinations of 2 outpatient screening tests to operative hysteroscopy, 68% were correctly classified by HSG/OHS, 58% by HSG/SIS, and 64% by OHS/SIS (P: NS). The average time length for the OHS was 9.1 min., which was significantly greater than for both HSG (average, 5.3 min) and SIS (average, 6.1 min.) (P<.0001 for both). HSG and SIS were not statistically different regarding procedure time length. The average pain score (0-10) for SIS was 2.7, compared with 5.8 and 5.3 for HSG and OHS, respectively. Both HSG and OHS mean pain scores were significantly greater than the SIS mean. CONCLUSION(S) OHS, SIS, and HSG were statistically equivalent regarding evaluation of uterine cavity pathology in infertile women.

Multiple pregnancies: a call for action

The 1990s have been referred to as the “Technology Decade” because of the evolution of the Internet, exponential growth of .com companies, and soaring stock market. The Technology Decade has also had a profound impact on assisted reproductive technologies (ARTs) through scientific advances that have increased implantation rates, pregnancy rates, and unfortunately, multiple-pregnancy rates. In fact, between 1988 and 1997 (the most recent figures available), the multiple-pregnancy rate increased faster than the NASDAQ Composite! We could only hope for a “correction” in the multiple pregnancy rates such as the NASDAQ Composite experienced over the first part of the year 2000 (Figure 1; ref. 1–9).

Impact of a cryopreservation program on the multiple pregnancy rate associated with assisted reproductive technologies.

OBJECTIVE To determine the impact of a cryopreservation program on pregnancy rates and multiple-pregnancy rates in ART cycles. DESIGN Retrospective study. SETTING University teaching hospital. PATIENT(S) Women who underwent stimulation for in vitro fertilization at the Jones Institute for Reproductive Medicine between October 1987 and June 1999. INTERVENTION(S) Analysis of pregnancy and multiple-pregnancy rates based on the number of embryos transferred. MAIN OUTCOME MEASURE(S) Implantation; pregnancy and multiple-pregnancy rates. RESULT(S) Pregnancy rates per transfer increased from 9% when one embryo was transferred to 20% with two embryos, 35% with three embryos, 40% with four embryos, and 41% with five embryos. The rate of twin pregnancies increased to 21% with two embryos, 23% with three embryos, 21% with four embryos, and 22% with five embryos. The triplet pregnancy rates were 8% with three embryos, 9% with four embryos, and 2% with five embryos. A theoretical model limiting the number of embryos transferred to two with cryopreservation and subsequent transfer yields a cumulative pregnancy rate of 77%, a twin rate of less than 20%, and no triplet or higher-order pregnancies. CONCLUSION(S) The use of a cryopreservation program can help maximize pregnancy rates while minimizing multiple-pregnancy rates. Cryopreservation should be considered in all assisted reproductive technology cycles.

Evaluation of the clinical efficacy of embryo cryopreservation.

To fully evaluate the advantages of a cryopreservation program a method needs to be established to express the additional patients pregnant from cryopreservation. The patient specific method considers cryopreservation as augmentation only among patients without a pregnancy from the fresh transfer, or from previously transferred frozen material from the same harvest. In an analysis of the pregnancy rate at the Jones Institute between January 1996 and December 1998 we found a fresh pregnancy rate of 40.8% in the good responders and 28.8% in poor responders. The patient specific pregnancy rate in the same cycles was 53.4% in good responders and 32.3% in poor responders. Good responders less than 35 years of age with ten or more mature eggs at retrieval had a fresh pregnancy rate of 40.2% and a patient specific pregnancy rate of 57.9%. It is exceedingly important for the physician and patient to understand and comprehend the potential in cryopreserved material.

The Impact of High-Order Multiple Pregnancies

Between 1980 and 1997 the number and rate of twin, triplet, and higher-order multiple births has climbed at an unprecedented pace within the United States. The number of live births in twin deliveries rose 52% between 1980 and 1997, and the number of live births in triplet and higher-order multiple pregnancies increased an astounding 404%. In sharp contract, single births during the same time period rose 6%. The last several years has witnessed an even more remarkable aspect to the trend in multiple pregnancies in that there was nearly a 1,000% increase in the incidence of multiple gestation among women 45–49 years of age between 1980 and 1997 (1). These extraordinary increases in the incidence of multiple pregnancy is a public health concern due to the considerable medical, social, and financial consequences of multiple gestation.