Julian S. Pampiglione

An analysis of factors influencing the establishment of a clinical pregnancy in an ultrasound-based ambulatory in vitro fertilization program

In the study period (June 1984 to December 1986), 2232 cycles were stimulated in 1294 patients. Ultrasound-directed oocyte recovery (UDOR) was performed as an ambulatory procedure in 1737 (77.8%) cycles, resulting in 1375 embryos transfers (ET). Age, etiology, menstrual cycle length, number of oocytes collected, and number of embryos transferred were important determinants of the outcome. The number of attempts at in vitro fertilization did not affect the clinical pregnancy rate (CPR). In patients receiving four embryos, the CPR appeared to be highest when up to seven embryos were available for transfer. The fertilization rate in an individual cycle had a good prognostic value, the implantation rate being highest when 7 to 9 oocytes were retrieved and greater than 60% of these were fertilized. When 10 or more oocytes were collected, the implantation rate showed a progressive decline, regardless of the fertilization rate. Furthermore, multiple pregnancies failed to occur when greater than 12 oocytes were retrieved or more than eight embryos were available for transfer. These data suggest that, in excessively stimulated cycles, the quality of oocytes and embryos or uterine receptiveness may be suboptimal, and the transfer of more than four embryos is unlikely to increase the success rate.

The clinical outcome of reinsemination of human oocytes fertilized in vitro

To assess the value of reinseminating human oocytes, the results of 1,662 embryo transfers were analyzed. In 1,460 transfers embryos arose from oocytes that had fertilized and cleaved after initial insemination. The pregnancy rate was significantly higher than in transfers of embryos (n = 76) resulting solely from reinseminated oocytes (27% versus 3%). Adding reinseminated embryos to those fertilizing on initial insemination at transfer failed to raise the pregnancy rate. Only 2 of 158 (1.3%) reinseminated embryos implanted compared with 540 of 4,181 (12.9%) fertilized and cleaved on initial insemination (P less than 0.001). Reinseminated embryos do occasionally produce viable pregnancies. It is therefore worth considering replacement of these embryos if initial fertilization has entirely failed. Patients should be counseled as to the low chance of implantation with these embryos.

Outcome of triplet pregnancies resulting from IVF at Bourn Hallam 1984-1987.

43 consecutive sets of triplet pregnancies progressing beyond 16 weeks and conceived following in vitro fertilisation at the Bourn Hallam Centre between 1984-1987 were included in the study. Follow-up information was available in the 31 sets born to United Kingdom residents. 91 live births resulted at an average gestation of 33 weeks and 2 days (range 26-38 weeks). All but one of the deliveries was by Caesarean section. The average birth weight was 1.85 kg and was significantly higher in the first-born triplet than in the third (1.93 kg versus 1.74 kg, respectively). The perinatal mortality rate amongst the triplets was 32.26 per thousand births, and the neonatal death rate was 21.98 per thousand live births. This compares favourably with the latest published data on perinatal mortality rates in triplets.

Ultrasound-guided peritoneal oocyte and sperm transfer.

Peritoneal oocyte and sperm transfer (POST) was performed under ultrasound guidance and local anesthesia by the transabdominovesical route for a patient with unexplained infertility. This resulted in an intrauterine pregnancy confirmed by a raised β-human chorionic gonadotropin (hCG) level and an ultrasound scan.

The effect of cycle length on the outcome of in vitro fertilization

In order to study the effect of cycle length on the pregnancy rate in an in vitro fertilization and embryo transfer (IVF-ET) program, 173 consecutive patients were divided into short menstrual cycle (mode 26 days or less) and normal cycle (mode 27 days or more) groups. Patients were randomly allocated to one of two treatments, commencing ovarian stimulation with human menopausal gonadotropin (hMG) on either day 2 or day 4 of their cycle. The number of oocytes retrieved and embryos transferred did not differ significantly. The amount of hMG used and day of human chorionic gonadotrophin administration both differed significantly (P less than 0.01) between regimens but was independent of cycle length. Both the clinical pregnancy rate (30.2% versus 9.4%, P less than 0.05) and the number of cleaved embryos giving rise to gestation sacs (16% versus 3.4%, P less than 0.02) was significantly higher in patients with a normal cycle length. Mode cycle length has a significant bearing on the outcome of IVF-ET cycles.

Experience with peritoneal oocyte and sperm transfer as an outpatient-based treatment for infertility

Fifty-nine patients underwent 74 peritoneal oocyte and sperm transfer procedures. Forty-nine had previously failed treatment with inseminated frozen donor sperm and 10 had unexplained infertility. All procedures were carried out under ultrasound direction on an outpatient basis without general anesthetic by the transabdominal or vaginal route. Eighteen (24%) procedures resulted in pregnancy. Of these patients, 16 have delivered live infants (1 set of triplets, 2 twins, and 13 singletons) and 2 miscarried. Peritoneal oocyte and sperm transfer offers an outpatient-based alternative to gamete intrafallopian transfer (GIFT) for in vivo conception. It can also be used in patients scheduled for intrauterine insemination where stimulation is excessive because the number of oocytes replaced can be limited.

Transvaginal peritoneal oocyte and sperm transfer for the treatment of nontubal infertility

OBJECTIVE To investigate if peritoneal oocyte and sperm transfer (POST) performed transvaginally is an effective treatment for nontubal infertility. DESIGN, SETTING, AND PATIENTS Prospective study of 18 patients (4 with unexplained infertility, 13 with failed donor insemination, and 1 with male factor infertility) having 20 cycles of transvaginal POST in a specialist infertility unit. INTERVENTIONS Ovarian stimulation was achieved with human menopausal gonadotropin (hMG) alone, hMG and clomiphene citrate, or gonadotropin-releasing hormone agonist with hMG. Oocyte recovery was performed transvaginally under ultrasound guidance, the pouch of Douglas rinsed repeatedly and an embryo transfer catheter used to transfer 4 x 10(6) progressively motile sperm in 1 mL and up to four oocytes into the pouch of Douglas. Luteal support was provided with human chorionic gonadotropin injections given 2 and 5 days later. RESULTS The mean age of the patients was 32.65 +/- 5.0, and the mean length of infertility 5.07 +/- 2.32 years. The mean number of oocytes transferred was 3.53 +/- 0.87. Three pregnancies were achieved in the failed donor insemination group and 1 each in those with unexplained and male factor infertility, giving overall clinical pregnancy and live birth rates of 25% and 20% per initiated cycle. All pregnancies were achieved in those who had three or four oocytes transferred. CONCLUSION Transvaginal POST is a useful assisted conception technique for the treatment of nontubal infertility.

Ultrasound directed follicle aspiration for oocyte collection using the perurethral technique

Our experience in 242 consecutive ultrasound directed follicle aspirations using the perurethral technique is reported. The mean number of follicles punctured per patient was 9.6 (range 20 to 35), resulting in a mean oocyte yield of 6.1 (range 0 to 31) per patient. It was necessary to change to another ultrasound directed route in 20 patients, and we failed to retrieve oocytes in a further 6 patients. There were no serious complications. The fertilization and cleavage rates were 68% and 91%, respectively. Embryo transfer was performed in 178 cases, resulting in 39 clinical pregnancies (21.9%). Ultrasound directed follicle aspiration by the perurethral route is an efficient way of collecting oocytes and is acceptable to patients. There is no need for general anaesthesia, so this technique is well suited to in vitro fertilization programs based on outpatient procedures.