Korula George

Affordable ART: a different perspective

BACKGROUND Although ≈ 10% of the population is affected by infertility, the treatment option of in-vitro fertilisation (IVF) remains unaffordable for the majority of infertile couples. We have initiated a lowcost programme incorporating an uncommonly used, but recognized, ovarian stimulation protocol, together with certain costlimiting initiatives in an established assisted reproductive technology (ART) set up. METHODS The medical records of women who underwent the lowcost programme were analysed. Clomiphene citrate 50 mg daily was administered from Day 2 of the cycle and continued till the day of hCG trigger, thus preventing the LH surge. Intermittent doses of human menopausal gonadotrophin 150 IU were administered on alternate days from the 5th day onwards. Oocyte retrieval was carried out once at least two follicles of >18 mm were identified. The cycle was monitored by ultrasound only, with embryo transfer being carried out on Day 3. Clinical outcomes were recorded together with an estimation of the direct costs per cycle. Direct cost calculations did not include professional charges or facility costs. RESULTS Of 143 women evaluated, 104 women underwent embryo transfer. The live birth rate and clinical pregnancy rate per embryo transfer were 19 and 22%. The live birth rate per initiated cycle was 14% (20/143). The multiple pregnancy rate was 26% with no case of ovarian hyperstimulation syndrome being recorded. The average direct cost per cycle was US

Blastocyst stage transfer vs cleavage stage embryo transfer

675 for IVF and US

Letrozole or clomiphene citrate as first line for anovulatory infertility: a debate

725 for an ICSI treatment cycle. CONCLUSIONS Using this protocol, together with several costcutting measures, we achieved an acceptable live birth rate per transfer of 19% at a reasonable cost. This approach could be used by established ART centres to provide treatment to couples who cannot afford conventional ART.

A rare case report: ovarian heterotopic pregnancy after in vitro fertilization

OBJECTIVE: To evaluate the efficacy of blastocyst transfer in comparison with cleavage stage embryo in a similar cohort of women. DESIGN: Retrospective analysis. SETTING: University teaching hospital. MATERIALS AND METHODS: Women aged 35 or less undergoing in vitro fertilization/intracytoplasmic sperm injection between January 2005 and December 2006 were included in the study. When four or more grade 1 embryos were observed on day 3, extended culture till day 5 was undertaken. This policy was compared with a cohort of women who had at least three grade 1 embryos on day 3 and who had undergone a cleavage stage embryo transfer during the time period of January 2002–December 2004. Primary outcome evaluated was implantation rate and clinical pregnancy rate. RESULTS: Group 1 consisted of 50 women who underwent extended culture and blastocyst transfer. Group 2 comprised of 85 women who had cleavage transfer. The implantation rate for embryos transferred in group 1 was significantly higher than that for embryos transferred on day 3 (40.16% vs 11.43%). The clinical pregnancy rate was also significantly better with blastocyst transfer as compared with cleavage stage transfer (62% vs 29.76%). Significantly fewer embryos were required for transfer at the blastocyst stage compared with day 3 transfer (2.54 vs 3.45). CONCLUSION: In selected cases, blastocyst transfer with fewer embryos can be performed with high implantation and clinical pregnancy rates. This policy could lead to a reduction in the incidence of higher-order pregnancies.

Fertility and age.

Clomiphene citrate has been traditionally used as the drug of choice in treating women with anovulatory infertility. In the last decade letrozole, an aromatase inhibitor has emerged as alternative ovulation induction agent. Literature confirms that letrozole has a definitive role in anovulatory women who have not responded to the clomiphene therapy. However its role as an alternative to clomiphene as first line therapy continues to be debated. Although it is probable that the overall benefits of letrozole surpass clomiphene citrate, currently available data does not confirm this view. There is need for large well-designed trials.

Effectiveness of GnRH antagonist in intrauterine insemination cycles

OBJECTIVE To report a case of ovarian heterotopic pregnancy after an IVF cycle. DESIGN Case report. SETTING Reproductive medicine unit, Christian Medical College Hospital, Vellore, India. PATIENT(S) A woman with an ovarian heterotopic pregnancy. INTERVENTION(S) Laparoscopic removal of ovarian ectopic pregnancy. MAIN OUTCOME MEASURE(S) Early detection and successful treatment of heterotopic pregnancy. RESULT(S) Successful laparoscopic management of ovarian pregnancy resulting in a single viable ongoing intrauterine pregnancy. CONCLUSION(S) Clinicians need to be aware of such rare and potentially fatal presentations after IVF, because early diagnosis and management in these cases can yield a favorable outcome.

Prevalence of chromosomal abnormalities and Y chromosome microdeletion among men with severe semen abnormalities and its correlation with successful sperm retrieval

The changing social scenario together with economic growth and an increase in job opportunities has to a great extent reduced gender inequality and has resulted in more and more older women seeking help from infertility clinics. Fertility and aging have always been closely linked and the age of the female partner remains the single most important factor in predicting success with treatment. Although tests for the ovarian reserve are an important informative tool and are helpful in selecting treatment options, they are poor predictors of the outcome.

Local endometrial injury in women with failed IVF undergoing a repeat cycle: A randomized controlled trial

OBJECTIVE To evaluate the effectiveness of GnRH antagonists in women undergoing controlled ovarian stimulation and intrauterine insemination cycles (COS/IUI). STUDY DESIGN Randomized controlled trial. Recruited women were randomized into two groups: GnRH antagonist and control group. The primary outcomes were incidence of premature LH surge and clinical pregnancy rates. RESULTS One hundred and forty-one consecutive women were included in the study, with 70 in the antagonist group and 71 in the control arm. The baseline clinical characteristics were similar in both groups. The incidence of premature LH surge and premature luteinization was lower in the antagonist group as compared to the control group (5% vs. 10.3%, P=0.45 and 5% vs. 13.8, P=0.31) but not statistically significant. The clinical pregnancy rates were lower in the antagonist group (2.8% vs. 10%, P=0.12), which was also not statistically significant. CONCLUSION The addition of GnRH antagonist during controlled ovarian stimulation and intrauterine insemination cycles does not lead to improvement in clinical pregnancy rates.

Chorionic villous sampling through transvaginal ultrasound approach: A retrospective analysis of 1138 cases.

AIM: To estimate the prevalence of chromosomal abnormalities and Y chromosome microdeletion among men with azoospermia and severe oligozoospermia and its correlation with successful surgical sperm retrieval. SETTING AND DESIGN: A prospective study in a tertiary level infertility unit. MATERIALS AND METHODS: In a prospective observation study, men with azoospermia and severe oligozoospermia (concentration <5 million/ml) attending the infertility center underwent genetic screening. Peripheral blood karyotype was done by Giemsa banding. Y chromosome microdeletion study was performed by a multiplex polymerase chain reaction. RESULTS: The study group consisted of 220 men, 133 of whom had azoospermia and 87 had severe oligozoospermia. Overall, 21/220 (9.5%) men had chromosomal abnormalities and 13/220 (5.9%) men had Y chromosome microdeletions. Chromosomal abnormalities were seen in 14.3% (19/133) of azoospermic men and Y chromosome microdeletions in 8.3% (11/133). Of the 87 men with severe oligozoospermia, chromosomal abnormalities and Y chromosome microdeletions were each seen in 2.3% (2/87). Testicular sperm aspiration was done in 13 men and was successful in only one, who had a deletion of azoospermia factor c. CONCLUSIONS: Our study found a fairly high prevalence of genetic abnormality in men with severe semen abnormalities and a correlation of genetic abnormalities with surgical sperm retrieval outcomes. These findings support the need for genetic screening of these men prior to embarking on surgical sperm retrieval and assisted reproductive technology intracytoplasmic sperm injection.

Ovulation triggers in anovulatory women undergoing ovulation induction

OBJECTIVE To evaluate the effectiveness of local endometrial injury in women undergoing in vitro fertilization (IVF) with at least one previous unsuccessful attempt. STUDY DESIGN Randomized controlled trial. Recruited women were randomized into two groups. In group A (pipelle group), women underwent pipelle biopsy twice in the luteal phase in the cycle prior to IVF. In group B (control), women did not undergo any intervention prior to IVF. The primary outcome was clinical pregnancy rate. The secondary outcomes included live birth, miscarriage, multiple pregnancy and preterm delivery rates. RESULTS One hundred and eleven women were included in the study with 55 in the pipelle group and 56 in the control arm. The baseline clinical characteristics were similar in both groups. The clinical pregnancy rates were not significantly different between pipelle and control group (34.09% vs. 27.65%; Odds ratio, OR 1.35, 95% confidence interval, CI 0.55-3.30). The live birth (31.81% vs. 25.53%; OR 1.36, 95% CI 0.55-3.39), multiple pregnancy (33.33% vs. 61.54%; OR 0.31, 95% CI 0.07-1.47), miscarriage (6.66% vs. 7.69%; OR 0.86, 95% CI 0.05-15.23) and preterm delivery rates (35.71% vs. 66.66%; OR 0.28, 95% CI 0.05-1.4) were also not significantly different between the two groups. CONCLUSION Current study did not find any improvement in IVF success rates following endometrial injury in woman undergoing IVF after previous failed attempt.