M. Bustillo

Ultrasonographic predictors of implantation after assisted reproduction

OBJECTIVE To assess the utility of endometrial thickness, echogenic endometrial pattern, and uterine artery impedance measured as pulsativity index in predicting implantation. DESIGN Prospective case-controlled study of infertile patients undergoing assisted reproductive technologies (ARTs). PATIENTS Four hundred five women undergoing ARTs were studied: 100 women after ET of thawed embryos in natural cycles (frozen ET), 107 women after standardized IVF-ET, 99 women receiving donor oocytes after controlled endometrial development with estrogen and P, and 99 women undergoing IUI with various ovarian stimulation regimens (none, 16; GnRH, 7; clomiphene citrate [CC], 29; hMG, 47). INTERVENTIONS Transvaginal ultrasonographic examination performed on the day of hCG administration during stimulated cycles; on E2 day 15 during controlled endometrial cycles; and on the day of ovulation during natural, CC, and GnRH pump cycles. MAIN OUTCOME MEASURE The endometrial thickness, echogenic pattern, and pulsativity index results in 170 conception cycles were compared with 235 nonconception cycles. RESULTS When conception and nonconception cycles were compared, no difference in mean endometrial thickness and significant differences in the frequency of nonmultilayered pattern and pulsativity index > 3.3 were observed. Forty-seven percent of nonconception and 9% of conception cycles were associated with at least one of these factors. CONCLUSION Ultrasonic measurements of pulsativity index, resistance index, and echogenic pattern are useful in predicting implantation after assisted reproduction.

Ultrasonographic findings of pregnancy losses after treatment for recurrent pregnancy loss: intravenous immunoglobulin versus placebo

OBJECTIVE To describe the ultrasonographic findings of pregnancies that terminated in repeat abortion in women participating in an ongoing randomized placebo-controlled clinical trial evaluating the efficacy of intravenous (IV) immunoglobulin (Ig) in the treatment of recurrent spontaneous abortion (SA). DESIGN A prospective descriptive study of ultrasonographic findings of pregnancies from 27 women experiencing repeated recurrent SAs after entry into a clinical trial. SETTING Clinical practice at the Genetics & IVF Institute in Fairfax, Virginia. PATIENTS Women experiencing two or more consecutive recurrent SAs received either 500 mg/kg per mo IV Ig or placebo (albumin). To date 90 women have been enrolled in the clinical trial and 52 have achieved pregnancy. The outcome of the 52 pregnancies include 16 deliveries, 9 ongoing pregnancies, and 27 losses. INTERVENTIONS Ultrasonographic examinations performed in 27 women experiencing pregnancy loss are the subject of this study. MAIN OUTCOME MEASURES The frequency of ultrasonographic findings of empty gestation sac (blighted ovum) and intrauterine fetal demise (IUFD) is compared between patients receiving IV Ig and placebo. RESULTS Ultrasonographic findings of the 27 pregnancies losses included 11 blighted ova and 16 IUFDs. Of 11 blighted ova, 8 (73%) were in women receiving IV Ig and 3 (27%) were receiving placebo. Sixteen IUFDs were observed: 3 (19%) in women receiving IV Ig and 13 (81%) in women receiving placebo. Of 11 pregnancy losses occurring in women receiving IV Ig, 8 (73%) were blighted ova, 3 (27%) were IUFDs. Sixteen pregnancy losses occurred in women receiving placebo: 3 (19%) were blighted ova and 13 (81%) were IUFDs. The differences in frequency of blighted ova between IV Ig- and placebo-treated women was significant. CONCLUSION IV Ig is not effective in preventing blighted ova and may be effective in preventing IUFDs.

Transcervical ultrasound-guided intrafallopian placement of gametes, zygotes, and embryos

Since the pioneering work of Patrick Steptoe and Robert Edwards resulted in the first birth following human in vitro fertilization (IVF), there has been great interest in improving existing methods and developing new techniques for assisted reproduction. In 1984, Ricardo Asch and his colleagues described the first human pregnancy after placement of male and female gametes into the fallopian tube (gamete intrafallopian transfer or GIFT) (1). This procedure involved the aspiration of ovarian follicles by laparoscopy or minilaparotomy and the replacement of oocytes with spermatozoa into one or both normal fallopian tubes. The claimed advantage of this technique over IVF is that placing the gametes into normal oviducts may mimic more closely the natural conditions for fertilization, embryo cleavage, and tubal transport of the embryo into the uterine cavity. It is hoped that, in selected patients, the use of the in vivo physiologic oviductal milieu may improve implantation and term pregnancy rates. The related techniques of PROST (pronuclear-stage transfer) (2), ZIFT (zygote intrafallopian transfer)

Serum progesterone and estradiol concentrations in the early diagnosis of ectopic pregnancy after in vitro fertilization-embryo transfer

To determine if discriminatory P or E2 concentrations can be established for early diagnosis of EP after IVF, 282 pregnancies were studied 11, 13, 15, and 17 days after ET. Receiver-operator characteristic analysis of P and E2 indicated no clinically useful threshold value for EP. No significant differences in P or E2 was seen when intrauterine and extrauterine pregnancies or viable and nonviable pregnancies were compared. All EPs had P < 50 ng/mL and E2 < 500 pg/mL at 11 days after ET. Serum P and E2 cannot differentiate EPs from intrauterine pregnancies nor viable from nonviable pregnancies resulting from IVF.

Small increases in circulating luteinizing hormone (LH) concentrations shortly before human chorionic gonadotropin (hCG) are associated with reduced in vitro fertilization (IVF) pregnancy rate

The effects of slight elevations in serum LH just before hCG administration on IVF cycle outcome were studied in 219 women undergoing retrieval. One hundred seven patients were stimulated using human menopausal gonadotropin (hMG), and 112 received clomiphene citrate and hMG. Serum LH, estradiol (E2), and progesterone concentrations were measured before and during controlled ovarian stimulation. Retrospectively the women were subdivided into three groups based on serum LH before hCG: Group I, <50% LH rise from baseline (BL) value (mean of day 2 and day 7); Group II, LH rise ≥50% but <2×BL; and, Group III, LH rise ≥2×BL. The fertilization and cleavage rates were similar in all groups. However, a ≥50% rise in serum LH before hCG was associated with a significantly reduced IVF pregnancy rate.