M.I. Abuzeid

Elevated progesterone levels in the late follicular phase do not predict success of in vitro fertilization-embryo transfer

OBJECTIVE To examine the effects of subtle elevation in P levels in late follicular phase on the outcome of IVF-ET cycles, using GnRH agonist (GnRH-a) and hMG +/- FSH protocol. DESIGN A retrospective analysis of data. PATIENTS Fifty-four patients who completed 63 IVF-ET cycles were treated with midluteal GnRH-a, followed by hMG +/- pure FSH. Depending on serum P levels on the day of hCG administration, patients were divided in two groups. In group 1, P levels were < or = 0.9 ng/mL (conversion factor to SI unit, 3.180) and in group 2, the levels were > 0.9 ng/mL. RESULTS Luteinizing hormone levels, on the day of hCG administration, as measured by RIA, were suppressed completely. In cycles with subtle P rise (71%), we observed a significantly higher serum E2 concentration, greater number of mature follicles, and greater number of oocytes retrieved. There were no differences between the two groups in fertilization rate, number of embryos transferred, clinical pregnancy rate, implantation rate, and miscarriage or delivery rates. CONCLUSIONS We conclude that in IVF-ET cycles, when pretreated with GnRH-a, P levels may increase on the day of hCG administration despite LH suppression and such elevation may not affect adversely the final outcome.

Testicular sperm extraction and intracytoplasmic sperm injection: A simplified method for treatment of obstructive azoospermia

OBJECTIVE To assess the effectiveness of a simple method of testicular sperm extraction for the treatment of obstructive azoospermia. DESIGN Retrospective study. SETTING Teaching tertiary medical center. PATIENT(S) Seventeen men with obstructive azoospermia. INTERVENTION(S) The patients underwent 19 cycles of intracytoplasmic sperm injection (ICSI) using testicular sperm. In 5 cycles, testicular sperm extraction was performed after failed microepididymal sperm aspiration. In 14 cycles, testicular sperm extraction was performed in the office under local anesthesia from the outset. The outcome was compared with ICSI cycles using ejaculated sperm (95 cycles) and epididymal sperm (12 cycles fresh and 9 cycles frozen-thawed). MAIN OUTCOME MEASURE(S) Clinical pregnancy and implantation rates. RESULT(S) There were no differences in the fertilization, cleavage, implantation, or clinical pregnancy rates among ICSI cycles using testicular, epididymal (fresh or frozen-thawed), or ejaculated sperm. CONCLUSION(S) When used in conjunction with ICSI, testicular sperm extraction from small excisional biopsy is a simple and cost-effective method for the treatment of obstructive azoospermia.

Short follicular phase of stimulation following corifollitropin alfa or daily recombinant FSH treatment does not compromise clinical outcome: a retrospective analysis of the Engage trial

To evaluate whether a short follicular phase of ovarian stimulation compromises the chance of pregnancy, subjects from a double-blind, randomized trial treated with a single dose of corifollitropin alfa (n=756) or daily recombinant FSH (n=750) were categorized as early responders if three follicles ≥17 mm were reached and human chorionic gonadotrophin (HCG) was administered prior to or on stimulation day 8, and as normal responders if three follicles ≥17 mm were reached and HCG was administered after stimulation day 8. In the corifollitropin alfa and recombinant FSH groups, 23.2% and 29.1%, respectively, were early responders (P=0.01). Regardless of the treatment group, the initial ovarian response was higher in early responders, but with two extra days of stimulation, the number and size of follicles on the day of HCG in the normal responders was similar to those of the early responders. The number of oocytes was similar in both response groups following corifollitropin alfa treatment (13.6 versus 14.5) and recombinant FSH treatment (12.8, both groups). The ongoing pregnancy rates were comparable for early and normal responders regardless of the treatment group, supporting successful outcome following a stimulation period of only 1 week.

Congenital Absence of the Utero-Ovarian Ligament: A Clinical Dilemma

An elongated utero-ovarian ligament is associated with an increased risk for ovarian torsion. Our review of literature revealed no published studies on absent utero-ovarian ligament and its management. To present a unique case of congenital absence of the utero-ovarian ligament and the clinical dilemma associated with it. A 37-year-old G6P1 female presented to us with recurrent pregnant loss. She had regular periods with dysmenorrhea and no dyspareunia. The patient underwent diagnostic laparoscopy, which revealed congenital absence of the left utero-ovarian ligament. The left ovarian was adhered to the right utero-sacral ligament secondary to endometriosis. It was a clinical dilemma as to whether we should free the ovary from its current position and reattach it to the posterior surface of the uterus near the normal insertion of the utero-ovarian ligament. We decided to leave the ovary.

Intracytoplasmic sperm injection for treatment of non-obstructive azoospermia

Four cases from a tertiary care teaching medical center were studied to assess the potential of sperm extraction, fertilization and the establishment of pregnancy in couples with non-obstructive azoospermia. Four couples with non-obstructive azoospermia underwent intracytoplasmic sperm injection after testicular sperm extraction. Multiple small biopsies were obtained from each testis under general anesthesia in search for sperm, and to establish a histologic diagnosis. The histopathology includes incomplete maturation arrest, hypospermatogenesis, germ cell hypoplasia and incomplete tubular sclerosis. Testicular sperm extraction resulted in the retrieval of immotile sperm from three patients, and a few motile sperm from one patient. Of 60 oocytes which were injected with testicular sperm, 32 (53.3%) fertilized and 27 of these (84.4%) cleaved. Twelve embryos were transferred to three patients and the remaining 15 embryos were cryopreserved. In one patient, no embryos resulted. One clinical pregnancy was established and a normal female infant, weighing 7 lbs 11 oz, was delivered vaginally in August 1996. This study shows that sperm can be extracted from patients with non-obstructive azoospermia when multiple biopsies are obtained. Fertilization, cleavage, clinical pregnancy and delivery of normal babies can be achieved using intracytoplasmic injection of extracted sperm.