M. Surrey

Clinical and Endocrine Effects of a Microdose GnRH Agonist Flare Regimen Administered to Poor Responders Who Are Undergoing In Vitro Fertilization

OBJECTIVE To assess the endocrine and clinical responses to microdose GnRH agonist (GnRH-a) that was administered in the early follicular phase before controlled ovarian hyperstimulation to poor responders who were candidates for IVF-ET. DESIGN Prospective nonrandomized trial with historical controls. SETTING Tertiary care university-affiliated infertility practice. PATIENT(S) Thirty-four IVF-ET candidates with a prior poor response to a standard long-protocol GnRH-a controlled ovarian hyperstimulation regimen (cycle A). Patients were divided into two groups based on their age at the initiation of cycle A (Group 1: < or = 39 years, n = 15; Group 2: > or = 40 years, n = 19). INTERVENTION(S) Low-dose oral contraceptive (x 21 d) followed by GnRH-a (leuprolide acetate; 40 micrograms s.c. b.i.d.) flare and urofollitropin initiated on day 3 of GnRH-a administration (cycle B). MAIN OUTCOME MEASURE(S) Comparative analysis of clinical responses (total urofollitropin dose used and number of oocytes retrieved as well as fertilization and clinical and ongoing pregnancy rates) and endocrine responses (serum E2, FSH, LH, T, and P levels) between cycles A and B in the two groups. Early follicular phase serum E2 and FSH changes in groups 1 and 2 were compared with changes in nine normal responder controls who were receiving a standard long-protocol GnRH-a/urofollitropin regimen (group 3). RESULT(S) Maximal E2 levels as well as clinical and ongoing pregnancy rates were higher in cycle B patients receiving microdose GnRH-a. Cancellation rates in cycle B were lower than in cycle A. Statistically significant increases in treatment day 6 serum FSH levels were noted during cycle B in both groups 1 and 2 but not in group 3 controls. No abnormal rises in LH, P, or T were noted in any of the groups. CONCLUSION(S) Microdose GnRH-a enhances urofollitropin response and clinical outcome in poor responders undergoing IVF-ET. This may be due to enhanced release of early follicular phase endogenous FSH without concomitant deleterious rises in androgen levels or corpus luteum rescue.

Correlation between salpingoscopic and laparoscopic staging in the assessment of the distal fallopian tube

OBJECTIVE To correlate the severity and extent of intraluminal tubal abnormalities assessed by transfimbrial salpingoscopy with traditional criteria for evaluating distal tubal disease at laparoscopy. DESIGN Prospective 2-year clinical trial with long-term follow-up. SETTING University-affiliated tertiary care reproductive medicine and surgery practice. PATIENTS Fifty-five infertile women with suspected distal tubal disease or unexplained infertility. INTERVENTIONS Transfimbrial salpingoscopy was performed at the time of laparoscopy and terminal neosalpingostomy when appropriate. Salpingoscopic and laparoscopic findings of 91 fallopian tubes were scored independently. RESULTS No correlation between laparoscopic and salpingoscopic findings was noted in group I tubes (n = 51) categorized as having minimal disease or no pathology by traditional staging. In contrast, a strong correlation was noted between findings obtained from these two techniques in group II tubes (n = 40) diagnosed as having moderate-to-severe tubal disease at laparoscopy. Intrauterine pregnancy was achieved in 38.9% (7/18) of patients with mean salpingoscopy scores < or = to 12 versus 3.8% (1/26) of patients with mean scores > 12. Life-table analyses of cumulative estimated pregnancy rates were significantly different between the groups. CONCLUSIONS Fallopian tubes with minimal pathology appreciated at laparoscopy may have more significant intraluminal disease appreciated at salpingoscopy. In contrast, laparoscopic and salpingoscopic findings do correlate well in cases of more severe distal disease. Elevated mean salpingoscopy scores are associated with an extremely poor prognosis for conception.

Laparoscopic sterilization: American Association of Gynecologic Laparoscopists' 1993 membership survey

The 1993 membership survey of the American Association of Gynecologic Laparoscopists received 938 responses, or 13% of the membership. The surgeons reported performing 22,966 sterilizations and 36,482 diagnostic procedures. The distribution of sterilization techniques has remained stable since 1985. Complication rates associated with diagnostic procedures remain consistently higher than those with sterilizations. One death was reported from sterilization, none for diagnostic procedures.

Multicenter feasibility study of a new coaxial falloposcopy system.

We compared falloposcopy employing a new coaxial system with traditional laparoscopic chromotubation and hysterosalpingography in a prospective, multicenter clinical trial at five tertiary infertility centers. Based on findings at hysterosalpingography or laparoscopic chromotubation, the 16 women (22 tubes) in group 1 had a presumed diagnosis of proximal tubal obstruction, and the 4 (7 tubes) in group 2 had unexplained infertility. Cannulation was successfully achieved in 83.3% of tubes. In group 1, 85% (17/20) of visualized tubes were patent and 35% (7/20) were normal. In group 2, 40% (2/5) of visualized tubes were abnormal. Management was changed in 52.4% of women as a result of falloposcopic findings. Falloposcopy with this new coaxial system allows improved visualization with less bulky and less traumatic instruments. The system provides valuable information regarding the fallopian tube lumen that correlates poorly with that obtained with more traditional techniques.

Introduction of a new coaxial falloposcopy system

Coaxial falloposcopy is a transcervical approach to visualizing the entire fallopian tubal lumen from the uterotubal ostium (UTO). To eliminate bulky camera attachments and poor image quality, a new falloposcopy system was developed with a small articulating-tip hysteroscope, stabilizing device to maintain UTO alignment, flexible coaxial catheter and guidewire, and 0.4-mm outer diameter falloposcope with enhanced fiberoptics. We used the instrument in 23 women with a diagnosis of proximal (PTO) or distal (DTO) tubal obstruction (group 1, 16 patients, 30 tubes) or unexplained infertility (group 2, 4 patients, 7 tubes) after previous hysterosalpingogram or laparoscopy. Successful cannulation was achieved in 31 (83.3%) of 37 tubes. Fibrosis of the UTO prevented access to two tubes. In group 1, 14 of 23 tubes with presumed PTO were patent and normal at falloposcopy. In group 2, pathology was present in two of seven tubes. A false positive diagnosis was made in 61% of tubes with presumed PTO and false negative diagnosis in 29% of presumably normal tubes. Coaxial falloposcopy is an effective means of assessing the tubal lumen and should become a more routine part of infertility evaluations.

The Day of Blastocyst Vitrification Significantly Effects Implantation in Subsequent Frozen Embryo Transfers

Icsi vs. Insemination for Trophectoderm Biopsy PGS Cycles: Is There Any Difference in Chromosomal Abnormalities or Pregnancy Rates? J. Barritt, PhD, D. L. Hill, PhD, H. Danzer, MD, M. Surrey, MD, S. Ghadir, MD, W. Chang, MD, S. Munne, PhD. ART Reproductive Center, 450 N. Roxbury Dr, Ste 520, Beverly Hills, CA 90210; Southern California Reproductive Center, 450 N. Roxbury Dr, Ste 500, Beverly Hills, CA 90210; Reprogenetics, 3 Regent Street, Suite 301, Livingston, NJ 07039.

The proximity of warmed embryo transfer of “intentional freeze” embryos from vitrification impacts implantation rates

OBJECTIVE: There is mounting evidence that performing blastocyst transfer at least one menstrual cycle from that in which the patient’s eggs were retrieved improves implantation, presumably due to a more receptive uterine environment. Doing this requires vitrification of blastocysts, warming and transferring them in a subsequent cycle that is 1, 2 or more menstrual cycles from that in which the embryos were created. We wanted to exam if implantation rates were affected by this proximity. DESIGN: Retrospective data analysis from a private laboratory for assisted reproductive technology. MATERIALS AND METHODS: From 2011 to 2013, 216 transfers (excluding donors and surrogates) did not have a fresh blastocyst transfer, electing to have all embryos intentionally vitrified. In 104 of these transfers the patient also had PGD by array comparative genomic hybridization (aCGH). Transfers of warmed blastocysts were performed anywhere from within 40 days of the vitrification cycle, 41-70 days or>70 days and beyond, representing endometrial lining recreation from 1–3 cycles. Based on the idea that it would take somewhere 70 days post-vitrification. RESULTS: Non-PGD defined embryo transfers occurring 70 day group (P 70 day group. Noticeably 11/112 (10%) of the cases in the ‘‘no PGD’’ group were >37, whereas 61/104 (59%) of the ‘‘PGD’’ group were >37. This outcome is therefore reflective of a elimination of the ‘‘age effect’’ in patients 37–41 years old when aCGH-defined blastocysts are used for transfer. CONCLUSION: Our data demonstrates that performing a warmed embryo transfer soon after the vitrification cycle does not allow themost optimal uterine receptivity. Most dramatically demonstrated in warmed cycles after PGD in which at least 2 endometrial lining recreations increased pregnancy rates so significantly that the ‘‘age effect’’ in older patients was overcome by doing intentional freezes with PGD. We strongly recommend not performing warmed ETs of blastocysts <40 days from vitrification.

‘Cook®ing-in’ new MINC incubators: they really can be installed, pass quality control testing and be ready for patient embryos in only 7 days

Objective: “Burn-in” of new incubators is normally performed over as long a period of time as possible. Mouse embryo studies have repeatedly demonstrated that incubators need to “off-gas” residual volatiles from various components before they will pass testing and be cleared for clinical use. We evaluate how quickly the COOK mini-incubator (MINC) can be installed, tested and cleared for clinical use.

What patients can expect for percentage of embryos biopsied and normal embryos available for fresh blastocyst transfer when undergoing trophectoderm biopsy with 24-chromosome genetic analysis

Jason Barritt, PhD, Santiago Munne, PhD, Mark Surrey, MD, Hal Danzer, MD, Shahin Ghadir, MD and David Hill, PhD. ART Reproductive Center, 450 North Roxbury Drive Suite 520 Beverly Hills, California, United States, 90210; Reprogenetics, 3 Regent Street Suite 301 Livingston, New Jersey, United States, 07039 and Southern California Reproductive Center, 450 North Roxbury Drive Suite 500 Beverly Hills, California, United States, 90210.

Pregnancy rates following fresh day 6, fresh day 7 or frozen embryo transfer (FET) of euploid blastocysts after micro-array comparative genomic hybridization (aCGH) analysis

Jason Barritt, PhD, David Hill, PhD, Mark Surrey, MD, Sophia Tormasi, MS, Lauren Kerr, MS and Santiago Munne, PhD. ART Reproductive Center, 450 North Roxbury Drive Suite 520 Beverly Hills, California, United States, 90210; Southern California Reproductive Center, 450 North Roxbury Drive Suite 500 Beverly Hills, California, United States, 90210 and Reprogenetics, 3 Regent Street Suite 301 Livingston, New Jersey, United States, 07039.