Mark A Damario

Blood on the embryo transfer catheter is associated with decreased rates of embryo implantation and clinical pregnancy with the use of in vitro fertilization-embryo transfer

OBJECTIVE To examine the relation between blood found on the transfer catheter after ET and the rates of embryo implantation and clinical pregnancy with the use of IVF-ET. DESIGN Retrospective cohort study. SETTING A tertiary care center for assisted reproductive technology. PATIENT(S) Three hundred seven couples who underwent 354 ETs between January 1, 1994, and June 30, 1996. INTERVENTION(S) A semiquantitative system for recording the amount of blood found inside and outside the transfer catheter after ET. MAIN OUTCOME MEASURE(S) Embryo implantation rate and clinical pregnancy rate (PR). RESULT(S) Blood found outside the transfer catheter after ET was associated with decreased rates of embryo implantation and clinical pregnancy. In contrast, blood located inside the transfer catheter after ET, the type of catheter used for ET, the number of transfer attempts, and the time required for ET did not significantly affect either the embryo implantation rate or the clinical PR. CONCLUSION(S) Blood found outside, but not inside, the transfer catheter after ET is associated with lower rates of embryo implantation and clinical pregnancy with the use of IVF-ET. An emphasis on atraumatic transfer techniques, with prevention of bleeding at the time of ET, should contribute to improved pregnancy outcome with the use of IVF-ET.

Body mass index and uterine receptivity in the oocyte donation model

OBJECTIVE To evaluate the relationship of body mass index (BMI) to uterine receptivity under conditions of programmed hormonal support and standardized embryo quality. DESIGN Retrospective cohort study.A tertiary referral center. PATIENTS Ninety-seven consecutive first-cycle recipients of anonymous oocyte donation. After programmed hormone replacement, recipients had transfer of embryos derived from oocyte donation. Anonymous oocyte donors received ovarian stimulation and underwent transvaginal ultrasound-guided oocyte retrieval. SETTING A receiver operator characteristic (ROC) curve of implantation versus BMI. Area under the ROC curve was 0.51, 95% confidence interval (CI) 0.41-0.62, suggesting no relationship between BMI and implantation. There was no difference in implantation rates between obese (BMI >or=30) and nonobese (BMI <30) recipients, odds ratio 1.1, 95% CI 0.5-2.4. CONCLUSION(S) Uterine receptivity was unimpaired in women with increased BMI when hormonal support and embryo quality were standardized.

Treatment of atypical endometrial hyperplasia with an insulin-sensitizing agent

Endometrial cancer and hyperplasia have long been associated with diabetes. Hyperinsulinemia may have a direct mitogenic effect on the endometrium and may inhibit the effect of progestogen therapy. This case report describes the treatment of a patient with atypical endometrial hyperplasia with an insulin-sensitizing agent. A 37-year-old patient presented after failed treatment of endometrial hyperplasia with progestogen therapy. One month after initiating metformin therapy the patients endometrial biopsy demonstrated proliferative endometrium. This patients atypical endometrial hyperplasia regressed after the initiation of treatment with an insulin-sensitizing agent. This relatively new class of drugs may provide an adjunct to the therapy of endometrial hyperplasia.

Crinone 8%∗ vaginal progesterone gel results in lower embryonic implantation efficiency after in vitro fertilization-embryo transfer ☆

OBJECTIVE To evaluate the outcome of IVF-ET after the use of Crinone 8% (Wyeth-Ayerst Laboratories, Inc., Philadelphia, PA) vaginal progesterone gel and to compare these results with those seen in our program with the use of IM progesterone-in-oil. DESIGN Retrospective cohort study. SETTING A tertiary referral reproductive medicine unit. PATIENT(S) Patients <40 years of age undergoing IVF-ET cycles. INTERVENTION(S) Patients were treated with either Crinone 8% vaginal progesterone gel (90 mg) administered daily or IM progesterone-in-oil (50 mg) administered daily. MAIN OUTCOME MEASURE(S) Biochemical pregnancy rate, implantation rate, and clinical and ongoing pregnancy rates. RESULT(S) The use of Crinone 8% vaginal progesterone gel was associated with a lower implantation rate (16.6% versus 26.2%; odds ratio [OR] = 0.56; 95% confidence interval [CI], 0.35-0.89) compared with the use of IM progesterone-in-oil. Biochemical pregnancies were more common after the use of Crinone 8% vaginal progesterone gel as defined by either biochemical pregnancies per transfer (15.9% versus 5.7%; OR = 3.11; 95% CI, 1.17-8.32) or biochemical pregnancies as a proportion of positive serum hCG titers (29.2% versus 9.8%; OR = 3.80; 95% CI, 1.33-10.86). Clinical pregnancy rates also were lower with the use of Crinone 8% vaginal progesterone gel (36.4% versus 52.9%; OR = 0.51; 95% CI, 0.26-0.99). CONCLUSION(S) Implantation efficiency is reduced, as demonstrated by lower embryonic implantation rates and higher biochemical pregnancy rates, when Crinone 8% vaginal progesterone gel rather than IM progesterone-in-oil is used for luteal phase support after IVF-ET.

Embryo cryopreservation at the pronuclear stage and efficient embryo use optimizes the chance for a liveborn infant from a single oocyte retrieval

OBJECTIVE To estimate the potential for a liveborn in our program achieved through either fresh or frozen embryos derived from a single oocyte retrieval. DESIGN Retrospective analysis. SETTING A tertiary referral reproductive medicine unit. PATIENT(S) All consecutive patients undergoing oocyte retrieval from January 1, 1996, to June 30, 1997. INTERVENTION(S) All couples undergoing IVF-ET at our center are counseled about a specific embryo transfer number after oocyte retrieval based on demographic and historical factors. Only this specified number of embryos is retained in culture. All normally fertilized (2PN) oocytes exceeding this number are immediately cryopreserved at the pronuclear stage. For couples who do not conceive after fresh embryo transfers, frozen embryo transfers are subsequently performed by usually thawing only the number of embryos intended for transfer, thereby conserving remaining embryos for further potential frozen embryo cycles. MAIN OUTCOME MEASURE(S) Liveborn delivery per oocyte retrieval.39.0 years were 61.2%, 59.7%, and 18.5%, respectively. CONCLUSION(S) For women <39 years of age, the efficient use of embryo cryopreservation at the pronuclear stage and economical embryo utilization policies results in cumulative chances for a liveborn exceeding 60%.

Interstitial Heterotopic Pregnancy in a Woman Conceiving by In Vitro Fertilization After Bilateral Salpingectomy

Heterotopic pregnancy, defined as the coexistence of an intrauterine pregnancy and an ectopic pregnancy, occurs in approximately 1 in 100 pregnancies conceived by in vitro fertilization (IVF), particularly when multiple embryos are transferred into the uterus. The ectopic gestation of the combined pregnancy usually occurs within the ampulla of the fallopian tube. If it implants within the interstitial portion of the fallopian tube, however, the resulting interstitial pregnancy eventually can rupture through the uterus, leading to sudden, severe hemorrhage and maternal death. This article describes the rupture of an interstitial heterotopic pregnancy in a 37-year-old woman conceiving by IVF after bilateral salpingectomy. The interstitial pregnancy was removed by laparotomy to protect the intrauterine pregnancy from damage. Physicians should consider interstitial ectopic pregnancy as a cause of abdominal pain, even when a viable pregnancy occurs by IVF after salpingectomy.

Pronuclear stage cryopreservation after intracytoplasmic sperm injection and conventional IVF: implications for timing of the freeze

OBJECTIVE To compare clinical outcomes of frozen embryo transfers using cryopreserved pronuclear stage oocytes that had undergone either intracytoplasmic sperm injection (ICSI) or conventional IVF. DESIGN Observational. SETTING A tertiary referral reproductive medicine unit. PATIENT(S) Couples undergoing either ICSI or conventional IVF from January 1, 1995 to December 31, 1997. INTERVENTION(S) Patients underwent a standard controlled ovarian hyperstimulation protocol and transvaginal ultrasound-guided oocyte retrieval. All normally fertilized (2PN) oocytes exceeding a specified embryo number designated for fresh transfer were immediately cryopreserved at the pronuclear stage. Our cryopreservation method included timing of the freeze according to pronuclear morphology. Subsequent frozen embryo thaw-transfer cycles were usually performed by thawing only the intended number of embryos for transfer. MAIN OUTCOME MEASURE(S) Thaw survival rate, implantation rate, clinical pregnancy rate, delivery rate. RESULT(S) Ninety-six thaw-transfer cycles (n = 72) and 93 thaw-transfer cycles (n = 67) were undertaken in patients who had previously undergone conventional IVF or ICSI, respectively. Embryo thaw survival rates (IVF, 90.4%; ICSI, 91.1%) were similar. Clinical pregnancy (IVF, 40.6%; ICSI, 44.1%) and delivery (IVF, 36.4%; ICSI, 39.8%) rates per transfer, as well as implantation (IVF, 19.1%; ICSI, 19.9%) rates, were also similar. There were only four clinical pregnancy losses in both groups. CONCLUSION(S) Embryo thaw survival is similar for cryopreserved pronuclear stage oocytes derived from ICSI and conventional IVF. Clinical pregnancy, implantation and delivery rates were also similar for the two groups. In addition, there was no increase in the rate of pregnancy loss in ICSI patients after frozen embryo transfers.

Hypersensitivity to progesterone-in-oil after in vitro fertilization and embryo transfer

OBJECTIVE To report the occurrence and management of pulmonary compromise, marked leukocytosis, and eosinophilia in a patient receiving P-in-oil after IVF and embryo transfer. DESIGN Case report.A tertiary referral reproductive medicine unit. PATIENT(S) A 29-year-old patient receiving P-in-oil supplementation after IVF embryo transfer. INTERVENTION(S) Extensive diagnostic testing and surveillance for hypersensitivity to P in sesame oil; development of an alternative oil-based P-in-oil suspension. MAIN OUTCOME MEASURE(S) Tolerance of alternative P vehicle; clinical pregnancy. RESULT(S) The patient tolerated an alternative P oil vehicle and successfully achieved a clinical pregnancy after frozen embryo transfer. CONCLUSION(S) Although rare, hypersensitivity reactions may occur in patients receiving P-in-oil supplementation after IVF embryo transfer. Testing for tolerance and subsequent use of alternative P vehicles may be an effective strategy in managing patients with sensitivity to P-in-oil.

Transabdominal-transperitoneal ultrasound-guided oocyte retrieval in a patient with mullerian agenesis

OBJECTIVE To describe the approach of transabdominal-transperitoneal ultrasound-guided oocyte retrieval undertaken in a patient with müllerian agenesis and ovarian malposition who underwent a successful gestational carrier treatment cycle. DESIGN Case report. SETTING A tertiary-referral reproductive medicine unit. PATIENT(S) A 26-year-old patient with müllerian agenesis. Her 44-year-old mother served as the gestational carrier. INTERVENTION(S) Controlled ovarian hyperstimulation, transabdominal-transperitoneal ultrasound-guided oocyte retrieval, embryo transfer. MAIN OUTCOME MEASURE(S) Oocyte recovery rate, fertilization rate, pregnancy test. RESULT(S) Six oocytes were retrieved using a percutaneous transperitoneal needle puncture under ultrasound guidance. Two cleavage-stage embryos were transferred to the gestational carrier, resulting in a twin pregnancy. CONCLUSION(S) For various reasons, patients with müllerian agenesis may not be candidates for standard transvaginal ultrasound-guided oocyte retrieval. Although laparoscopic oocyte retrieval has been frequently used in this setting, the approach of transabdominal-transperitoneal ultrasound-guided oocyte retrieval may offer further advantages in select cases.

Anonymous oocyte donation performed exclusively with embryos cryopreserved at the pronuclear stage

OBJECTIVE To evaluate the clinical outcomes of patients who participated in an anonymous oocyte donation program that used embryos cryopreserved at the pronuclear stage. DESIGN Observational study. SETTING A tertiary care reproductive medicine unit. PATIENT(S) Anonymous oocyte donors and their respective recipients. INTERVENTION(S) Oocyte donors underwent a standard controlled ovarian hyperstimulation protocol and transvaginal ultrasound-guided oocyte retrieval. Oocyte recipients underwent at least one programmed hormone replacement cycle with transcervical ET. MAIN OUTCOME MEASURE(S) Thaw survival, implantation, clinical and ongoing pregnancy rates. RESULT(S) Thirty-six oocyte retrievals resulted in one ET to date. The mean numbers of oocytes that were retrieved and normally fertilized were 18.2 and 11.6, respectively. Fifty-one embryo thaw-transfer cycles were performed, with an embryo thaw survival rate of 93.5%. The clinical and ongoing pregnancy rates per ET were 52.9% and 51%, respectively. The overall implantation rate was 28.7%. The percentage of oocyte retrievals that resulted in at least one ongoing pregnancy to date was 69.4%. CONCLUSION(S) Anonymous oocyte donation can be conducted efficiently with the exclusive use of embryos cryopreserved at the pronuclear stage. This approach facilitates synchronization of the donor-recipient pair, eliminates the risk that recipients will begin hormonal therapy without embryo availability, and produces an acceptable ongoing pregnancy rate per oocyte donation.