Mark Surrey

Adhesion reformation and de novo adhesion formation after reproductive pelvic surgery

At second-look laparoscopy, 82 of 161 women (51%) were noted to have adhesions at at least one new location. Such adhesions occurred at 31% of available sites. Among 121 women with adhesions at the initial operative procedure, the rate and type of recurrence assessed on the ovaries, fimbriae, and other sites were independent of the initial type. Additionally, neither the rate nor the type of adhesion recurrence observed at the time of second-look laparotomy was determined by the variable amount of time between the initial and second-look operative procedures. We conclude that reproductive pelvic surgical procedures are frequently complicated not only by adhesion reformation but by de novo adhesion formation as well.

Effect of prolonged gonadotropin-releasing hormone agonist therapy on the outcome of in vitro fertilization- embryo transfer in patients with endometriosis

OBJECTIVE To evaluate the effect of a 3-month course of GnRH agonist administered immediately before IVF-ET in infertile patients with endometriosis. DESIGN Prospective, randomized trial. SETTING Three tertiary care assisted reproductive technology programs. PATIENT(S) IVF-ET candidates with surgically confirmed endometriosis. INTERVENTION(S) Twenty-five patients received three courses of a long-acting GnRH agonist, 3.75 mg i.m. every 28 days, followed by standard controlled ovarian hyperstimulation. Twenty-six patients received standard controlled ovarian hyperstimulation with mid-luteal phase GnRH agonist down-regulation or microdose flare regimens. MAIN OUTCOME MEASURE(S) Response to controlled ovarian hyperstimulation, ongoing pregnancy rates per cycle, group implantation rates, and implantation rate per embryo transfer procedure. RESULT(S) The extent of surgically confirmed endometriosis was greater in patients who received the long-acting GnRH regimen for 3 months before IVF-ET. The groups did not differ significantly in terms of dose or duration of gonadotropin stimulation, number of oocytes retrieved, fertilization rate, or number of embryos transferred. Patients who received the long-acting GnRH regimen had significantly higher ongoing pregnancy rates (80% vs. 53.85%) and a trend toward higher implantation rates (42.68% vs. 30.38%). CONCLUSION(S) Prolonged use of GnRH agonist before IVF-ET in patients with endometriosis resulted in significantly higher ongoing pregnancy rates than did standard controlled ovarian hyperstimulation regimens. No deleterious effect on ovarian response was observed.

Diminished effect of maternal age on implantation after preimplantation genetic diagnosis with array comparative genomic hybridization.

OBJECTIVE To assess the relationship between maternal age, chromosome abnormality, implantation, and pregnancy loss. DESIGN Multicenter retrospective study. SETTING IVF centers in the United States. PATIENT(S) IVF patients undergoing chromosome screening. INTERVENTION(S) Embryo biopsy on day 3 or day 5/6 with preimplantation genetic diagnosis (PGD) by array comparative genomic hybridization. MAIN OUTCOME MEASURE(S) Aneuploidy, implantation, pregnancy, and loss rates. RESULT(S) Aneuploidy rates increased with maternal age from 53% to 93% for day 3 biopsies and from 32% to 85% for blastocyst biopsies. Implantation rates for euploid embryos for ages <35-42 years did not decrease after PGD: ranges 44%-32% for day 3 and 51%-40% for blastocyst. Ongoing pregnancy rates per transfer did not decrease for maternal ages <42 years after PGD with day 3 biopsy (48.5%-38.1%) or blastocyst biopsy (64.4%-54.5%). Patients >42 years old had implantation rates of 23.3% (day 3), 27.7% (day 5/6), and the pregnancy rate with day 3 biopsy was 9.3% and with day 5 biopsy 10.3%. CONCLUSION(S) Selective transfer of euploid embryos showed that implantation and pregnancy rates were not significantly different between reproductively younger and older patients up to age 42 years. Some patients who start an IVF cycle planning to have chromosome screening do not have euploid embryos available for transfer, a situation that increases with advancing maternal age. Mounting data suggests that the dramatic decline in IVF treatment success rates with female age is primarily caused by aneuploidy.

Accuracy of FISH analysis in predicting chromosomal status in patients undergoing preimplantation genetic diagnosis

OBJECTIVE The purpose of this study was to determine the positive predictive value (PPV) and negative predictive value (NPV) of FISH analysis and to determine which chromosomal abnormalities are most frequently confirmed. DESIGN Prospective observational. SETTING IVF laboratory. PATIENT(S) Two hundred forty-one embryos were analyzed from 98 patients. INTERVENTION(S) FISH reanalysis. MAIN OUTCOME MEASURE(S) Embryos that would have been discarded in patients undergoing preimplantation genetic diagnosis (PGD) were fixed and FISH reanalysis was performed. Results of reanalysis were compared with the day 3 diagnosis while PPV and NPV were calculated. RESULT(S) Among the 241 embryos, 198 embryos were abnormal and 43 were normal by day 3 FISH analysis. The PPV was 83% and the NPV was 81%. PPV was also determined for specific categories of aneuploidy, and certain abnormalities such as monosomies, trisomies, tetrasomies, and polyploidies were frequently confirmed on reanalysis (PPV >80%), whereas Turner syndrome diagnosis was not (PPV = 17%). CONCLUSION(S) FISH analysis offers a PPV of 83% and NPV of 81% when evaluating a single blastomere in conjunction with PGD. FISH errors and mosaicism are primarily responsible for the errors associated with FISH analysis in PGD.

The effect of timing of embryonic progression on chromosomal abnormality

OBJECTIVE To evaluate the relationship between aneuploidy and timing of blastocyst formation. DESIGN Historical cohort study. SETTING Private IVF clinic. PATIENT(S) Ninety-four couples undergoing IVF treatment in combination with chromosomal screening of embryos. The mean maternal age was 39.2 years and average number of embryos per patient 5.3. INTERVENTION(S) A total of 530 embryos were biopsied on day 3 and underwent chromosome screening with microarray-based comparative genomic hybridization. MAIN OUTCOME MEASURE(S) Effect of day of embryo blastulation and morphologic grade on aneuploidy rate. RESULT(S) Day 5 morulas that progressed to blastocysts on day 6 were significantly less likely to be aneuploid (79.8%) than day 5 morulas that did not progress to blastocysts (92.9%). However, there was no significant difference in aneuploidy rates when embryos that became blastocysts on day 5 were directly compared with embryos that became blastocysts on day 6. CONCLUSION(S) Delayed blastulation is not associated with increased aneuploidy rates, but absence of blastulation is associated with increased aneuploidy. Therefore, we conclude that when choosing a morula for transfer on day 5, there may be a benefit in waiting an extra day for the possibility of blastulation to occur.

Appendiceal Disease in Women with Endometriosis and Right Lower Quadrant Pain

STUDY OBJECTIVE To evaluate the frequency and range of appendiceal disease in women with endometriosis and right lower quadrant (RLQ) pain, and to estimate the value of preoperative gastrograffin enema (GGE) as a screen for the disease. DESIGN Nonrandomized clinical trial (Canadian Task Force classification II-2). SETTING University-affiliated hospital with a private practice setting. PATIENTS A subpopulation of 65 women from a group of 337 patients undergoing laparoscopy for symptomatic endometriosis. INTERVENTION Preoperative GGE was performed whenever possible in these women. At laparoscopy, the appendix was removed if it appeared abnormal or if the preoperative GGE was positive. MEASUREMENTS AND MAIN RESULTS Of 65 women (19%) with symptomatic endometriosis and preoperative RLQ pain, 52 (80%) underwent appendectomy as part of surgery. Of these 52 excised appendixes, 39 (75%) had histologically confirmed pathology including appendicitis or periappendicitis, endometriosis, fibrous obliteration, lymphoid hyperplasia, and carcinoid tumor. Preoperative GGE had sensitivity of 74% and specificity of 83% for appendiceal disease. Its positive predictive value was 95% and negative predictive value was 42%. No complications from laparoscopic appendectomy occurred. CONCLUSION Disease of the appendix is common in women with endometriosis and RLQ pain. Appendectomy is particularly likely if preoperative GGE is positive.

Micromanipulation in a center for reproductive medicine

Several variations of micromanipulation of the female gamete (zona drilling, zona cracking, ooplasmic sperm injection, partial zona dissection) have been applied recently to human IVF to overcome severe male factor. Of the first 16 cycles attempted using partial zona dissection, one pregnancy resulted leading to a normal term delivery. Careful removal of the coronal cells, as well as stepwise removal of sucrose postpartial zona dissection, will facilitate this procedure and greatly reduce potential damage to the oocyte by pH, mechanical, or thermal injury. Micromanipulation has become a routine service offered in our program in cases where the likelihood of a poor IVF outcome is either known or suspected, and also serves as a replacement for simple reinsemination in cases of failed fertilization.

Is Gender Selection an Appropriate Use of Medical Resources

Gender selection by PGD is an appropriate use of medical resources. Children borne through PGD for gender determination would be welcome and would come into a couples life at a planned, opportune time. If the practice were made more available through insurance coverage, the size and makeup of families could become a matter of choice rather than chance for couples favoring this approach.

The clinical ramifications of polycystic ovarian morphology in oocyte donors

ObjectiveTo determine the relationship between Polycystic Ovary (PCO) morphology and In Vitro Fertilization (IVF) outcome in oocyte donation cycles.DesignCross sectional studySettingPrivate IVF clinicPatients164 consecutive ovum donors and their recipients were reviewed, 149 were included in the study where 113 patients had normal ovarian morphology and 36 patients had PCO morphology.InterventionsAll donors underwent ovarian stimulation in conjunction with GnRH agonist or antagonist in standard fashion.Main Outcome MeasuresBaseline donor characteristics were recorded, as well as details of IVF stimulation and embryo data. Recipient data on pregnancy and miscarriage were also collected.ResultsPatients with PCO ovaries had significantly higher peak estradiol levels and required less gonadotropins during IVF stimulation. In addition, the baseline characteristics between donor groups did not differ except for ovarian morphology. The number of oocytes retrieved and indicators of embryo quality did not differ between the two groups, and there was no significant difference between pregnancy and miscarriage rates in the recipients.ConclusionsOocyte donors with PCO morphology have equivalent pregnancy rates and do not need to be excluded as potential donors.

Successful outcome after preimplantation genetic screening and very delayed embryo transfer

We report the positive outcome of a delayed single ET of a preimplantation genetic screening-defined embryo in an otherwise routine case of IVF-ET. To our knowledge, this is the first report of a fresh ET 48 hours longer than what is generally considered the limit of days after egg retrieval (six) to safely perform an ET.