Mason C. Andrews

The program for in vitro fertilization at Norfolk

Several aspects of the program of in vitro fertilization (IVF), or, as it is called in Norfolk, the program for the Vital Initiation of Pregnancy (VIP), have been or are in the process of publication. However, because there has been no overall account, it seems appropriate to give a brief report of a general nature covering the period from the beginning of the effort in late February 1980 through December 31, 1981. Although minor changes were constantly made in the protocol, there were two major revisions. Therefore, a discussion of the program during three distinct periods, i.e., 1980, 1981—Phase I, and 1981—Phase II, is necessary. During 1980 and 1981 all patients had either no fallopian tubes or irreparable tubes.

Three years of in vitro fertilization at Norfolk

During the 3 years from 1981 to 1983, 319 consecutive patients in 560 cycles were treated in a program of in vitro fertilization at Norfolk. All patients were stimulated by human menopausal gonadotropin supplemented by human chorionic gonadotropin. There were transfers in 429 cycles, resulting in 105 pregnancies. Over the 3-year span, the pregnancy rate by cycle was 19%; by transfer, 25%; and by patient, 33%.

The importance of the follicular phase to success and failure in in vitro fertilization

One hundred seventy-five cycles in patients with irreparable tubal disease were stimulated by human menopausal gonadotropin/human chorionic gonadotropin for the purpose of in vitro fertilization. As judged by the height of the peripheral estradiol response, the patients were classified as high, intermediate, or low responders. In addition, the estradiol pattern of the response was found to be separable into six categories. The pregnancy rate was found to be related to the height and to the pattern of peripheral response. The overall pregnancy rate in this consecutive series was 19% but varied according to the height and pattern of response from 40% to 0%.

An analysis of the obstetric outcome of 125 consecutive pregnancies conceived in vitro and resulting in 100 deliveries

One hundred twenty-five consecutive pregnancies conceived in vitro resulted in 100 deliveries of 115 babies. There were 23 clinical abortions (18.4%) and two tubal pregnancies. During the same interval 30 preclinical pregnancies occurred, but these pregnancies did not progress. There were 26 multiple pregnancies (37.1%) before the twelfth week; these reduced spontaneously to 14 (22.2%) multiple births at delivery. Eight infants were delivered prematurely, and three of these died. Three babies had some congenital abnormality. Vaginal bleeding occurred during pregnancy in 59% of patients. Cesarean section was the method of delivery in 56% of patients. Other complications of pregnancy were similar to those of comparable populations.

Impaired reproductive performance of the unicornuate uterus: intrauterine growth retardation, infertility, and recurrent abortion in five cases.

UNICORNUATEUTERUS has been reported very seldom,lm3 and the few reports provide no basis for assessment of the reproductive capability of such organs.4-6 In this article, we address this gap by analyzing six pregnancies in five patients. The following cases (Fig. 1) represent our entire experience in infertility and obstetric practice at Norfolk General Hospital and Johns Hopkins Hospital between 1969 and 1981. Furthermore, a search of the records in these institutions revealed only three additional cases during this period, but one was ineligible for pregnancy, and follow-up was inadequate in the other two.

Papillary peritoneal carcinomatosis after prophylactic oophorectomy

Prophylactic oophorectomy has been recommended in patients with a strongly positive family history for ovarian carcinoma. A patient with a strongly positive family history underwent a prophylactic oophorectomy and, 5 years later, developed a primary peritoneal papillary serous adenocarcinoma. A prophylactic oophorectomy does not afford complete protection in some patients with familial ovarian cancer syndrome. Any tissue derived from the coelomic epithelium may potentially undergo multifocal malignant transformation.

In vitro fertilization in Norfolk, Virginia, 1980-1983

Three years of progress of the Vital Initiation of Pregnancy (VIP) Program in Norfolk is reported. No conception resulted from 41 oocyte aspirations during spontaneous menstrual cycles in 1980. An average of 3.7 oocytes per cycle, or a 73.5% recovery rate, resulted in 362 human menopausal gonadotropin/human chorionic gonadotropin-induced cycles from January 1981 to March 1983. Forty pecent of the oocytes recovered from these cycles were preovulatory, 35% atretic, and 25% immature. Immature oocytes were often matured in vitro, fertilized, and found to produce pregnancies. A total of 62 pregnancies occurred, which represents a 17 or 23% pregnancy rate, based on laporoscopies or embryo transfers, respectively. There were 11 preclinical and 7 clinical miscarriages. Twenty-nine normal babies have been delivered, including a set of twins. The remainder appears to be normally progressing pregnancies. Polyspermia was observed in 8.8% of the fertilizable oocytes.

Reconstructive pelvic operations for in vitro fertilization.

Lysis of adhesions, bilateral salpingectomy, and ovarian suspension were carried out in 54 normal ovulatory patients with long-standing infertility that was associated with severe pelvic adhesions after multiple laparotomies for reimplantation of the fallopian tubes, salpingostomy, lysis of adhesions, or severe endometriosis. Ovulation was induced in 39 patients after laparotomy for in vitro fertilization, with the use of human menopausal gonadotropin, pure follicle-stimulating hormone, and human chorionic gonadotropin. Oocyte retrieval by laparoscopy was accomplished in 37 patients, and embryo transfer was carried out in 36. Pregnancy after in vitro fertilization and embryo transfer occurred in 14 patients. Although severe adhesions recurred in four patients, a significant improvement was obtained after the procedure in the others.

THE USE OF PROGESTINS FOR ORAL CONTRACEPTION

Contraception by the use of steroids and their interference with the ovulatory cycle is attracting increasing attention. Studies such as reported here are determining acceptability and safety.