N. Rana

The effect of endometriosis, its stage and activity, and of autoantibodies on in vitro fertilization and embryo transfer success rates*

OBJECTIVES To analyze IVF cycle parameters, including pregnancy rates (PR), in women with and without endometriosis and to evaluate the effect of the stage and activity of endometriosis and of autoantibodies. DESIGN A retrospective analysis of 237 consecutive IVF cycles (193 patients), 119 in women with and 118 without endometriosis. The endometriosis group was further subdivided according to the stage and activity of the disease and autoantibody positivity. SETTING Hospital-based and freestanding IVF programs with the same IVF team. PATIENTS One hundred ninety-three women of reproductive age undergoing IVF; 84 had prior diagnosis of endometriosis, and 109 had other indications for IVF. Within the endometriosis group, 40 did and 44 did not have evidence of active disease. Autoantibodies were measured in 50 patients. INTERVENTIONS The IVF protocol was standard with GnRH agonist administered from the midluteal phase of the preceding cycle. Variables included the method of ET and the use of corticosteroids. MAIN OUTCOME MEASURES Number of follicles produced, number of eggs retrieved, fertilization rates, number of embryos transferred, and PR per transfer. RESULTS There was no difference between groups in the response to stimulation, number of oocytes retrieved, number fertilized, and number cleaved. The overall PR was 27% per transfer; it was similar in women with and without endometriosis (29% and 25%, respectively). There was also no difference in PR according to the stage or activity of the disease. However, PR in autoantibody-positive and -negative patients were significantly different (22.9% and 45.7%, respectively). Among autoantibody-positive patients treated with corticosteroids, 8 of 10 conceived. CONCLUSIONS This study confirms previous reports that IVF success rates are comparable in women with and without endometriosis regardless of the activity and stage of the disease. However, our study also indicates that autoantibodies may affect adversely implantation of embryos and that this effect can be overcome by administration of corticosteroids.

Retroperitoneal subpancreatic ectopic pregnancy following in vitro fertilization in a patient with previous bilateral salpingectomy: how did it get there?

An unusual case of retroperitoneal ectopic pregnancy is reported. The patient, a 34 year old nulligravida, underwent IVF/ET following bilateral salpingectomy. A small, degenerating, intrauterine gestational sac suggested failing intrauterine pregnancy. There was no intraperitoneal free fluid. On Day 41 after ET, the patient was hospitalized because of acute epigastric pains. A pseudocyst of the head of pancreas was demonstrated by CT scan. A day later, exploratory laparotomy, because of a precipitous drop in the hemoglobin, revealed a massive retroperitoneal hematoma and an embryo in the gestational sac attached to the head of pancreas and major blood vessels. The patient did well following surgery. The mechanisms of retroperitoneal embryo migration are discussed and literature is reviewed.

Correlation between fetal heart rate, crown-rump length, and β-human chorionic gonadotropin levels during the first trimester of well-timed conceptions resulting from infertility treatment

OBJECTIVES To evaluate sequential changes in fetal heart rate (FHR) during the first trimester of well-timed pregnancies resulting from infertility treatment and to correlate the data with fetal growth curve and beta-hCG levels. DESIGN Serial measurements of FHR, crown-rump length (CRL) and beta-hCG at weekly intervals throughout the first trimester in 67 consecutive conceptions, resulting from infertility treatment. The day of preovulatory LH surge or of exogenous hCG administration was known in each case. SETTING Hospital based and private assisted reproductive technology centers. RESULTS Mean FHR was 108 +/- 12, 26 to 30 days after LH/hCG (5 weeks, 4 days from last menstrual period [LMP]) in embryos 3 +/- 0.3 mm in size; the FHR gradually increased, reaching a peak of 177 +/- 10 on days 51 to 55 (9 weeks from LMP) in embryos of 23 +/- 5.5 mm; it decreased to 156 +/- 5 on days 76 to 80 (12 weeks, 5 days from LMP) in embryos of 62 +/- 5.7 mm. There was, previously not reported, high level correlation between beta-hCG and FHR during the entire first trimester and positive correlation between FHR and CRL during the first 55 days from conception. CONCLUSIONS During the first trimester of pregnancy, FHR closely follows beta-hCG pattern. Correlation between beta-hCG and FHR is an interesting phenomenon that needs further investigation.

Subcutaneous estradiol pellets for endometrial preparation in donor oocyte recipients with a poor endometrial response

Purpose: The purpose of this study was to evaluate the clinical effectiveness of subcutaneous estradiol pellets in donor oocyte recipients with an inadequate endometrial response.Methods: The subjects were 13 women with ovarian failure and a maximal endometrial thickness <10 mm on standard estrogen regimens, as demonstrated during mock and/or prior oocyte donation cycles. They underwent pellet implantation (100–250 mg of estradiol) 6–13 weeks before oocyte donation.Results: Maximal (mean ± SD) endometrial thickness was 8.7±1.5 mm on standard regimens, in contrast to 11.7± 1.8 mm on pellets, while estradiol levels were 674±844 and 815±706 pg/ml, respectively. The estradiol:estrone ratio on pellets was >1. There was 1 pregnancy with early loss during 10 cycles on other estrogen regimens and 12 pregnancies during 19 cycles on pellets. The pregnancy and implantation rates were, respectively, 63 and 27% on pellets and 41 and 14% on standard regimens in historical controls.Conclusions: We conclude that estradiol pellets after a single administration provide constant estradiol levels extending into the first trimester of pregnancy, a physiologic estradiol:estrone ratio, and a better endometrial response than standard estrogen regimens. Implantation and pregnancy rates are higher. This approach may be especially suitable for recipients with a poor endometrial response.