S. Gordts

Belgian legislation and the effect of elective single embryo transfer on IVF outcome

In order to reduce the number of multiple pregnancies following IVF, the Belgian government agreed to reimburse laboratory expenses for six IVF cycles up to the age of 42 years, in exchange for restriction of the number of embryos replaced. Data on assisted reproduction outcome before and after the introduction of this new legislation were analysed retrospectively in terms of implantation, pregnancy and multiple pregnancy rates. After the introduction of the new law, the percentage of single embryo transfer increased from 14 to 49%. Implantation rates were 25.9 and 23% respectively. There was no difference in the overall pregnancy rate before and after the introduction (36 versus 37%). Twin pregnancies, however, decreased from 19 to 3%. These findings indicate that elective single embryo transfer significantly decreases the twin pregnancy rate without a reduction in the overall pregnancy rate.

Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion.

Endometriosis in the adolescent has, in recent years, been discovered to be a challenging problem in gynaecology. Although the pain may start at a young age, even before the onset of menstruation, the diagnosis by laparoscopy is almost always postponed for several years, by which time destructive lesions have affected the tubo-ovarian structures and severely compromised fecundability. Several factors may play a role, but one important reason for this disease progression is likely to be the delay in diagnosis. Therefore, transvaginal ultrasounds and transvaginal access with a less invasive needle endoscopy are recommended for exploration of the pelvis, diagnosis of endometriosis and treatment at an early stage before severe lesions develop.

The effective cumulative pregnancy rate of different modes of treatment of male infertility

Summary The clinical efficacy of conventional and advanced methods of treatment was assessed in 814 couples with infertility due to a male factor. The monthly and effective cumulative rate of ongoing or term pregnancies was calculated during 4712 couple‐months. Treatment of varicocele by transcatheter embolization, resulting in 3.9% pregnancies per cycle and an effective cumulative pregnancy rate of 41% after 1 year, is more effective than counselling and timed intercourse (9% pregnancies after 12 months). Intrauterine insemination (IUI) of washed spermatozoa produced 17% pregnancies in the initial 4 months, but the success rate of the subsequent cycles (1.7% per cycle) was not different from that of the controls.

The history of Belgian assisted reproduction technology cycle registration and control: a case study in reducing the incidence of multiple pregnancy

STUDY QUESTION What is the effect of a legal limitation of the number of embryos that can be transferred in an assisted reproductive technology (ART) cycle on the multiple delivery rate? SUMMARY ANSWER The Belgian national register shows that the introduction of reimbursement of ART laboratory costs in July 2003, and the imposition of a legal limitation of the number of embryos transferred in the same year, were associated with a >50% reduction of the multiple pregnancy rate from 27 to 11% between 2003 and the last assessment in 2010, without any reduction of the pregnancy rate per cycle. WHAT IS KNOWN ALREADY Individual Belgian IVF centres have published their results since the implementation of the law, and these show a decrease in the multiple pregnancy rate on a centre by centre basis. However, the overall national picture remains unpublished. STUDY DESIGN, SIZE, DURATION Cohort study from 1990 to 2010 of all ART cycles in Belgium (2685 cycles in 1990 evolving to 19 110 cycles in 2010), with a retrospective analysis from 1990 to 2000 and prospective online data collection since 2001. PARTICIPANTS/MATERIALS, SETTING, METHODS Registration evolved from paper written reports per centre to a compulsory online registration of all ART cycles. From 2001 up to mid-2009, data were collected from Excel spread sheets or MS Access files into an MS Access database. Since mid-2009, data collection is done via a remote and secured web-based system (www.belrap.be) where centres can upload their data and get immediate feedback about missing data, errors and inconsistencies. MAIN RESULTS AND THE ROLE OF CHANCE National Belgian registration data show that reimbursement of IVF laboratory costs in July 2003, coupled to a legal limitation in the number of embryos transferred in utero, were associated with a 50% reduction of the multiple pregnancy rate from 27 to 11% without reduction of the pregnancy rate per cycle, and with an increase in the number of fresh and frozen ART cycles due to improved access to treatment. LIMITATIONS, REASONS FOR CAUTION There is potential underreporting of complications of ART treatment, pregnancy outcome and neonatal health. WIDER IMPLICATIONS OF THE FINDINGS Over the 20 years of registration, the pregnancy rate has remained constant, despite the reduction in the number of embryos transferred, optimization of laboratory procedures and stimulation protocols, introduction of quality systems and implementation of the EU Tissue Directive over the period 2004-2010. STUDY FUNDING/COMPETING INTEREST(S) No external funding was sought for this study. None of the authors has any conflict of interest to declare.

Paternal contribution to aneuploidy in preimplantation embryos

The association between sperm indices and the chromosomal status of preimplantation embryos was assessed in 230 couples with a female partner younger than 36 years undergoing 295 cycles of preimplantation diagnosis for aneuploidy: 105 cycles had normozoospermic samples, 134 cycles presented with oligoasthenoteratozoospermia (OAT), while the remaining cycles had spermatozoa retrieved from the seminal tract due to obstructive (29 cycles) or non-obstructive azoospermia (NOA, 27 cycles). One blastomere was biopsied from day-3 embryos and analysed for chromosomes XY, 13, 15, 16, 17, 18, 21, and 22. From the testing of 1549 embryos, the proportion of chromosomally abnormal embryos was significantly lower in normozoospermic patients (55%) than in OAT (62%, P < 0.025) and NOA patients (69%, P < 0.005). Complex abnormalities were the most frequent defect in NOA (68%), which also demonstrated the highest incidence of gonosomal aneuploidy (12%). From the re-analysis of all blastomeres in 493 non-transferred embryos, 95% of NOA embryos were chaotic mosaics. In conclusion, a severe male infertility condition could contribute to the generation of chromosomal abnormalities in the resulting embryos. This might occur especially in NOA patients in which the high incidence of chromosomal abnormalities is mainly due to mosaicism and gonosomal aneuploidy.

The epithelium of human hydrosalpinges: a light optical and scanning electron microscopic study

Summary. Multiple tubal biopsies from 21 patients with thin‐walled dilated hydrosalpinges and from 12 patients with thick‐walled fibrous hydrosalpinges were studied. All the biopsies were examined by light microscopy and scanning electron microscopy and the ciliated surface area at multiple locations measured by planimetry. These biopsies were compared with control biopsies taken from 13 normal women at varying stages of the menstrual cycle.

Transvaginal hydrolaparoscopy in the treatment of polycystic ovary syndrome

OBJECTIVE To evaluate the efficacy of transvaginal endoscopic ovarian capsule drilling. DESIGN Retrospective efficacy study. SETTING Private tertiary care center. PATIENT(S) Thirty-nine PCOS patients with previously failed ovulation induction; mean duration of infertility 26.5 months (SD +/-2.6); mean age 30.38 years (SD +/-3.8); mean body mass index of 29.4 (SD +/-9.7). INTERVENTION(S) Through transvaginal hydrolaparoscopy in a 1-day clinic setting, drilling of the ovarian capsule is performed with a 5-Fr bipolar needle (Karl Storz, Tüttlingen, Germany) creating 10-15 holes of +/-0.20 mm in each ovary. MAIN OUTCOME MEASURE(S) Evaluation of feasibility, spontaneous resumption of ovulatory cycles and pregnancy rates. RESULT(S) Ovarian capsule drilling was performed in 39 patients. Six patients were lost of follow-up. In total, 25 out of 33 patients (76%) became pregnant with a mean duration between procedure and onset of pregnancy of 7.2 months (SD +/-5.4). Natural conception with or without controlled ovarian hyperstimulation and/or intrauterine insemination occurred in 13 of the 16 patients (81%). Of the 17 patients referred to our IVF program, 12 became pregnant. There were no multiple pregnancies or complications. CONCLUSION(S) The transvaginal approach for ovarian capsule drilling offers a valuable alternative to the standard laparoscopic procedure.

The comprehensiveness of the ESHRE/ESGE classification of female genital tract congenital anomalies: a systematic review of cases not classified by the AFS system

STUDY QUESTION How comprehensive is the recently published European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) classification system of female genital anomalies? SUMMARY ANSWER The ESHRE/ESGE classification provides a comprehensive description and categorization of almost all of the currently known anomalies that could not be classified properly with the American Fertility Society (AFS) system. WHAT IS KNOWN ALREADY Until now, the more accepted classification system, namely that of the AFS, is associated with serious limitations in effective categorization of female genital anomalies. Many cases published in the literature could not be properly classified using the AFS system, yet a clear and accurate classification is a prerequisite for treatment. STUDY DESIGN, SIZE AND DURATION The CONUTA (CONgenital UTerine Anomalies) ESHRE/ESGE group conducted a systematic review of the literature to examine if those types of anomalies that could not be properly classified with the AFS system could be effectively classified with the use of the new ESHRE/ESGE system. An electronic literature search through Medline, Embase and Cochrane library was carried out from January 1988 to January 2014. Three participants independently screened, selected articles of potential interest and finally extracted data from all the included studies. Any disagreement was discussed and resolved after consultation with a fourth reviewer and the results were assessed independently and approved by all members of the CONUTA group. PARTICIPANTS/MATERIALS, SETTING, METHODS Among the 143 articles assessed in detail, 120 were finally selected reporting 140 cases that could not properly fit into a specific class of the AFS system. Those 140 cases were clustered in 39 different types of anomalies. MAIN RESULTS AND THE ROLE OF CHANCE The congenital anomaly involved a single organ in 12 (30.8%) out of the 39 types of anomalies, while multiple organs and/or segments of Müllerian ducts (complex anomaly) were involved in 27 (69.2%) types. Uterus was the organ most frequently involved (30/39: 76.9%), followed by cervix (26/39: 66.7%) and vagina (23/39: 59%). In all 39 types, the ESHRE/ESGE classification system provided a comprehensive description of each single or complex anomaly. A precise categorization was reached in 38 out of 39 types studied. Only one case of a bizarre uterine anomaly, with no clear embryological defect, could not be categorized and thus was placed in Class 6 (un-classified) of the ESHRE/ESGE system. LIMITATIONS, REASONS FOR CAUTION The review of the literature was thorough but we cannot rule out the possibility that other defects exist which will also require testing in the new ESHRE/ESGE system. These anomalies, however, must be rare. WIDER IMPLICATIONS OF THE FINDINGS The comprehensiveness of the ESHRE/ESGE classification adds objective scientific validity to its use. This may, therefore, promote its further dissemination and acceptance, which will have a positive outcome in clinical care and research. STUDY FUNDING/COMPETING INTEREST(S) None.

Clinical factors determining pregnancy outcome after microsurgical tubal reanastomosis

OBJECTIVE To evaluate pregnancy rates after tubal microsurgical anastomosis. DESIGN Retrospective study. SETTING Private tertiary care center. PATIENT(S) Two hundred sixty-one women undergoing tubal microsurgical anastomosis. INTERVENTION(S) Tubal anastomoses were performed by minilaparotomy using microsurgical principles and approximating proximal and distal tubal ends in a two-layer technique with 8-0 ethylon. MAIN OUTCOME MEASURE(S) Pregnancy outcome was analyzed for the technique of sterilization, location of anastomosis, tubal length, age, and semen parameters. RESULT(S) After exclusion of 89 patients lost to follow-up (34%) and 8 who did not attempt to conceive, 164 of the 261 patients were analyzed.The overall intrauterine pregnancy rate was 72.5%, with a miscarriage rate of 18% and a tubal pregnancy rate of 7.7%. Related to age, the cumulative intrauterine pregnancy rate was, respectively, 81%, 67%, 50%, and 12.5% for patients <36, 36-40, 40-43, and >43 years. Mean time to pregnancy was respectively 6.9, 6.2, and 12.7 months, respectively, for patients aged <36, 36-39, and 40-43 years According to the type of sterilization, intrauterine pregnancies occurred in 72% after ring sterilization, 78% after clip sterilization, 68% after coagulation, and 67% after Pomeroy sterilization. Intrauterine pregnancies and ectopic pregnancies, respectively, occurred in 80% and 3.4% in the isthmo-isthmic, 63% and 18% in the isthmo-ampullar, 75% and 8.3% in the isthmo-cornual, 100% and 0% in the ampullo-ampullar, and 60% and 0% in the ampullo-cornual anastomosis groups. Tubal length after anastomosis did not influence the pregnancy rate. In case of fertile sperm, the pregnancy rate was found to be 80%, and it decreased to 50% in case of subfertile semen. CONCLUSION(S) Our results clearly demonstrate the validity of tubal microsurgical anastomosis, establishing a quasinormalization of the fertility potential and offering the opportunity for a spontaneous conception.

Reversibility after female sterilization

Summary. The factors influencing the result of reversal of tubal sterilization were investigated in a series of 78 patients who requsted this operation during a 5‐year period between 1977 and 1982. In the Falopering group isthmo‐isthmic anastomosis resulted in a 92% pregnancy rate. On the other hand, no pregnancy occurred when the final tubal length after anastomosis was less than 4 cm. Ectopic pregnancy occurred in 5% of the patients.