Selmo Geber

Results of IVF in patients with endometriosis: the severity of the disease does not affect outcome, or the incidence of miscarriage

The literature suggests that the results of in-vitro fertilization (IVF) for patients with endometriosis depend on the stage of the disease, and that patients with severe endometriosis have a higher failure rate. Miscarriage is said to be more prevalent in women treated for endometriosis. In the study reported here, 140 patients with endometriosis underwent 182 cycles of IVF using gonadotrophin-releasing hormone analogues (GnRHa). Patients with endometriosis only were allocated to one group (group 4). The results were compared with those of three other groups of patients undergoing the same treatment within the same period. Group 1 consisted of couples with male factor only (45 cycles), group 2, couples with unexplained infertility (196 cycles) and group 3, couples with a tubal factor only (1139 cycles). The mean age of the patients, mean number of human menopausal gonadotrophin (HMG) ampoules administered, oestradiol concentration on the day of human chorionic gonadotrophin administration, number of days of HMG, mean number of oocytes retrieved and retrieval rate were not significantly different. The fertilization rate was significantly lower in group 1; no difference was observed in the other three groups. The mean number of normally fertilized embryos was not significantly different. The number of transferred embryos in each cycle and the implantation rates were similar in the four groups. The overall pregnancy rate per transfer was 39% in group 1, 48% in group 2, 45% in group 3 and 40% in group 4.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical experience with preimplantation diagnosis of sex by dual fluorescent in situ hybridization

PurposeOur purpose was to assess the clinical application of dual fluorescent in situhybridization (FISH) for the diagnosis of sex in the human preimplantation embryo.ResultsOver a 2-year period, 18 couples at risk of transmitting X-linked recessive disorders underwent preimplantation diagnosis of embryo sex by dual FISH with X and Y chromosome-specific DNA probes. A total of 27 in vitro fertilization (IVF) treatment cycles led to nine pregnancies; 7 reached the stage of clinical recognition, of which 2 spontaneously aborted. There were five live births, three singleton and two twin: none in disagreement with the diagnosed sex. The diagnosis was corroborated in 51 of the 74 nontransferred embryos. The efficiency of the procedure improved throughout the four treatment cycles. This was reflected in the increased proportion of double embryo transfers (from 50% in series 1 and 2 to 100% in series 3 and 4), with a consequent improvement in pregnancy rate (from 28 to 71% per embryo transfer). The excess of male embryos (male∶female, 60∶40 overall) and the high proportion of biopsied embryos with abnormal numbers of X and Y chromosome signals (14.5%) effectively reduced the number of normal female embryos available for transfer.ConclusionDual FISH is an efficient technique for determination of the sex of human preimplantation embryos and the additional ability to detect abnormal chromosome copy numbers, which is not possible via the polymerase chain reaction, (PCR), makes FISH the preferred technique.

Proliferation of blastomeres from biopsied cleavage stage human embryos in vitro: an alternative to blastocyst biopsy for preimplantation diagnosis

Normally fertilized human embryos were biopsied at cleavage stages on the third day after in-vitro fertilization (IVF). One or two blastomeres at the 8-cell stage were removed and co-cultured with the biopsied embryos. Embryos and blastomeres were assessed daily for morphological development until day 6, when the number of cells were counted by labelling the nuclei. In all, 53% of the biopsied embryos (25 out of 47) reached the blastocyst stage between day 5 and 6 and the proportion was the same irrespective of the number of cells removed. There was no significant difference between biopsied embryos from which one or two blastomeres respectively had been removed with regard to total cell numbers at the blastocyst stage (56.2 +/- 3.0 and 64.7 +/- 5.5), number of trophectoderm (45.4 +/- 3.5 and 44.0 +/- 5.7) and inner cell mass cells (14.0 +/- 1.2 and 16.6 +/- 1.8). Overall, 72% of the isolated blastomers divided at least once over 3 days in culture and 50% divided more than once. The mean overall cell number after 3 days in culture was 3.7 +/- 0.48 per blastomere (range 1-8 cells) if one cell was removed and 6.9 +/- 1.0 if two cells were removed. If the undivided blastomeres are excluded, the mean cell number was 4.8 +/- 0.51 and 8.3 +/- 1.0 respectively. Over this period, 55% of the blastomeres cavitated. Of the blastomeres taken from embryos that developed to the blastocyst stage, 92% divided and 76% cavitated. In those from arrested embryos, 50% divided (P < 0.002) and 32% cavitated (P < 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between two forms of vaginally administered progesterone for luteal phase support in assisted reproduction cycles

The use of progesterone for luteal phase support has been demonstrated to be beneficial in assisted reproduction cycles using gonadotrophin-releasing hormone analogues (GnRHa). Two micronized progesterone preparations are available for vaginal administration: capsules and gel. The objective of this study was to compare the efficacy of these two forms for luteal phase support in assisted reproduction cycles. A total of 244 couples undergoing IVF/intracytoplasmic sperm injection cycles were included in the study and were randomly allocated (sealed envelopes) into two groups: group 1 (122) received vaginal capsules of 200 mg of micronized progesterone (Utrogestan), 3 times daily, and group 2 (122) received micronized progesterone in gel (Crinone 8%), once daily. Both groups received progesterone for 13 days beginning day 1 after oocyte retrieval, continuing until the pregnancy test was performed and until 12 weeks of pregnancy. Groups were compared by clinical data and assisted reproduction results and had similar ages and causes of infertility. Although the pregnancy rate was higher for those receiving progesterone gel than capsules (44.26 and 36.06% respectively), this difference was not statistically significant. The study showed that vaginal progesterone gel and capsules used for luteal phase support in assisted reproduction cycles with long protocol GnRHa result in similar pregnancy rates.

Comparison Between a Single Dose of Goserelin (Depot) and Multiple Daily Doses of Leuprolide Acetate for Pituitary Suppression in IVF Treatment: A Clinical Endocrinological Study of the Ovarian Response

AbstractPurpose: Compare the efficacy and safety of two different GnRHa, used for pituitary suppression in IVF cycles.nMethods: A total of 292 patients using depot goserelin (Group 1) and 167 using daily leuprolide acetate (Group 2) were compared. Days required to achieve pituitary function suppression, duration of ovarian stimulation, total dose of HMG, number of aspirated follicles, number of oocytes retrieved, and presence of functional ovarian cyst were analyzed.nResults: The time taken to achieve downregulation was similar. The mean number of ampoules used for superovulation was higher in Group 1; however, this difference was observed only for patients >40 years old that started GnRHa in the follicular phase. There was no difference between the two groups in the duration of superovulation, in the number of follicles aspirated, and the number of oocytes retrieved. In the group of patients with >40 years the incidence of ovarian cysts was higher in Group 2.nConclusions: Both routes of GnRHa have similar effects for pituitary suppression and ovulation induction in assisted reproductive technology. Therefore the long-acting GnRHa is an excellent option, as only a single subcutaneous dose is necessary, decreasing the risk of the patient to forget its use and, most important, it does not interfere in the patients quality of life.

Laser confers less embryo exposure than acid tyrode for embryo biopsy in preimplantation genetic diagnosis cycles: a randomized study

We compared two methods of zona pellucida drilling. 213 embryos were biopsied with acid Tyrode. Each biopsy took 3 minutes and the entire procedure ~29 minutes. 5% of blastomeres lysed, 49% of embryos became blastocyst and 36% of patients became pregnant. 229 embryos were biopsied with laser. Each biopsy took 30 seconds and the entire procedure ~7 minutes. 2.5% of blastomeres lysed, 50.6% of embryos became blastocyst and 47% of patients became pregnant. We can conclude that laser can be used for embryo biopsy. Reduction of embryo exposure and of removed blastomeres is associated with increased blastocysts available for transfer and a better clinical outcome.

Cost-Effectiveness of the Freeze-All Policy

OBJECTIVEnTo evaluate the cost-effectiveness of freeze-all cycles when compared to fresh embryo transfer.nnnMETHODSnThis was an observational study with a cost-effectiveness analysis. The analysis consisted of 530 intracytoplasmic sperm injection (ICSI) cycles in a private center in Brazil between January 2012 and December 2013. A total of 530 intracytoplasmic sperm injection (ICSI) cycles - 351 fresh embryo transfers and 179 freeze-all cycles - with a gonadotropin-releasing hormone (GnRH) antagonist protocol and day 3 embryo transfers.nnnRESULTSnThe pregnancy rate was 31.1% in the fresh group and 39.7% in the freeze-all group. We performed two scenario analyses for costs. In scenario 1, we included those costs associated with the ICSI cycle (monitoring during controlled ovarian stimulation [COS], oocyte retrieval, embryo transfer, IVF laboratory, and medical costs), embryo cryopreservation of supernumerary embryos, hormone measurements during COS and endometrial priming, medication use (during COS, endometrial priming, and luteal phase support), ultrasound scan for frozen- thawed embryo transfer (FET), obstetric ultrasounds, and miscarriage. The total cost (in USD) per pregnancy was statistically lower in the freeze-all cycles (19,156.73 ± 1,732.99) when compared to the fresh cycles (23,059.72 ± 2,347.02). Even in Scenario 2, when charging all of the patients in the freeze-all group for cryopreservation (regardless of supernumerary embryos) and for FET, the fresh cycles had a statistically significant increase in treatment costs per ongoing pregnancy.nnnCONCLUSIONSnThe results presented in this study suggest that the freeze-all policy is a cost-effective strategy when compared to fresh embryo transfer.

Ovarian pregnancy after IVF-ET in a patient with absent tube.

Ovarian ectopic pregnancy is an extremely rareevent, with an incidence of 1:7000 deliveries (1)and 2.6% of all ectopic pregnancies (2) after nat-ural conception. In cycles of assisted reproduction,the incidence becomes even more rare (3). Marcusand Brinsden (4) have reported an incidence of 7:2,745 pregnancies, and 7:116 ectopic pregnancies afterinvitrofertilizationcycles.Wereportacaseofovarianpregnancy after IVF–ET treatment for primary infer-tility due to tubal factor (one fallopian tube absentand the other blocked).

Successful ovarian autotransplant with no vascular reanastomosis in rats.

Preservation of ovarian functions in woman with premature ovarian failure remains an issue in reproductive medicine. Hormone replacement therapy for maintaining endocrine functions, and cryopreservation of embryos or oocytes for those who wish pregnancy, are some of the choices. However, ovarian transplantation is a more physiological alternative, although problems related to ovarian ischemia have been reported. Herein, we investigated the viability of autologous transplantation of the ovarian tissue into the rat peritoneum, without vascular reanastomosis. Twenty animals in the study group had both ovaries excised, and each ovary was dissected into two halves. A half of an ovary was autotransplanted to the peritoneal surface, closely located to the left epigastric vessels. This simple procedure does not require surgical vascular reanastomosis while it maintains appropriate follicular growth and therefore should be further considered as an alternative for women undergoing oophorectomy, not only to maintain endocrine functions but also for fertility preservation.

Endometriose de cicatriz cirúrgica: estudo retrospectivo de 72 casos

PURPOSE: to identify the incidence and associated factors of surgical scar endometriosis. METHODS: a retrospective cohort observational study performed from the medical records of female patients attended at the Clinical Hospital of Univesidade Federal de Minas Gerais (UFMG) with histopathological diagnosis of scar endometriosis from May 1978 to December 2003. RESULTS: a total of 72 patients were included in the study. The incidence of scar endometriosis after cesarean section was significantly higher than after episiotomy (0.2% and 0.06%, respectively; p<0.00001) with relative risk of 3.3. The womenx92s age, when diagnosed, ranged from 16 to 48 years old, (mean=30.8 years old). The scar location varied according to the previous surgery: 46 scars after cesarean sections, one after hysterectomy and one after abdominal surgery (48 lesions in the abdominal wall); 19 scars after episiotomy, one because of relapse and two after pelvic floor surgeries (22 pelvic wounds); two women had not been submitted to previous gynecological surgery (one umbilical endometrioma and one lesion in the posterior vaginal wall). Pain was the most frequent symptom (80%), followed by a node (79%) and, in more than 40%, the pain and the node suffered modification with menstruation. Other less frequent complaints were: dyspareunia, secondary infertility, pelvic pain, dysmenorrhoea, scar secretion, menorrhagia pain when evacuating. The mean time observed between the surgery and the beginning of the symptoms was of 3.7 years. The average size of the endometriomas was 3.07 cm. The diagnosis based on clinic evaluation was correct in 71% of the cases. The choice of treatment in all the cases was the surgical excision. In only one incident there was relapse and new intervention. CONCLUSIONS: scar endometriosis is a rare situation originated, in most cases, after obstetrical surgical procedure, with higher risk after cesarean section. It is a highly suggestive clinical condition, with a rare necessity of complementary diagnostic procedures, and the best treatment choice is the surgical excision.