Shauna Reinblatt

EFFECTS OF OVARIAN ENDOMETRIOMA ON EMBRYO QUALITY

The proportions of good, fair, and poor embryos in 13 women with bilateral endometriomas were compared with those of 39 women without endometriomas and were found to be similar (47.2% vs. 41.1%, 28.3% vs. 32.8%, and 24.3% vs. 26.0%, respectively). Therefore, it appears that the presence of bilateral endometriomas during IVF treatment is not associated with reduced embryo quality.

Comparison of automated and manual follicle monitoring in an unrestricted population of 100 women undergoing controlled ovarian stimulation for IVF

BACKGROUND Ovarian response to gonadotrophin stimulation is monitored with serial ultrasound (US) examinations. Sonography-based Automated Volume Count (SonoAVC) is a relatively new three-dimensional (3D) US technology, which automatically generates a set of measurements including the mean follicular diameter (MFD) and a volume-based diameter (d(V)) for each follicle in the ovaries. The present study aimed to assess the applicability and reproducibility of this automated follicle measurement method in an IVF programme. METHODS For this prospective method comparison study, 100 women undergoing US monitoring of a controlled ovarian stimulation cycle were recruited. Each follicle was manually measured by taking the mean of maximal diameters on three orthogonal planes with two-dimensional (2D) US. A 3D volume of each ovary was then captured. The ovarian volumes were later analysed using SonoAVC. The agreement between the two methods for the numbers of follicles and the size of the leading follicle was assessed with the Bland-Altman method. The reproducibility of SonoAVC measurements was assessed with the intraclass correlation coefficient (ICC). RESULTS Both SonoAVC-generated MFD and d(V)-based follicle counts, as well as the leading follicle diameter, had good agreement with conventional 2D US measurements. SonoAVC measurements had very good reproducibility, with ICC ≥0.8 for most evaluations. CONCLUSIONS Automated follicle monitoring with SonoAVC can replace or be used interchangeably with conventional 2D measurements. Automated follicle monitoring can save time, provide a method of quality control and create opportunities for developing HCG criteria based on follicular volume or for monitoring patients from a distance.

Ovarian stimulation and intrauterine insemination in women aged 40 years or more

Fertility decreases with advancing age. This study retrospectively reviewed the results of ovarian stimulation and intrauterine insemination (IUI) in women 40 years old with diminished ovarian reserve or unexplained infertility who underwent treatment with ovarian stimulation/IUI with clomiphene citrate or gonadotrophin and compared them with the results of IVF and in-vitro maturation (IVM) treatments. The main outcome measures were pregnancy and live-birth rates. The profiles of the patients in ovarian stimulation, IVM and IVF groups were comparable. There were no clinical pregnancies in the clomiphene citrate and IVM groups. The clinical-pregnancy rates in the gonadotrophin and IVF groups were 2.6% and 16.9% and the live-birth rates were 2.6% and 13.7%, respectively. Compared with ovarian stimulation, IVF is most effective for women aged 40 years or more. Attempting success with ovarian stimulation or IVM will delay conception unnecessarily.

Effects of different body mass indices on in vitro maturation in women with polycystic ovaries

OBJECTIVE To evaluate the effect of body mass index (BMI) on in vitro maturation (IVM) outcomes in women with polycystic ovaries. DESIGN Retrospective, cohort study. SETTING Tertiary IVF unit. PATIENT(S) One hundred thirteen women with polycystic ovaries. INTERVENTION(S) One hundred sixteen cycles of IVM. Patients were divided into subgroups according to their BMI: underweight, normal weight, overweight, obese, and morbidly obese. We evaluated the effects of BMI on the number of oocytes matured in vivo, maturation rate in vitro, fertilization and cleavage rates, number of embryos transferred, implantation rates, pregnancy rates, and delivery rates. MAIN OUTCOME MEASURE(S) Pregnancy rate and delivery rate. RESULT(S) The number and quality of oocytes among women with different BMIs were similar. There was no significant difference in the endometrial thickness and rates of implantation, pregnancy, and delivery among women with different BMIs. The pregnancy rate in underweight women was 50%, normal weight 47.9%, overweight 29.1%, obese 27.2%, and in morbidly obese women was 30.7%. The miscarriage and delivery rates were also similar. CONCLUSION(S) The results of IVM are independent of BMI.

Fertilization and embryo development with spermatozoa obtained from testicular sperm extraction into oocytes generated from human chorionic gonadotropin-primed in vitro maturation cycles

OBJECTIVE To evaluate the fertilization rate and embryo development resulting from intracytoplasmic sperm injection (ICSI) of spermatozoa retrieved by testicular sperm extraction (TESE) in hCG-primed in vitro maturation (IVM) cycles. DESIGN Case-control study. SETTING University teaching hospital. PATIENT(S) Twenty-four IVM cycles were performed in 21 patients (mean age, 32.3 ± 2.4 years) with polycystic ovaries (PCO) whose partners were nonobstructive azoospermic. Twelve cycles where IVM oocytes were also retrieved were compared with a control group consisting of age-matched IVM cycles with ICSI using ejaculated spermatozoa (n = 12). INTERVENTION(S) In vitro maturation treatment with TESE sperm. MAIN OUTCOME MEASURE(S) Fertilization and embryo development between sibling oocytes matured in vivo and in vitro. RESULT(S) Eight singleton pregnancies and one twin pregnancy were obtained after ET (9/24, 37.5%). In the 12 IVM cycles where in vivo-matured oocytes were also obtained, the fertilization rate after TESE-ICSI was significantly higher in in vivo-matured oocytes than in sibling in vitro-matured oocytes (84.2% vs. 53.2%). The proportion of good quality embryos was also higher (63.5% vs. 40.2%). In the control group of cycles with ejaculated spermatozoa, there was no difference in fertilization rates between sibling oocytes matured in vivo and in vitro (84.6% vs. 79.6%). CONCLUSION(S) Our results suggest that IVM of immature oocytes combined with TESE-ICSI is an option for couples with PCO and azoospermia. However, there are lower fertilization and good quality embryo rates achieved when TESE-ICSI was done with in vitro-matured oocytes. Additional studies are necessary to determine the role of this treatment combination.

Priming in vitro maturation cycles with gonadotropins: salvage treatment for nonresponding patients

OBJECTIVE To compare the treatment outcomes in in vitro maturation (IVM) cycles primed with human menopausal gonadotropin with those for pure IVM cycles in patients with polycystic ovary syndrome. DESIGN Prospective observational. SETTING University-based tertiary medical center. PATIENT(S) Patients undergoing IVM cycles (primed IVM, 47; pure IVM, 118). INTERVENTION(S) IVM treatment with and without human menopausal gonadotropin stimulation. MAIN OUTCOME MEASURE(S) Pregnancy rates. RESULT(S) The clinical pregnancy rate demonstrated a tendency toward improvement in the primed IVM group (53.1% vs. 43.6%, 20.1% vs. 14.0% and 40.4% vs. 30.8%, [corrected] respectively) with better implantation and delivery rates (20.1% versus 14.4%; 95% confidence intervals 1.0-3.06 and 40.4% versus 24.6%; 95% confidence intervals 0.1-0.8, respectively). We found no significant difference in pure IVM compared with primed IVM in the number of eggs collected, size of leading follicle, fertility rate, cleavage rate, and the number of embryos transferred. Total mature eggs and maturation rate were significantly higher in the group of pure IVM (11 ± 2.1 versus 8.7 ± 0.5 and 68.5% ± 17.5% versus 60.9% ± 0.4%, respectively). Importantly, the endometrial thickness was significantly improved in primed IVM cycles (7.9 ± 1.9 mm versus 7.1 ± 0.8 mm), possibly leading to better implantation and pregnancy rates. CONCLUSION(S) Patients who fail to demonstrate endometrial or follicular growth during IVM cycles may benefit from gonadotropin priming during the same cycle.

How old is too old for in vitro maturation (IVM) treatment

OBJECTIVE Fertility declines with age. A study of the outcomes of in vitro maturation (IVM) in women of different ages has not been reported to date. The aim of our study was to evaluate the impact of age on treatment response and on pregnancy rates after IVM treatment. STUDY DESIGN We reviewed the data of all IVM cycles and recorded the total number of oocytes, total metaphase II (MII) oocytes, the number and quality of embryos as well as pregnancy rates. The main outcome measures were number and maturity of retrieved oocytes and pregnancy rates. RESULTS Compared to cycles in women ≤25 years, the number of oocytes and total MII oocytes were significantly lower in women over 40 years. The number of good quality embryos in women ≤25 years (3.6±1.7) was higher than in women aged 40 years (0.8±1.2, P<0.0001). The ongoing pregnancy rates in women aged 20-25 years were 36.8%, 26-35 years were 30.0% and in those 36-39 years were 31.9%. No clinical pregnancy was observed in women over the age of 40. CONCLUSION Women over 40 years are poor candidates for IVM treatment.

What are the best semen parameters to predict pregnancy in intrauterine insemination cycles

Background/Aim: Intrauterine insemination (IUI) is widely used for sub-fertile couples. The optimal method of evaluating semen analysis as a predictor of pregnancy is still not concluded. The aim of this study was to determine the best semen analysis parameter to predict pregnancy in IUI treatments and to evaluate when the sperm is insufficient to IUI, and the couple has to proceed with IVF. Materials and Methods: We evaluated all patients who underwent ovulation induction with IUI. The data were analyzed in different combinations to build the best model. Results: The semen analysis parameters that were found as the best predictors for pregnancy include volume, concentration, motility and morphology from the sperm analysis during the infertility evaluation. A cut-off of total motile normal morphology sperm count (TMNC) 6 from these parameters yielded very low probability of pregnancy and in those cases it is recommended to refer patients to IVF. Conclusion: The model includes the normal morphology in the formula of total motile sperm count more accurately and significantly predicts pregnancy rate than the data of sperm in the day of IUI. Semen analysis results with TMNC 6 should be considered as a threshold for referral to IVF.

Septic Uterus After Uterine Artery Embolization for Uterine Myomas Triggered by Endometrial Biopsy

BACKGROUND Women who undergo uterine artery embolization (UAE) and subsequently have heavy vaginal bleeding require assessment to establish the cause. Endometrial sampling in such women should not necessarily carry more than the usual risk. CASES Two women who had undergone UAE presented with recurrence of heavy vaginal bleeding. In order to rule out possible endometrial malignancy, we performed an endometrial biopsy. Both patients had large and necrotic intramural myomas adjacent to the endometrium. They developed septic uterus shortly after endometrial biopsy and each required a hysterectomy. The postoperative course in the first case was complicated by deep vein thrombosis and enterovaginal fistula. CONCLUSION Because of the high risk of infection, women with a history of UAE and necrotic myoma adjacent to the endometrium should not undergo endometrial biopsy. We recommend evaluation of the relation of myomas to the endometrium.