Suzan Lenz

Ultrasonically guided percutaneous aspiration of human follicles under local anesthesia: a new method of collecting oocytes for in vitro fertilization *

Follicular aspiration was performed in 30 infertile patients by ultrasonically guided percutaneous puncture. In 18 cases the procedure was carried out under local anesthesia and in the remaining 12 under general anesthesia. The follicles were located with a dynamic sector scanner, and a needle was introduced through the abdominal wall and bladder into the follicles. Fifty follicles with a mean diameter of 19.6 mm were aspirated, and 26 oocytes were collected, giving an average recovery rate of 52%. Oocytes were obtained in 17 (57%) of the cases. Extensive pelvic adhesions did not impede the procedure, and the only complication was a transient hematuria in four patients. The technique was found to be atraumatic and inexpensive and therefore considered valuable for harvesting oocytes for in vitro fertilization.

Ultrasonic study of follicular maturation, ovulation and development of corpus luteum during normal menstrual cycles.

Abstract. Ovarian follicular growth, ovulation and development of corpus luteum was monitored with ultrasound in 29 normal menstrual cycles in 14 women. Results were correlated to changes in serum estradiol, LH and progesterone levels. The follicles reached a maximum diameter of 20.5±2.70 mm (mean±SD) with an intercycle variation of 16 to 25 mm, and growth rates ranged between —2 and 6 mm from the day before the LH peak to the day of the LH peak. Cumulus echoes were observed in all follicles with a maximum diameter of more than 17 mm and the cumulus appeared from 1 to 3 days before ovulation. On the day after the LH peak, the follicle was still present in two cycles and had disappeared from 15 cycles. In 11 cases different morphologic patterns could be visualized at the former sites of the follicles. In the middle of the luteal phase the mature corpus luteum was seen as an echogenic area in 16 cases and as a cyst in 1 case.

Abnormal ultrasonic pattern in contralateral testes in patients with unilateral testicular cancer

SummaryUltrasound examination and biopsy of the nonaffected testis was performed in 78 men with a unilateral testicular cancer. Each testis was measured in three planes and the volume was calculated using the formula of an ellipsoid. The ultrasonic texture of each testis was given a score ranging from 1 to 5 as follows: 1, very regular; 2, slightly irregular; 3, irregular with small echogenic points; 4, very irregular or with coarse echogenic points; and 5, irregular with demarcated areas raising suspicion of tumor. Biopsies were examined for the presence of tubules with carcinoma in situ (CIS), germinative epithelium, Sertoli cell only, and obliterations; the thickness of tubular membranes and the amount of Leydig cells were registered. The mean ultrasonic testicular volume was 12.88 ml (range 3–24 ml), which was smaller than that previously reported for normal men and larger than that previously reported for infertile men. The ultrasonic testicular volume was inversely correlated to the score. Score 4 was given to 46% of the testes (median score, 4), and the score distribution was different from that reported in normal men (median, 2) and in infertile men (median, 3). In all, 9 testes contained CIS tubules, and 8 of these were given score 4; 1 testis with CIS in only 5% of the tubules was given score 3. The predictive value of score 4 for the testis to contain CIS was 22.2%, and the predictive value of a score different from 4 that the testis would not contain CIS was 97.6%. We conclude that a large percentage of contralateral testes in men with unilateral testicular cancer have an abnormal echotexture and that CIS is most likely found in testes given score 4 by ultrasound.

Are ultrasonic-guided follicular aspiration and flushing safe for the oocyte?

Oocyte collection was carried out in 53 patients by ultrasonically guided abdominal puncture under local or epidural anesthesia. Follicles were aspirated and flushed two to six times using a syringe with culture medium. A total of 196 oocytes was collected and 84 of those (42.9%) were found in the flushes. Mechanical damage was observed in 5.1% of the oocytes. Cleavage rates in mature oocytes (157) after 48 hr in culture were similar in the aspirate group (56.5%) and in the flush group (54.2%). Ten clinical pregnancies were obtained, corresponding to a pregnancy rate of 18.9%.

Intrauterine capsules for incubation of gametes and subsequent release of embryos

In order to obtain incubation in uteri of spermatozoa, oocytes, and embryos, for treatment of patients referred for in vitro fertilization, a capsule was produced which could contain the human gametes and allow human fertilization and embryo growth after intrauterine introduction. Agar was chosen for capsule material and a mold was constructed for the production of capsules. The material was tested in vitro using mouse embryos and human oocytes and sperm. Intrauterine resolution was tested on mice and by insertion on 11 women. Empty capsules were inserted into the uterine cavity in 15 cycles the day after the luteinizing hormone peak and followed by daily ultrasound examinations. The resolution time was adjusted by changing the wall thickness of the capsules. The final type was dissolved after 3 to 4 days. No complications were observed and capsules could be inserted on all occasions. The major problem was expelling of capsules, which occurred in seven cycles. The problem seemed to be solved by the administration of indomethacin at the day of insertion.

Intrauterine fertilization capsules—A clinical trial

Treatment of 26 women with tubal infertility was attempted using intrauterine capsules loaded with oocytes and spermatozoa. The stimulation protocol was as used for in vitro fertilization and embryo transfer and consisted of short-term use of Buserelin, human menopausal gonadotropin, and human chorionic gonadotropin. Oocytes were collected by ultrasonically guided transvaginal aspiration, and spermatozoa were prepared by swim-up technique. The gametes were placed in agar capsules 4 hr after oocyte collection, and the capsules were introduced to the uterine fundus using an insertion tube and piston from an intrauterine device. Six complete capsules and parts of two other capsules were expelled. None of the women became pregnant, compared with a pregnancy rate of 21% per aspiration following in vitro fertilization and embryo transfer during the same period.

9 Gamete intrauterine transfer

Summary Gamete intrauterine transfer has been performed at a very limited scale until now. The main target group of patients for such a treatment would be women with infertility due to the tubal factor, but other infertile patients could benefit also, as the procedures reduce incubation time in the laboratory and implies fertilization in vivo. Few studies have been reported from 1982 to 1990 on the transfer of oocytes and spermatozoa directly to the uterus, and only five clinical pregnancies have been achieved. Transfer of oocytes and spermatozoa inside a biodegradable capsule has only been performed in one study comprising 26 cycles with no ensuing pregnancies. A critical evaluation and a status is carried out.

Obstetric behavior and ultrasonic uterine characteristics of oligomenorrheic women.

Two groups of age‐, parity‐, and pregnancy‐matched women, viz. 78 with oligomenorrhea (A) and 78 with normal menstrual intervals (B), plus all women with regular menstruation but in whom severe Müllerian malformations had been diagnosed during the same period (C) were followed in a prospective study to detect complications, sonographic changes, and the serum oxytocinase concentration during pregnancy and labor. Among the matched groups A and B, ultrasonic scanning revealed uterine changes in 45% and 9%. respectively (p < 0.0005) during the 2nd trimester. Among the oligomenorrheic women who had HSG, fairly mild Müllerian malformations were fo—in 40%. The sonographic method in these mild and moderate anomalies had its Iimmations, and the findings were interpreted in several cases as fibroma or contractions. Complications occurred in 51% of the group A women who carried their pregnancies to term versus 20% in group B (p < 0.0005). Among the primiparae the complication rates were 47% and 22%, respectively (p < 0.025). Bleeding in early pregnancy (25%), an unstable fetal lie (28%), malpresentations (14%), and premature contractions or delivery (11%) were more common in group A (p < 0.05—0.01). On stratification of the oligomenorrheic group without or with Müllerian anomalies (A2 and A) the overall complication rates were 55% and 73%, respectively, and 86% in group C. Mutually, these differences are not statistically different, but all differ significantly from the control group (B) (p < 0.005). As regards specific complications, group A1, unlike the other groups, differed statistically from the control group only in malpresentation. No differences in the serum oxytocinase concentration between the three main groups were demonstrable. It is concluded that obstetric complications in women with the syndrome ‘minor Müllerian anomalies and oligomenorrhea’ are presumably not due solely to the congenital anatomic effect, but rather to its combination with pathophysiological muscular dysfunction.

Ectopic Pregnancy and Spontaneous Abortions Following in-vitro Fertilization and Embryo Transfer

Abstract. In‐vitro fertilization and embryo transfer was performed in 25 patients with diseased oviducts. Three pregnancies were achieved, but all ended in early abortion. One patient had ectopic pregnancy, one spontaneous abortion having a severe autosomal chromosome abnormality, and one had a rise in serum hCG but vaginal bleeding started 18 days after embryo transfer. We conclude that repeated ultrasonic examinations of all pregnancies following in‐vitro fertilization and embryo transfer is recommendable until intra‐uterine implantation has been confirmed and that amniocentesis should be offered to all these patients.