Wilfried Feichtinger

Transvaginal sector scan sonography for needle guided transvaginal follicle aspiration and other applications in gynecologic routine and research.

A transvaginal sector scanner probe has been developed for precise needle-guided transvaginal follicle aspiration under sonographic control. The first results of transvaginal needle-guided follicle aspiration are presented. A high recovery rate was obtained (86% /follicle). The pregnancy rate after in vitro fertilization and embryo replacement was remarkably high (21.3%/cycle). Because exceptionally high-quality images of the organs in the pelvis are obtained, there are numerous other potential applications for the trans-vaginal sector scanner.

Smoking and In Vitro Fertilization: A Meta-Analysis

Purpose: Including our own data and seven relevant publications from the literature, this meta-analysis aimed to establish the influence of the status of female smokers on the clinical pregnancy rate after the first attempt at in vitro fertilization–embryo transfer (IVF-ET).Methods: We started to collect information about our own patients smoking habits in January 1996 to evaluate prospectively the influence on IVF success. Information regarding 799 patients (607 nonsmokers and 192 smokers) was obtained. Additionally we retrieved seven relevant publications from the unabridged MEDLINE1982–1996. They were recalculated to first cycles, because from a biometrical point of view, only the results of the first IVF cycle are really well comparable, as the number of necessary IVF cycles always correlates with the number of pregnancies. These data were compared in the nonparametric sign test according to Dixon–Mood and calculated as relative success ratios, defined as the quotient of the probability of IVF-ET success of nonsmokers divided by that of smokers for each publication.Results: This meta-analysis, based on a total of 2314 first IVF-ET treatments, showed that almost twice as many IVF-ET cycles were needed for smokers as for nonsmokers to become pregnant. For the success quotient, we obtained a ratio of 1.79, with an associated 95% confidence interval of from 1.24 to 2.59. The total analysis shows, with a P value of less than 0.01, significantly higher pregnancy rates (21%) in nonsmokers compared to smokers (14%).Conclusions: Based on the analyzed data there exists—from a statistical point of view—a significant negative effect on the chances of success for smokers to become pregnant compared to nonsmokers.

Successful clinical application of laser for micromanipulation in an in vitro fertilization program

This is a report of our preliminary experience with assisted hatching by laser with a case of an ongoing twin pregnancy. We used an erbium laser to create a 20 to 30-micrometer opening in the zona pellucida of human embryos to facilitate the embryonic hatching after the embryo transfer. Our report proves that it is possible to obtain a pregnancy using a simple and quick laser method instead of mechanical or chemical procedures within the scope of micromanipulation.

Comparison of stimulation with clomiphene citrate in combination with recombinant follicle-stimulating hormone and recombinant luteinizing hormone to stimulation with a gonadotropin-releasing hormone agonist protocol: a prospective, randomized study

OBJECTIVE To compare IVF-ET outcome with a new stimulation protocol using clomiphene citrate (CC) with recombinant FSH and LH to stimulation with the standard long GnRH-a protocol. DESIGN Prospective randomized study. SETTING Outpatient infertility clinic in Vienna, Austria. PATIENT(S) Two hundred ninety-four infertile women undergoing IVF-ET; 154 IVF cycles stimulated with CC + recombinant FSH + recombinant LH (group A) and 140 cycles with long GnRH-a suppression + recombinant FSH (group B). INTERVENTION(S) Controlled ovarian hyperstimulation, egg retrieval, and ET. MAIN OUTCOME MEASURE(S) Cycle parameters (number of oocytes, fertilization, number of embryos) and outcome (pregnancy rate, cancellation rate, ovarian hyperstimulation syndrome [OHSS]). RESULT(S) Pregnancy rate per ET was 42.9% (implantation rate, 21.3%) in group A and 36.6% (17.4%) in group B. Cancellation rates were similar. The OHSS occurred in four cases (3%) in group A and 12 cases (10%) in group B. CONCLUSION(S) Stimulation with CC + recombinant FSH + recombinant LH leads to comparable pregnancy rates vs. the long protocol. With this new stimulation, less gonadotropins are used and there is less need for monitoring (lower cost for patient and clinic). The risk of OHSS is reduced as well. Therefore, this protocol should be regarded as the first-line treatment.

The Effect of Smoking on Oocyte Quality and Hormonal Parameters of Patients Undergoing In Vitro Fertilization–Embryo Transfer

Purpose:The aim of the present study was to investigate the influence of smoking on different parameters such as oocyte count, embryo score, and basal hormone values within the scope of in vitro fertilization–embryo transfer (IVF-ET).Methods:Eight hundred thirty-four women undergoing IVF-ET treatment were classified as smokers or nonsmokers on the basis of questionnaires. Additionally, we divided them into three groups according to their stimulation protocol—“combined stimulation” [I; clomiphene citrate plus human menopausal gonadotropin (hMG)], “ultrashort” [II; gonadotropin releasing hormone agonist (GnRHa) plus hMG or follicle-stimulating hormone (FSH)], and “long downregulation protocol” (III)—and further classified again as smokers or nonsmokers within the groups.Results:In general, smoking patients were significantly (P = 0.0195) younger than nonsmokers and showed a significantly (P = 0.0379) lower embryo score and a tendency (P = 0.0931) to produce fewer oocytes. There was no significant difference concerning the number of normally or pathologically fertilized and transfered oocytes and embryos suitable for cryopreservation. Women who smoked had significantly (P = 0.0112) higher basal 17-β-estradiol (E2), luteinizing hormone (LH) (P = 0.0001), and dehydroepiandrosteronesulfate (DHEAS) (P = 0.0039) levels, but their basal human prolactin (HPRL) levels were significantly (P = 0.0033) lower than those of nonsmokers. According to the stimulation protocol used, we found the following results. Smoking patients in group I showed a significantly (P = 0.023) lower embryo score and produced fewer oocytes (P = 0.0113), with fewer of them being fertilized (P = 0.0072) and transferred (P = 0.0067). Women who smoked had significantly (P = 0.0002) higher basal LH levels, but their HPRL levels were significantly (P = 0.031) lower than those of nonsmokers. Furthermore, they had a thinner endometrium on the day of embryo transfer (P = 0.0366). In group II we measured significantly elevated basal E2levels (P = 0.0089) and higher LH values (P = 0.0092) in smokers. Group III showed a trend (P = 0.0565) toward lower HPRL values in smokers.Conclusions:Although the fertilization rate of oocytes and the pregnancy rate were not significantly different between smokers and nonsmokers, we found significantly alterated hormonal parameters and negatively influenced oocyte parameters, particularly after clomiphene stimulation. So we might consider using only GnRHa protocols for smoking patients. Additionally, we advise our patients to stop smoking before an IVF-ET treatment because of the complex effects of smoking on the reproductive and hormonal system.

Air in the uterine cavity after embryo transfer

OBJECTIVE To examine the effect on the pregnancy rate (PR) caused by air bubbles loaded into the transfer catheter to bracket the embryo-containing medium. DESIGN Prospective, randomized study. SETTING One hundred ninety-six consecutive ETs in the Institute of Sterility Treatment. INTERVENTIONS Air bubbles were loaded into the transfer catheter concomitantly with the medium in group I (n = 98), whereas in group II (n = 98) no air bubbles were used. RESULTS The PR of group I equals that of group II. CONCLUSIONS Bracketing the embryo-containing medium by air bubbles offers several advantages, especially the possibility of tracking the air on the ultrasound monitor to localize the embryos after the ET. For these reasons we recommend using the proven method.

Relationship of the individual uterine size and the endometrial thickness in stimulated cycles

At present there is no agreement regarding the usefulness of monitoring the endometrial thickness in stimulated cycles. We tested prospectively the hypothesis of a linear relationship of the given individual uterine size and the endometrial thickness in stimulated cycles using a 240 degrees transvaginal sector scanner. There was a strong correlation of the uterine dimension with the endometrial thickness in the midfollicular and the early luteal phase. Our findings suggest that the endometrial thickness is determined by the individual uterine architecture and therefore not predictive of the likelihood of implantation.

Could aspiration of the Graafian follicle cause luteal phase deficiency

Luteal phase quality was evaluated in 32 patients wih nonstimulated cycles after laparoscopic oocyte recovery for in vitro fertilization. A luteal phase deficiency occurred in two cases (6.2%), the mean duration of the luteal phase was 13.5 +/- 1.3 days in 30 patients, and two patients developed amenorrhea of 23 and 43 days respectively after laparoscopy in spite of normal progesterone values 7 and 9 days after oocyte recovery. Six embryo transfers were performed after fertilization and regular cleavage of the obtained oocytes. No pregnancy resulted from the embryo transfers, although the patients had apparently normal luteal phases. In one patient there was a transient beta-subunit human chorionic gonadotropin (beta-hCG) elevation in serum. Luteal phase deficiency should not be main cause of a nonsuccessful embryo transfer. However, a prophylactic luteal phase support after oocyte recovery and embryo transfer in nonstimulated cycles is proposed.

Laparoscopic or ultrasonically guided follicle aspiration for in vitro fertilization

Ultrasonically guided follicular aspiration is presented as an alternative method to laparoscopy for oocyte harvesting. The method is described in detail and compared to laparoscopic oocyte pickup. The success rate of this technique reached in 1984 compared to that of laparoscopic oocyte pickup was the same: the oocyte recovery rate was 93%, the fertilization rate was 58%, and the pregnancy rate was 13% (normal ongoing pregnancies per treatment cycle). Ultrasonically guided follicular aspication is shown to be superior to laparoscopic oocyte recovery as far as ovarian accessibility and complication rate are concerned.

Number and Size of Antral Follicles as Predictive Factors in In Vitro Fertilization and Embryo Transfer

AbstractPurpose: The purpose of the study was to evaluate whethernumber and size of antral follicles can predict the outcomeof in vitro fertilization—embryo transfer. Methods: A total of 113 patients were prospectively includedinto this study. After 19 days of down-regulation, numberand size of follicles were determined by using recent three-dimensionaltransvaginal ultrasound technology. Beforeapplication of gonadotropin, all follicles had been definedas antral follicles. According to size, antral follicles werecategorized into four different groups: group I includedantral follicles < 5 mm, group II follicles 5–10 mm; groupIII 11–20 mm; and group IV >20 mm. Pregnant and non-pregnantpatients were compared in terms of their numberof antral follicles of group I–IV. These four groups were thencompared regarding implantation rate, number of retrievedoocytes, endometrium thickness, and age. Results: Pregnant patients showed an significant highernumber of follicles with the size between 5 and 10 mm (P=0.04). A significant correlation was found between numberof retrieved oocytes and antral follicle size of 5–10 mm(P= 0.0001). Antral follicles with a diameter between 5and 10 mm decreased significantly with age (P = 0.008).In groups III and IV, a significant correlation was foundbetween antral follicle size (P = 0.016) and serum estradiollevel after gonadotropin-releasing hormone-agonist down-regulation (P = 0.011). Conclusions: We demonstrated that patients with a highernumber of follicles between 5 and 10 mm showed a significantlyhigher pregnancy rate, whereas patients with a dominantnumber of antral follicles > 11 mm have a highercancellation rate due to ovarian low response.