Yahia M. Amin

Complications of medically assisted conception in 3,500 cycles.

OBJECTIVE To investigate the incidence of complications in the use of assisted reproductive technology in the management of infertile couples. DESIGN Retrospective study. SETTING The Egyptian IVF & ET Center, Maadi, Cairo, Egypt. PATIENT(S) Two thousand nine hundred twenty-four patients underwent IVF-ET or intracytoplasmic sperm injection (ICSI) in 3,500 cycles. INTERVENTION(S) IVF-ET, ICSI, ejaculate sperm, epididymal sperm aspiration, and testicular sperm extraction. MAIN OUTCOME MEASURE(S) Complications of the procedure and complications of pregnancy in 702 patients. RESULT(S) Fifteen hundred ovum pickups for IVF-ET and 2,000 ovum pickups for ICSI were performed. Clinical pregnancy occurred in 1,078 patients (30.8%). Four groups of complications were identified. Complications of the procedure occurred in 291 patients (8.3%). Complications of pregnancy included ectopic pregnancy in 1.9%, heterotopic pregnancy in 0.2%. abortion in 20.6%, multiple pregnancy in 28%, pregnancy-induced hypertension in 10%, preterm labor in 21.5%, low birth weight in 30.5%, and intrauterine death in 2%. Coincidental complications occurred in five patients (0.15%). Other complications that were difficult to measure included psychological breakdown and socioeconomic problems. CONCLUSION(S) Assisted reproductive technology is effective for the management of infertility and has an acceptable incidence of complications. Complications rarely endanger the life of the patient. When this line of treatment is offered, the indications should be definitive. Patients should be monitored properly and measures should be taken to minimize the incidence of complications.

Fertilization and pregnancy rates after intracytoplasmic sperm injection using ejaculate semen and surgically retrieved sperm

OBJECTIVE To compare the fertilization rates and pregnancy rates (PRs) in intracytoplasmic sperm injection (ICSI) using sperm from ejaculates of normal and abnormal semen, epididymal sperm, and testicular sperm of obstructive and nonobstructive azoospermic patients. DESIGN Retrospective study. SETTING The Egyptian IVF-ET Center. PATIENT(S) Three hundred fifty patients underwent 366 ICSI cycles. INTERVENTION(S) ICSI, epididymal sperm aspiration, and testicular biopsy. MAIN OUTCOME MEASURE(S) Fertilization rates and PRs. RESULT(S) Patients were divided into five groups according to the quality and source of sperm. Patients in group 1 underwent 102 cycles of ICSI using ejaculated abnormal semen, group 2 underwent 44 cycles using epididymal sperm, group 3 underwent 82 cycles using testicular sperm from obstructive azoospermia, group 4 underwent 80 cycles using testicular sperm from nonobstructive azoospermia, and group 5 underwent 58 cycles using normal semen. There was no significant difference in the fertilization rates and PRs among groups 1, 2, and 3. In group 4, the fertilization rate and PR were significantly lower than in all other groups. In group 5, the fertilization rate was significantly higher than in all other groups. CONCLUSION(S) The fertilizing ability of sperm in ICSI is highest with normal semen and lowest with sperm extracted from a testicular biopsy in nonobstructive azoospermia. There was no significant difference in fertilization rates and PRs between ejaculated sperm of different parameters and surgically retrieved sperm in obstructive azoospermia.

Oocyte quality in patients with severe ovarian hyperstimulation syndrome

OBJECTIVE To study the oocyte quality in patients with ovarian hyperstimulation syndrome (OHSS). DESIGN Retrospective study. SETTING The Egyptian IVF-ET Center. PATIENT(S) Forty-two patients who developed severe OHSS (group A) were studied for the mean number of oocytes retrieved, percentage of high-quality oocytes, embryo quality, and fertilization, implantation, and pregnancy rates; these patients were compared with an age-matched control group who did not develop OHSS (group B; n = 183) after superstimulation for IVF or intracytoplasmic sperm injection. INTERVENTION(S) In vitro fertilization and ICSI. MAIN OUTCOME MEASURE(S) Fertilization and pregnancy rates. RESULT(S) In group A, the mean number of oocytes retrieved was significantly higher, whereas the percentage of high-quality oocytes and the fertilization rate were significantly lower than that in group B. There were no statistically significant differences in the quality of embryos transferred or the implantation or pregnancy rate between the groups. The percentage of high-quality oocytes and the fertilization rate were significantly lower in patients with polycystic ovaries (PCO) in both groups. CONCLUSION(S) The inferior quality and maturity of oocytes in OHSS reduced the fertilization rate but did not affect the quality or the number of embryos transferred or the pregnancy rate. The effect on oocyte quality could be due to the prevalence of PCO in this group of patients.

Prospective controlled randomized study of in vitro fertilization versus intracytoplasmic sperm injection in the treatment of tubal factor infertility with normal semen parameters

OBJECTIVE To compare the results of IVF and intracytoplasmic sperm injection (ICSI) in tubal factor infertility with normal semen parameters. DESIGN A prospective randomized study. SETTING The Egyptian IVF-ET Center. PARTICIPANTS One hundred sixteen patients infertile due to tubal factor were divided randomly into two groups. Group A(n = 58) was treated with IVF and group B(m = 58) was treated with ICSI. INTERVENTION In vitro fertilization and ICSI. MAIN OUTCOME MEASURE Pregnancy rate. RESULTS In group A, 736 oocytes were retrieved and normal (two pronuclear [2pN] fertilization occurred in 477 oocytes (64.8%). In group B, 748 oocytes were retrieved, 572 metaphase II oocytes were injected, and 2PN fertilization occurred in 400 oocytes (70% per injected oocyte and 53.5% per retrieved oocyte). Clinical pregnancy was diagnosed in 18 patients in group A (31%) and 19 patients in group B (32.8%). There was no significant difference in the pregnancy rate between the two groups. The fertilization rate per retrieved oocytes was significantly higher in group A. CONCLUSIONS Intracytoplasmic sperm injection does not offer a higher pregnancy rate as compared with IVF in the treatment of tubal factor infertility with normal semen.

A prospective randomized study comparing coasting with GnRH antagonist administration in patients at risk for severe OHSS.

This work evaluated possible advantages of gonadotrophin-releasing hormone (GnRH) antagonist administration as an alternative to coasting in prevention of severe ovarian hyperstimulation syndrome (OHSS) in women undergoing IVF/ intracytoplasmic sperm injection. A prospective randomized study comparing coasting (group A) (n = 96) and GnRH antagonist administration (group B) (n = 94) in patients at risk of OHSS was performed. The primary outcome measure was high quality embryos. The secondary outcome measures were days of intervention, number of oocytes, pregnancy rate, number of cryopreserved embryos and incidence of severe OHSS. There were significantly more high quality embryos (2.87 +/- 1.2 versus 2.21 +/- 1.1; P < 0.0001), and more oocytes (16.5 +/- 7.6 versus 14.06 +/- 5.2; P = 0.02), in group B as compared with group A. There were more days of coasting as compared with days of antagonist administration (2.82 +/- 0.97 versus 1.74 +/- 0.91; P < 0.0001). In conclusion, GnRH antagonist was superior to coasting in producing significantly more high quality embryos and more oocytes as well as reducing the time until HCG administration. There was no significant difference in pregnancy rate between the two groups. No OHSS developed in either group.

Analysis of 2,386 consecutive cycles of in vitro fertilization or intracytoplasmic sperm injection using autologous oocytes in women aged 40 years and above

OBJECTIVE To estimate the live-birth and miscarriage rates in 1-year age increments for women aged ≥40 years undergoing in vitro fertilization or intracytoplasmic sperm injection (ICSI-IVF) with autologous oocytes. DESIGN Retrospective database and chart analysis. SETTING Egyptian IVF and embryo transfer center. PATIENT(S) One thousand six hundred forty-five women aged ≥40 years undergoing 2004 fresh nondonor IVF-ICSI cycles. INTERVENTION(S) ICSI-IVF using ejaculate or surgically retrieved sperm. MAIN OUTCOME MEASURE(S) Pregnancy and live-birth rates per initiated cycle based on 1-year age increments. RESULT(S) The overall live-birth rate per initiated cycle was 6.7% (range: 10% to 0.5%). The pregnancy loss rate was 44.8% (range: 39.0% to 75.0%). The cutoff age was 43 years, when the pregnancy rate became statistically significantly lower. The live-birth rate per initiated cycle was statistically significantly higher for women <43 years old, 132 out of 1766 (7.4%) compared with women ≥43 years old, 7 out of 620 (1.1%). The miscarriage rate was 127 out of 295 (43.1%) compared with 15 out of 23 (65.2%) for the two age groups, respectively. CONCLUSION(S) The success rate of ICSI-IVF as measured by live-birth rate per initiated cycle was statistically significantly higher for women aged <43 years as compared with women aged ≥43 years. Once women have attained age 43 years, alternative methods such as oocyte donation cycles or previously cryopreserved embryos are likely to be more effective.

The use of vaginal natural progesterone for prevention of preterm birth in IVF/ICSI pregnancies.

The aim of this study was to evaluate the effect of vaginal natural progesterone on the prevention of preterm birth in IVF/intracytoplasmic sperm injection (ICSI) pregnancies. A single-centre prospective placebo-controlled randomized study was performed. A total of 313 IVF/ICSI pregnant patients were randomized into two groups for either treatment with daily 400 mg vaginal natural progesterone or placebo, starting from mid-trimester up to 37 weeks or delivery. Amongst the patients, there were 215 singleton and 91 twin pregnancies. There was no significant difference in risk of preterm birth among all patients (OR 0.672, 95% CI 0.42-1.0. There was a significantly lower preterm birth rate in singleton pregnancies in the natural progesterone arm (OR 0.53, 95% CI 0.28-0.97) and no significant difference between both arms in twin pregnancies (OR 0.735, 95% CI 0.36-2). In conclusion, the administration of 400 mg vaginal natural progesterone from mid trimester reduced the incidence of preterm birth in singleton, but not in twin, IVF/ICSI pregnancies.

Reduction of Human Menopausal Gonadotropin Dose Before Coasting Prevents Severe Ovarian Hyperstimulation Syndrome with Minimal Cycle Cancellation

regulation. While this is unclear, perhaps it is secondSuzanne Kavic M. V. Sauer ary to inadequate estrogen priming. On the other hand, menses do not accurately predict S. R. Lindheim1 Department of Obstetrics and Gynecology the presence of functional and nonfunctional ovarian Division of Reproductive Endocrinology cysts. There is controversy as to whether preexisting Columbia Presbyterian Medical Center ovarian cysts have an adverse effect on the outcome College of Physicians and Surgeons of IVF-ET (8). Small nonfunctional cysts (,25 mm) Columbia University may be confused with developing follicles and larger 622 West 168th Street functional cysts may adversely effect the local horNew York, New York 10032 monal environment (8). In summary, our report demonstrates that the presence 1 To whom correspondence should be addressed. of menses after the administration of GnRH-a is a valid predictor of pituitary down-regulation. On the other hand, the absence of menses only appears to be predictive of CAIRO, EGYPT failure of down-regulation in younger women. Serum estradiol, which has long been the gold standard for docuReduction of Human Menopausal menting suppression, may not always be necessary. However, transvaginal ultrasonography still provides important Gonadotropin Dose Before Coasting and meaningful information in the monitoring of patients Prevents Severe Ovarian undergoing assisted reproduction, since menstrual history Hyperstimulation Syndrome with alone does not preclude the presence of pathological or Minimal Cycle Cancellation functional ovarian cysts.

Impact of antimüllerian hormone assays on the outcomes of in vitro fertilization: a prospective controlled study

OBJECTIVE To assess the value of routine antimüllerian hormone (AMH) assays in patients considered high risk for cancellation. DESIGN Prospective controlled study. SETTING A private IVF center, Cairo, Egypt. PATIENT(S) In total 4,917 patients received counseling before starting IVF/intracytoplasmic sperm injection (ICSI). They were comprised of group A1 (n = 1,335), who were considered to be at risk for cancellation after ovarian stimulation, and group A2 (n = 3,582), who were considered low risk for cancellation. A control group, B (n = 4,639), included group B1 (n = 1,248) and group B2 (n = 3,391) based on the same criteria as groups A1 and A2. INTERVENTION(S) An AMH assessment was performed for group A1. All of the patients were stimulated using the long GnRH agonist protocol. Patients with low AMH levels received the flare-up protocol. MAIN OUTCOME MEASURE(S) The cancellation of IVF/ICSI cycles before or after stimulation, as well as the pregnancy rates (PR) in relation to AMH levels. RESULT(S) The group A1 patients (6.4%) did not start IVF due to low AMH, and some (6.6%) had their cycles canceled due to poor responses, compared with 2.6% in group A2 and 13.2% in group B1. The clinical PR was 42% in patients with normal AMH and 20% in patients with low AMH. The differences among these three groups were highly significant. CONCLUSION(S) The AMH assays reduced the cancellations, cost, and stress experienced by couples.

GnRH agonist plus vaginal progesterone for luteal phase support in ICSI cycles: a randomized study

In this prospective randomized study, the effect of daily gonadotrophin-releasing hormone agonist (GnRHa) in the luteal phase on IVF and intracytoplasmic sperm injection (ICSI) outcomes was assessed. Women (n = 446) were counselled for IVF-ICSI, and randomized on the day of embryo transfer to group 1 (daily 0.1 mg subcutaneous GnRHa until day of beta-HCG) (n = 224) and group 2 (stopped GnRHa on day of HCG injection) (n = 222). Both groups received daily vaginal progesterone suppositories. Primary outcome was clinical pregnancy rate. Secondary outcome was ongoing pregnancy rate beyond 20 weeks. Mean age, oestradiol on day of HCG, number of oocytes retrieved, number of embryos transferred, and clinical and ongoing pregnancy rates were 28.9 ± 4.5 years, 2401 ± 746 pg/mL; 13.5 ± 6.0 oocytes; 2.6 ± 0.6 embryos, and 36.2% and 30.4% consecutively in group 1 compared with 29.7 ± 4.7 years, 2483 ± 867 pg/mL, 13.7 ± 5.5 oocytes, 2.7 ± 0.6 embryos, 30.6% pregnancy rate, and 25.7% ongoing pregnancy rate in group 2. No significant difference was found between the groups. Subcutaneous GnRHa during the luteal phase of long GnRHa protocol cycles does not increase clinical or ongoing pregnancy rates after IVF-ICSI.