Cost-effectiveness of IVF in women 38 years and older.

OBJECTIVE: To compare the cost per delivery in women younger than 38 years with women equal to or older than 38 years of age attempting IVF. METHODS: All couples undergoing IVF treatment between October 1991 and September 1998 were enrolled in this study. A standard protocol of controlled ovarian hyperstimulation was employed throughout the study. Four hundred and seven cases were allocated to two groups - group I composed of patients younger than 38 years of age and group II of patient equal to or older than 38 years of age. The total cost of each successful outcome was the goal of our study. RESULTS: A total of 407 women underwent 722 stimulated cycles for IVF of which 122 cycles (16.89%) did not proceed to oocyte retrieval. We found statistically significant differences in the cancellation rate, the number of hMG ampoules, the number of oocytes retrieved, the number of oocytes fertilized, the number of embryos transferred, the clinical pregnancy rate, the rate of multiple pregnancy, the delivery per initiated cycle and the cost per delivery between the two groups (P<0.05, significant). The cost per delivery in group II was approximately 3.6 times that of group I. CONCLUSIONS: Women age 38 years or more have less chance of a successful outcome from IVF treatment. Couples contemplating IVF should be provided with accurate information about prognosis for the pregnancy and the financial costs.

Outcome of pregnancy in IVF-ET cycle at Ramathibodi Hospital.

As assisted reproductive technology is being developed, in vitro fertilization and embryo transfer (IVF-ET) are the treatments of choice for many infertility problems. The outcome of pregnancies achieved by IVF-ET is different from that of spontaneous pregnancies. In this retrospective study, the outcome of pregnancies from 400 IVF treatment cycles performed from October 1991 to October 1994 were reported. There were 80 pregnancies (20% per oocyte retrieval, 21.9% per embryo transfer) with an increased rate of abortion (30%), multiple pregnancy (20%), ectopic pregnancy (6.25%), heterotopic pregnancy (1.25%), preterm delivery (11.8%), low birth weight (35.8%) and cesarean section (62.7%). This study shows that the complication rate of pregnancies from IVF-ET cycles was higher than that found in spontaneous pregnancies. Some complications such as multiple pregnancies may be prevented by limiting the number of transferred embryos. From this study, all IVF-ET pregnancy should be considered as high risk pregnancies.

Determinants of multiple pregnancies in in vitro fertilization other than number of transferred embryos.

The aim of this study is to assess the many different parameters involved in the incidence of multiple pregnancies, such as maternal age, stimulation, endometrium, receptivity and the quality of the transferred embryos. During a 3.5 year period, 86 pregnancies were recorded in our IVF unit. A single gestational sac was identified by early ultrasonography in 67 patients, while in 19 others, multiple sacs were noted. Patient characteristics, treatment cycles and embryology results were similar in the two groups. When the number of transferred embryos was kept similar in both groups, EIR was found to be a valuable prognostic determinant for multiple pregnancies in IVF.

Chemiluminescence immunoassay versus radioimmunoassay for the measurement of reproductive hormones.

OBJECTIVES: To compare the hormonal values determined by chemiluminescence immunoassay (CIA) and radioimmunoassay (RIA). METHODS: Blood samples, drawn from eight volunteers during one menstrual cycle, were assayed for estradiol, progesterone, luteinizing hormone (LH), follicle stimulating hormone (FSH) and prolactin by CIA and RIA methods. The values obtained from these two assay techniques were compared. Statistical analysis were performed using the t-test, Pearson correlation coefficient and simple linear regression analysis. RESULTS: CIA yielded lower mean values of LH, FSH, progesterone, but higher mean values of prolactin than RIA. Mean estradiol levels assayed by the two methods were similar. There was a good correlation between the hormonal values performed by the two methods. By calculation, the CIA hormonal value could accurately predict the RIA value by 96.6, 93.9, 89.9 and 66.0% for progesterone, LH, FSH and prolactin, respectively. CONCLUSIONS: The disparity in the hormonal values obtained from different assay methods warrants clinicians to be aware of their clinical interpretation. Using the same reference range for different assay methods is not appropriate. A comparative study between the new and standard assays is essential.

"Simplified IVF": program for developing countries.

The aim of this study is to assess the results of the "Simplified IVF" program at Ramathibodi Hospital. Ramathibodi IVF program has been in operation since October, 1991. Some steps of the conventional IVF procedures have been modified due to the limitation of resources. The embryo laboratory is a simple, clean room situated in a different building from the oocyte recovery room. Short protocol of GnRHa/HMG is used for ovarian stimulation. Monitoring of the follicular development is performed by ultrasound alone with limited number of scans (2-3 times/cycle). Oocyte retrieval is carried out under transvaginal ultrasound guidance and the aspirate transported to the embryo laboratory in a simple insulated box. Luteal phase is supported by giving micronized progesterone. Eighty five couples have undergone 105 ovarian stimulation cycles. OR was done in 100 cycles from 80 couples. Total oocytes collected is 1091. The fertilization rate is 75 per cent. Embryos were transferred in 97 cycles. Clinical pregnancy occurred in 25 cycles. Pregnancy rate per OR and ET is 25 and 25.8 per cent respectively. Nineteen patients have delivered (6 twins, 13 singletons). Simplification of procedures has enabled the IVF service to be available in a center with limited resources without compromising the results. Other advantages are improvement of the patient's convenience, cost savings and less time consumed as well as being less stressful.

Two years' experience of intrauterine insemination for the treatment of infertility.

The result of a two year (1990-1991) trial of IUI is presented. Discontinuous Percoll-gradient centrifugation technic was used for motile sperm separation. In 174 couples with 610 treatment cycles, there were 49 clinical pregnancies. The pregnancy per patient was 28 per cent and the pregnancy per cycle was 8 per cent. Cycle fecundity by various factors which possibly influence the outcome were assessed. The success rate appeared to be higher in the young female age group, short duration of infertility, secondary infertility, unexplained infertility, a higher number of motile sperm inseminated and dual insemination in a cycle.

Epidemiology of hypertensive disorders of pregnancy and childbirth: population-based study, Thailand.

A geographically population-based epidemiological study was conducted in Thailand under the WHO International Collaborative Study of Hypertensive Disorders of Pregnancy. Prospectively collected data on blood pressure, proteinuria and edema in pregnancy of 4,126 pregnancies were analyzed correlating with pregnancy outcome. The prevalence of mothers with antenatal diastolic pressures equal to or greater than 90 mmHg was approximately 20 per cent. Hypertension with edema or proteinuria was observed in about 6 per cent of pregnancies and these were associated with a significant increase of low birthweight infants, but did not produce a significant increase in perinatal deaths. Although the incidence of eclampsia during the study period was not high, Hypertensive Disorders of Pregnancy remained the second leading cause of maternal mortality.

Early experience with gamete intrafallopian transfer at Ramathibodi Hospital.

This report summarises the result of the GIFT program at Ramathibodi Hospital during 1990-1991. There were 35 treatment cycles in 34 infertile couples. The age of the females varied from 29 to 41 years. Duration of infertility was 3 to 10 years. GIFT was performed during diagnostic laparoscopy in 26 cycles (78%). Other indications were endometriosis (5 cycles), concurrent with myomectomy (3 cycles) and unexplained infertility (1 cycle). Two cases received CC+HMG for superovulation, the others had GnRHa+HMG. Transvaginal ultrasound guided oocyte pick up yielded 2 to 10 oocytes (mean 5.8 oocytes per cycle). Two to 8 oocytes were transferred. All patients received progesterone or HCG for luteal support. In cases of diagnostic laparoscopy, the findings were normal (10 cases), endometriosis (7 cases), pelvic adhesion (6 cases) and myoma uteri 3 cases). No pregnancy was achieved among 18 GIFT cycles performed in 1990. In 1991, after changing some instruments and methods, there were 5 pregnancies out of 17 GIFT cycles (29%). The factors that influenced the outcome were good selection of instruments and method, maturity of oocytes and semen parameters.

Sperm motility after passage through the hen's egg yolk medium.

This study aimed to observe the percentage of motility of human spermatozoa after passage through 20 per cent hen's egg yolk medium. Twenty-one samples of freshly ejaculated human semen having a sperm density over 20 million per ml and a percentage of motile sperm over 50 per cent were used in the study. The percentage of sperm motility was estimated under the microscope by conventional method. The sperm motility was evaluated within 30 minutes after ejaculation and every one hour thereafter for 8 hours. After the first observation, the semen was divided into two parts, one part kept as a control and the other used for the experiment. The latter was washed in Tyrode's solution and overlaid on 20 per cent egg yolk column and allowed to migrate toward the bottom of the column for two and a half hours. The spermatozoa at the bottom of the column were brought out and washed in Tyrode's solution. The percentage of the sperm motility was observed every hour for 5 hours. After passing through the 20 per cent egg yolk medium, percentage of sperm motility was observed to increase from 66.2 to 87.2 while that of the control declined to 49.3. Five hours after passing through the egg yolk medium the percentage of motile sperm was still high, an average of 80 as compared to 17.4 for the control. Results of this study indicate that hen's egg yolk has a sperm motility stimulating property. Whether hen's egg yolk can be used as a sperm motility stimulant in the treatment of such conditions as asthenospermia and oligospermia is subjected for further study.

Sperm morphology after hen's egg yolk filtration.

Tyrode's washed spermatozoa were placed on top of 20 per cent hen's egg yolk column of 2 cm diameter and 10 cm in height. The spermatozoa were allowed to move downward for two and a half hours and those at the bottom of the column were removed for morphological examination under a light microscope after staining with hematoxylineosin. The study was made in 45 cases. It was found that the percentage of morphologically abnormal sperm decreased, after passing through the hen's egg yolk column, from the average of 9.98 to 0.71 per cent. It is suggested tha the hen's egg yolk method is suitable for improving sperm motility and morphology in certain infertile cases where husbands have a seminal defect.

Male sex-linked protein in human placental villi.

Due to the difference in genetic components between X and Y chromosomes, we believe that tissues of male and female individuals should contain different sex-linked protein. This study is aimed to determine whether there is any sex-linked protein in the placenta belonging to human male and female fetuses. Placentas from eleven male and eleven female fetuses were studied. Proteins from the placenta were extracted and fractionated by means of column chromatography. The protein fractions obtained from the male and female placental extracts were compared. It was found that there was a protein fraction present in the placenta of male fetuses but absent in those of the females. This protein fraction is called "male sex-linked protein" or "male protein". It is believed that this male protein is genetically determined and should also be found in every organ, not just only in the placenta.

Urinary excretion of placental male sex-linked protein during pregnancy.

The placental male protein in the maternal urine was examined by means of the column chromatographic method, the same method used in determination of the male protein in human placenta. The urinary examination was made in ten near-term pregnant women, five with male and five with female fetuses. It was found that the male protein was present in the urine of every pregnant woman with a male fetus and was absent in those with a female fetus. The result of this study suggests that the male protein in the placenta is released into the maternal circulation and excreted into the urine during pregnancy. The presence of the male protein in the pregnant women's urine may be used as a criteria in determining the presence of a male fetus.

Y spermatozoa in normal, oligospermic and in residual spermatozoa of post-vasectomy human semen.

PIP: From October 1986-February 1987, researchers at Mahidol University in Bangkok, Thailand conducted a study of 175 men to detect the percentage of Y spermatozoa in normal and oligospermia semen and in residual sperm of postvasectomy semen. After 3 days of abstinence, 46 medical student volunteers, 109 infertility clinic patients, and 20 post vasectomy patients masturbated to collect the needed samples. Researchers identified Y sperm by staining the semen with quinacrine hydrochloride and looking for the distinctive fluorescent spot at the head of the Y sperm. The semen of 124 cases was normal and the semen of the remaining cases was oligospermia. 98% of the medical students, 67% of the infertile men, and 30% of the postvasectomy patients had normal semen. Overall the average percentage of Y sperm stood at 43.8 (range=12.5-62). The total for normal and oligospermia semen was 44.36 and 41.32 respectively, but this difference was not significant (p.05). The infertile men had the highest average percentage of Y sperm (45.6) followed by medical student (43.86) and postvasectomy patients (30.82). Researchers do not know why the semen of postvasectomy men has a low percentage of Y sperm. The difference between the percentage of Y sperm of the postvasectomy patients and that of both the medical students and the infertile men was significant (p.0001). The percentage of those with Y sperm below 40% stood at 21.8 for the medical students, 16.5 for the infertile men, and 65 of the postvasectomy patients. Researchers need to conduct further studies to determine if these type of men are more likely to father female children. Possible explanations for the less than expected 50% of all sperm to be Y sperm may be that the F body technique cannot detect 10% of them or the Y chromosome is deep in the head and cannot be seen using this technique.^ieng