The use of the stimulated acrosome reaction test as a test of fertilizing ability in human spermatozoa.

OBJECTIVE: To assess if patients who do not fertilize human oocytes in vitro can be identified by a lack of acrosomal response of their spermatozoa to stimulation by the calcium ionophore A23187. DESIGN: The stimulated acrosomal response for all patients was calculated. Those not achieving fertilization were compared with a normogram constructed from donors and patients who achieved fertilization; the 0.5th centile (31.3% increase in the number of spermatozoa reacted) was used as a discriminant point. PATIENTS: Fifty-four IVF patients and 15 fertile sperm donors. SETTING: An outpatient based IVF program. INTERVENTIONS: Acrosome reaction stimulated by 2 hours incubation in a 5-mumol/L solution of the calcium ionophore A23187. RESULTS: Patients who fertilized oocytes responded as donors. Eight of 16 patients failing to fertilize oocytes showed a minimal increase in the number of acrosome-reacted spermatozoa (mean [+/- SD] rise 6.3% +/- 10.3%). An acrosomal response of < 31.3% predicts fertilization failure in 100% of cases. CONCLUSIONS: Failure of the acrosome to react is responsible for some failure of IVF.

Acrosome reactivity in spermatozoa of different morphology in response to stimulation with follicular fluid.

The ability of the morphologically abnormal spermatozoon to undergo the processes necessary for fertilization is unknown; one of the essential processes is the acrosome reaction. In order to assess this, spermatozoa from 10 known fertile donors were incubated with either follicular fluid or Earle's medium containing 3 mg/ml bovine serum albumin at 37 degrees C for 6 h. The spermatozoa were then stained with 2% Trypan Blue prior to being fixed in glutaraldehyde and stained for the presence of the acrosomal cap using the triple stain. Fifty live spermatozoa in each of four morphological categories (normal head, large head, small head, abnormal neck or tail) were examined and the number of acrosome-reacted spermatozoa determined. There was a significant difference between the morphological groups in the baseline number of acrosome-reacted spermatozoa, determined by examining sperm samples incubated in Earle's medium; however, the number of spermatozoa undergoing the acrosome reaction in response to stimulation with follicular fluid (i.e. the number of spermatozoa acrosome-reacted in follicular fluid minus the number acrosome-reacted in Earle's medium) was similar for all morphological groups. This suggests that abnormal sperm morphology did not affect the response of spermatozoa to activation of the acrosome reaction by exogenous stimuli.

Experience with peritoneal oocyte and sperm transfer as an outpatient-based treatment for infertility.

Fifty-nine patients underwent 74 peritoneal oocyte and sperm transfer procedures. Forty-nine had previously failed treatment with inseminated frozen donor sperm and 10 had unexplained infertility. All procedures were carried out under ultrasound direction on an outpatient basis without general anesthetic by the transabdominal or vaginal route. Eighteen (24%) procedures resulted in pregnancy. Of these patients, 16 have delivered live infants (1 set of triplets, 2 twins, and 13 singletons) and 2 miscarried. Peritoneal oocyte and sperm transfer offers an outpatient-based alternative to gamete intrafallopian transfer (GIFT) for in vivo conception. It can also be used in patients scheduled for intrauterine insemination where stimulation is excessive because the number of oocytes replaced can be limited.

Transvaginal colour flow imaging of the uterine arteries during the ovarian and menstrual cycles.

Uterine arterial blood flow was studied at defined times during the ovarian or menstrual cycles. Transvaginal colour pulsed ultrasound was used to identify the vessels in 23 healthy women. Blood flow impedance as reflected by the pulsatility index (PI) was determined for both arteries on 132 occasions. There was no significant difference in the PI values between the right and left arteries. The average PI value was used for subsequent analysis (range 0.5-5.6; mean 2.8). Peak mean PI values occurred on day 1 of menses (4.6), the day of the plasma oestradiol peak (3.7) and the day of the LH peak plus 3 (2.9). The lowest mean PI values (indicating the least impedance to blood flow) occurred on the day of the LH peak minus 6 (2.6), and the day of the LH peak plus 9 (1.9). There are complex temporal relationships between uterine blood flow, ovarian morphology, the concentrations of plasma oestradiol and progesterone and the thickness of the endometrium.

Outcome of triplet pregnancies resulting from IVF at Bourn Hallam 1984-1987.

43 consecutive sets of triplet pregnancies progressing beyond 16 weeks and conceived following in vitro fertilisation at the Bourn Hallam Centre between 1984-1987 were included in the study. Follow-up information was available in the 31 sets born to United Kingdom residents. 91 live births resulted at an average gestation of 33 weeks and 2 days (range 26-38 weeks). All but one of the deliveries was by Caesarean section. The average birth weight was 1.85 kg and was significantly higher in the first-born triplet than in the third (1.93 kg versus 1.74 kg, respectively). The perinatal mortality rate amongst the triplets was 32.26 per thousand births, and the neonatal death rate was 21.98 per thousand live births. This compares favourably with the latest published data on perinatal mortality rates in triplets.

The clinical outcome of reinsemination of human oocytes fertilized in vitro.

To assess the value of reinseminating human oocytes, the results of 1,662 embryo transfers were analyzed. In 1,460 transfers embryos arose from oocytes that had fertilized and cleaved after initial insemination. The pregnancy rate was significantly higher than in transfers of embryos (n = 76) resulting solely from reinseminated oocytes (27% versus 3%). Adding reinseminated embryos to those fertilizing on initial insemination at transfer failed to raise the pregnancy rate. Only 2 of 158 (1.3%) reinseminated embryos implanted compared with 540 of 4,181 (12.9%) fertilized and cleaved on initial insemination (P less than 0.001). Reinseminated embryos do occasionally produce viable pregnancies. It is therefore worth considering replacement of these embryos if initial fertilization has entirely failed. Patients should be counseled as to the low chance of implantation with these embryos.

Ultrasound directed follicle aspiration for oocyte collection using the perurethral technique.

Our experience in 242 consecutive ultrasound directed follicle aspirations using the perurethral technique is reported. The mean number of follicles punctured per patient was 9.6 (range 20 to 35), resulting in a mean oocyte yield of 6.1 (range 0 to 31) per patient. It was necessary to change to another ultrasound directed route in 20 patients, and we failed to retrieve oocytes in a further 6 patients. There were no serious complications. The fertilization and cleavage rates were 68% and 91%, respectively. Embryo transfer was performed in 178 cases, resulting in 39 clinical pregnancies (21.9%). Ultrasound directed follicle aspiration by the perurethral route is an efficient way of collecting oocytes and is acceptable to patients. There is no need for general anaesthesia, so this technique is well suited to in vitro fertilization programs based on outpatient procedures.

Gamete intra-fallopian transfer combined with diagnostic laparoscopy: a treatment for infertility in a district hospital.

Gamete intra-Fallopian transfer (GIFT) was combined with a diagnostic laparoscopy on a routine operating list in a district general hospital. The equipment used was entirely portable. Operations were programmed 6-12 weeks in advance using a fixed ovarian stimulation regimen. Of 47 patients treated, 38 (81%) responded appropriately to stimulation. Of these, 23 had partners with normal semen parameters and 5 of 21 (24%) who had GIFT conceived. Two others were found to have tubal damage. Their eggs were transported to an in-vitro fertilization unit at another hospital. Both conceived after embryo transfer. In 15 couples, the semen was found to be sub-optimal and none of these became pregnant. GIFT can be performed in a district hospital, on a fixed schedule in conjunction with a diagnostic laparoscopy. The technique appears unsuitable for patients with suboptimal semen and the backing of an in-vitro fertilization unit increases pregnancy rates.

The effect of cycle length on the outcome of in vitro fertilization.

In order to study the effect of cycle length on the pregnancy rate in an in vitro fertilization and embryo transfer (IVF-ET) program, 173 consecutive patients were divided into short menstrual cycle (mode 26 days or less) and normal cycle (mode 27 days or more) groups. Patients were randomly allocated to one of two treatments, commencing ovarian stimulation with human menopausal gonadotropin (hMG) on either day 2 or day 4 of their cycle. The number of oocytes retrieved and embryos transferred did not differ significantly. The amount of hMG used and day of human chorionic gonadotrophin administration both differed significantly (P less than 0.01) between regimens but was independent of cycle length. Both the clinical pregnancy rate (30.2% versus 9.4%, P less than 0.05) and the number of cleaved embryos giving rise to gestation sacs (16% versus 3.4%, P less than 0.02) was significantly higher in patients with a normal cycle length. Mode cycle length has a significant bearing on the outcome of IVF-ET cycles.

Two years' experience of ultrasound-directed oocyte retrieval.

The first 2 years' data of an outpatient-based in vitro fertilization program relying on transabdominal transvesical ultrasound-directed oocyte retrieval (TUDOR) is presented. A total of 935 patients were treated. Ovarian stimulation was performed in 1538 cycles, oocyte retrieval in 1226, and embryo transfer in 960. All ovaries were accessible for oocyte retrieval, even in those patients in whom laparoscopic retrieval had failed previously or was deemed impossible. No major complications due to TUDOR occurred and the incidence of all complications was 1.5%. The clinical pregnancy rate was 19.0% per embryo transfer, but increased throughout the 2 years to 30.0% per embryo transfer. The technique is easy to learn, effective, and appears to be superior to laparoscopy in terms of ovarian accessibility and safety.