Live births after intracytoplasmic sperm injection in the management of oligospermia and azoospermia in Nigeria.

Intracytoplasmic sperm injection has revolutionised the management of male infertility. We report two cases that demonstrate the successful application of this technology in Nigeria in the management of both oligospermia and azoospermia. The first case relates to the treatment of a 31-year-old woman who required intracytoplasmic sperm injection of her husband's sperm for the treatment of both tubal fertility and male infertility. She had three embryos transferred on 9th June 1999 and was delivered of healthy male and female infants by caesarean section in January 2000 at 33 weeks gestation. The second case describes a 38-year-old woman who required intracytoplasmic sperm injection of the husband's surgically collected sperm for the management of azoospermia. She had two embryos transferred on 16th December 1999 and was delivered of a healthy male infant by caesarean section on 19th July 2001.

Internal jugular vein thrombosis after assisted conception therapy.

Superovulation therapy during assisted conception may result in a hypercoagulable state. Five cases of upper extremity venous thrombosis were identified in women who conceived after ovarian stimulation for in vitro fertilization (IVF). They presented between 7 and 10 weeks' gestation with neck pain and swelling. Three had been treated for ovarian hyperstimulation syndrome and two had evidence of inherited thrombophilia. Four patients received thromboprophylaxis before presentation. Although thrombosis is an uncommon complication of IVF, patients should be counselled before treatment. Thrombophilia screening may be considered for 'high-risk' patients, although current regimes for thromboprophylaxis remain suboptimal.

The ultrasound diagnosis of retained fetal bones in West African patients complaining of infertility.

Prolonged retention of intrauterine bone is a recognised cause of secondary infertility. Between 1989 and 1995, eleven West African women had retained intrauterine bone as the cause of their infertility. All the women had had termination of pregnancies in their countries of origin. Transvaginal ultrasound scan detected bright intrauterine echoes suggestive of bone which was confirmed and removed at hysteroscopy. Subsequently eight women conceived spontaneously 12 pregnancies. Doctors treating West African women with infertility should be aware of this condition and include transvaginal ultrasound scan in their investigations.

Ultrasound derived indices of follicular blood flow before HCG administration and the prediction of oocyte recovery and preimplantation embryo quality.

The principal aim of the study was to relate ultrasound-derived indices of blood flow in individual follicles on the day of, but before, the administration of human chorionic gonadotrophin (HCG) to the subsequent recovery of oocytes and the production of preimplantation embryos. Data were obtained from 21 women (aged 29-43 years) with bilateral tubal occlusion, who were undergoing treatment by in-vitro fertilization (IVF) and embryo transfer. Transvaginal ultrasonography with colour Doppler imaging and pulsed Doppler spectral analysis were used to measure follicular volume and derive indices of blood flow. The end-points for each follicle were the volume, peak systolic velocity (PSV), pulsatility index (PI), and the recovery or non-recovery of an oocyte, the subsequent production or non-production of a preimplantation embryo and the morphological grade of each embryo. A total of 94 follicles were studied; 74 oocytes were recovered (79%) and 40 embryos (33 grade I or II) were produced. There were four clinical pregnancies (pregnancy rate 25.0% per transfer, 19.0% per patient). There was a significant correlation between whether or not follicular blood flow was detected and whether or not an oocyte was recovered (P < 0.05, chi 2 test). The values for volume and PI were not clinically useful. The PSV (cm/s, mean +/- SD) was higher in follicles that were associated with the production of an embryo (12.7 +/- 5.9) compared with those that were not (8.5 +/- 5.0; P < 0.05, Student's t-test). The probability of producing a grade I or grade II embryo was 75% if the PSV was > or = 10 cm/s. The corresponding value was 40% if the PSV was < 10 cm/s and 24% if blood flow was not detected (i.e. PSV < 3 cm/s). There was a significant increase (P < 0.05, Student's t-test) in the PSV before aspiration in those follicles associated with the subsequent production of an embryo. We conclude that the value for PSV, before the administration of HCG, can be used to identify follicles with a high probability of producing an oocyte and a high grade preimplantation embryo. The information may also be used to time the administration of HCG to achieve the optimum number and quality of embryos for patient management.

Prediction of oocyte recovery rate by transvaginal ultrasonography and color Doppler imaging before human chorionic gonadotropin administration in in vitro fertilization cycles.

OBJECTIVE: To detect and quantify follicular vascularity before hCG administration in women undergoing IVF-ET. To correlate follicular vascularity with the oocyte recovery rate after direct follicle aspiration. DESIGN: A prospective, longitudinal study of consecutive women undergoing IVF-ET at the assisted conception unit of King's College Hospital, London and having at least 20 follicles between the two ovaries on the day of hCG administration. INTERVENTIONS: An Acuson 128XP1O computed sonography system (Acuson Ltd., Uxbridge, United Kingdom) was used to measure follicular diameters, indices of blood flow impedance (pulsatility index), peak systolic velocities (Vmax), and the proportion of follicles demonstrating pulsatile vascularity, i.e., follicular vascularity index. For the purpose of analysis, each woman was classified into one of four groups (I to IV) based on their oocyte recovery rate. RESULTS: The mean age, duration of infertility, Dmax, pulsatility index, and Vmax were similar in the four groups, but the follicular vascularity index was higher in the groups with the highest oocyte recovery rates. Furthermore, there was a positive correlation between the follicular vascularity index and the oocyte recovery rate. CONCLUSION: The follicular vascularity index correlates positively with oocyte recovery rates. Detection and quantification of follicular vascularity with color Doppler imaging can therefore be used to predict oocyte recovery rate and hence may be useful in determining the most appropriate time to administer hCG to optimize oocyte recovery rates.

Intrafollicular hemodynamics before the administration of human chorionic gonadotropin in women at risk of the ovarian hyperstimulation syndrome.

OBJECTIVE: To test the hypothesis that alteration of intrafollicular hemodynamics precedes the ovarian hyperstimulation syndrome (OHSS). DESIGN: A prospective study. SETTING: The IVF unit and the Doppler imaging laboratory of King's College Hospital, London. PATIENTS: Twenty-four women undergoing IVF and considered to have an exaggerated response to ovarian stimulation and hence at risk of OHSS. INTERVENTIONS: Transvaginal Doppler imaging of the intrafollicular blood flow was performed before hCG administration to determine the indexes of intrafollicular hemodynamics. MAIN OUTCOME MEASURES: Moderate or severe OHSS. RESULTS: There was no statistically significant difference in mean age (32.63 +/- 1.77 versus 31.48 +/- 3.87), duration of infertility (6.00 +/- 2.19 versus 5.29 +/- 2.73), maximum peak systolic velocity (0.25 +/- 0.16 versus 0.26 +/- 0.21 m/s), mean of six maximal peak systolic velocity (0.15 +/- 0.04 versus 0.21 +/- 0.10), minimum pulsatility index (0.76 +/- 0.26 versus 0.59 +/- 0.23), mean of six minimal pulsatility indexes (0.89 +/- 0.30 versus 0.79 +/- 0.14), minimum resistance index (0.47 +/- 0.06 versus 0.41 +/- 0.10), and mean of six minimal resistance indexes (0.56 +/- 0.05 versus 0.53 +/- 0.06) of intrafollicular blood flow between the women who developed moderate or severe OHSS and matched controls. CONCLUSION: Measurement of intrafollicular hemodynamics before hCG administration does not predict the development of the OHSS.

Total ovarian volume before human chorionic gonadotrophin administration for ovulation induction may predict the hyperstimulation syndrome.

Total ovarian volumes were measured before the administration of HCG in 42 women undergoing treatment for infertility by in-vitro fertilization (IVF) and embryo transfer and considered to have an exaggerated response to stimulation ( > 20 follicles). Seven women who subsequently developed moderate or severe ovarian hyperstimulation syndrome (OHSS) (n = 7; group 1) were compared with 35 matched controls (five matched controls per case; n = 35; group 2) of similar age, number of follicles and duration of infertility who underwent follicular stimulation, oocyte recovery, in-vitro fertilization and embryo transfer during the same period but did not develop moderate or severe OHSS. The mean age, duration of infertility and total number of follicles were similar but the mean total ovarian volume was significantly higher in the group of women who developed moderate or severe OHSS compared with controls (271.00 +/- 87.00 versus 157.30 +/- 54.20 ml; P < 0.01). We conclude that total ovarian volume measured before HCG administration is higher in women who develop moderate or severe OHSS compared with controls and may therefore be used as an additional parameter in the preventative strategy for the ovarian hyperstimulation syndrome.

Laparoscopic zygote intrafallopian transfer using augmented local anesthesia.

In this study, 29 laparoscopic ZIFTs were performed in 21 patients using local anesthesia augmented with intravenous analgesia. The technique was well tolerated; significant discomfort arose only when the fallopian tubes were manipulated and was minimized by transferring zygotes to one tube only. Seven pregnancies resulted, of which three have delivered and one is ongoing.

A prospective study to investigate the value of flushing follicles during transvaginal ultrasound-directed follicle aspiration.

In this study, 50 transvaginal US-directed follicle aspiration procedures were performed with follicle flushing using a double-channel needle. The origin of each oocyte was established according to whether it had been obtained in the initial part of the aspirate, in the dead space aspirate, in the first to third flushes, or in the fourth to sixth flushes. Seventeen percent of total oocytes were found in follicle flushes. Only 3.2% of total oocytes were found in the fourth to sixth flushes, and their fertilization rate was reduced. Flushing follicles with a double-channel needle may result in the recovery of 20% more oocytes than would be obtained by aspiration alone.

Pregnancies after in vitro fertilization and transfer of human blastocysts.

In a study of 29 cycles of IVF, ET was performed on day 5 after oocyte recovery when embryos had developed to the morula/blastocyst stage. Three preclinical pregnancies and three live births resulted (2 singleton and 1 twin), giving a viable PR per ET of 10%. It is concluded that while day 5 ET may well be important in terms of embryo biopsy for the preimplantation diagnosis of genetic disease, day 2 ET remains preferable for therapeutic IVF. Although these data would not support the introduction of day 5 ET into routine therapeutic IVF, delayed ET should be considered as an alternative approach to preimplantation diagnosis. Indeed, because the latter will generally involve the treatment of normal, fertile couples, it might be predicted that embryo survival rates, and thus the rate of pregnancy after day 5 ET, would be better than those presented here.

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.

Development of spare human preimplantation embryos in vitro: an analysis of the correlations among gross morphology, cleavage rates, and development to the blastocyst.

Following in vitro fertilization, the criteria commonly used to select human embryos for transfer are the cleavage rate and gross morphology, the contention being that those embryos which divide more rapidly and have regular, spherical blastomeres are more likely to lead to a pregnancy. In order to assess the validity of this assumption, the development in vitro of spare embryos was investigated. Eggs and embryos were cultured in Earle's balanced salt solution containing 10% heat-inactivated patient's serum, and insemination was performed at 40 hr post human chorionic gonadotropin (hCG). At 82-90 hr post hCG, up to four embryos were transferred. Any spare embryos were cultured in the same medium for up to 6 days and scored daily for cell number and morphology using a "quality" scale of 4-1 according to degree of fragmentation and shape of the blastomeres. Of 317 fertilized eggs, 55 (17%) developed to the fully expanded blastocyst stage. The remaining embryos ceased development at the one-cell (6; 2%), two-cell (49; 15%), four-cell (110; 35%), eight-cell (61; 19%), and cavitating morula (36; 11%) stages. The relationship between developmental arrest and gross morphology is discussed.

Pregnancies following in vitro fertilization and ultrasound-directed surgical embryo transfer by perurethral and transvaginal techniques.

Ultrasound-directed surgical ET is useful in patients with a history of difficult cervical (nonsurgical) transfer, and was performed without complications in the small group reported here. The technique is straightforward, and requires no greater expertise than that necessary for ultrasound-guided oocyte collection. However, further studies are necessary to assess its role in the routine transfer of embryos following IVF.

Use of the heterologous ovum penetration test to predict the fertilising capacity of human spermatozoa.

The ability of human spermatozoa to penetrate zona-free hamster ova in a heterologous ovum penetration (HOP) test was compared with the fertilisation of human oocytes in 54 normospermic couples. Concordant results were seen in 45/54 (83%) cases. However, false-positive HOP test results occurred in 5/45 (11%) couples and false-negative results in 4/9 (44%) couples. The data suggest that a positive HOP test result is a good indication that fertilisation will occur, although a negative HOP test result does not necessarily mean that fertilisation will not take place.

Clinical evaluation of the heterologous oocyte penetration (HOP) test.

The heterologous oocyte penetration (HOP) test, using zona-free hamster oocytes, was used to assess the fertilising capacity of human spermatozoa. There was good correlation between the ability of ejaculated spermatozoa to penetrate the zona-free hamster oocytes and intact human oocytes. Using epididymal spermatozoa, the HOP test results showed that the ability to penetrate oocytes was acquired during their passage through the epididymis. Applied clinically, the HOP test enables a group of infertile men to be identified with a functional defect of their spermatozoa; these men may not be identified at routine seminal fluid analysis. Men with two negative HOP test results were confirmed as being infertile since their wives, if normal, conceived rapidly when donor spermatozoa were artificially inseminated.