[Effect of hysteroscopic examination on the outcome of in vitro fertilization].

BACKGROUND/AIM: Implantation failure after embryo transfer is one of the main problems of in vitro fertilization (IVF) and intrauterine pathologies can lead to unsuccessful outcome. The aim of this study was to determine if hysteroscopic examination of uterine cavity and consequent treatment of intrauterine lesions prior to IVF could improve the pregnancy rate in women under 38. METHODS: This study included 480 patients under 38, who had undergone IVF or IVF\ICSI--embryo transfer cycles, in which one or more good quality embryos were transferred. By transvaginal sonography performed within the past 2 months, the uterus was found normal in all the patients enrolled in our IVF unit. The patients were divided into three groups: group A--with no hysteroscopic evaluation and no pathology, group B --with hysteroscopy but no pathology, and group C--with abnormal hysteroscopy finding and corresponding treatment. RESULTS: The obtained results revaled no difference in the mean age, duration of infertility, number of mature oocytes in either group (p > 0.05). Clinical pregnancy rates in the groups A, B and C were 36.9%, 58.75% and 32.7%, respectively, and delivery rates were 27.5%, 48.7% and 25.7%, respectively. There was a statistically significant difference among the groups concerning pregnancy and delivery rates. CONCLUSION: Considering the results of this study we could conclude that hysteroscopy, as a routine examination, should be performed before the first IVF-ET cycle in all patients thereby reducing the failures and then the costs of IVF-ET.

[Labour after intracytoplasmic sperm injection].

INTRODUCTION: The aim of our study was to describe labour characteristics after intracytoplasmic sperm injection programme. This is the first study of those deliveries at the Department of Gynecology and Obstetrics in Novi Sad. PATIENTS AND METHODS: Subjects were 73 parturients and their babies from the intracytoplasmic sperm injection programme (48 singletons, 22 twins and 3 triplets), delivered from January 1st, 2001 to December 31st, 2006. RESULTS: At the Department of Gynecology and Obstetrics in Novi Sad, 0.65% of all deliveries are those from assisted reproductive programmes. 30.67% of all labours after assisted reproductive programmes are after intracytoplasmic sperm injection. One half of all labours after intracytoplasmic sperm injection are twins. The mean age of women is 33-34. More than 95% of all babies were delivered by Cesarean section. DISCUSSION: The most frequent pathologies in labours after intracytoplasmic sperm injection are hypertensive disorders and premature rupture of membranes. There is still a matter of debate what is a real cause for those pathologies, especially for hypertension (age of woman, laboratory factors and or induction of ovulation). CONCLUSION: At the Department of Gynecology and Obstetrics in Novi Sad, one third of all deliveries after assisted reproductive programme are after intracytoplasmic sperm injection. The most frequent pathologies after intracytoplasmic sperm injection are hypertensive disorders, which is similar to findings of other authors. The mean age of women is also similar to the mean European age of women after intracytoplasmic sperm injection.

[Gross characteristics of placentas from an assisted reproduction program].

INTRODUCTION: Even though placentas from assisted reproduction programs often differ from placentas of women who conceived naturally, they are rarely examined. The aim of our investigation was to determine some gross characteristics of placentas of women who conceived with assisted reproduction. MATERIAL AND METHODS: We examined 30 placentas from an assisted reproduction program (20 from in vitro fertilization and 10 from intrauterine insemination) and 30 placentas of women who conceived naturally. All women were age matched. All the women were at term. RESULTS: The mean weight of placentas from assisted reproduction program was 573 g and of those after natural conception--582.67g. The mean length of the umbilical cords was 64.3cm after assisted reproduction and 66.3cm after natural conception. The mean placenta thickness after assisted reproduction was 2,22 cm and after natural conception 2.28 cm. Eight placentas of the study group had a marginal insertion of the umbilical cord, which lead to a statistically significant difference when compared to placentas of women who conceived naturally: chi-square = 7.07; p>0.01. DISCUSSION: Marginal cord insertion into the placenta after assisted reproduction is also often described in the literature (as a possible "consequence" of embryo-transfer). CONCLUSION: There were no statistically significant differences in the mean weight and dimensions of placentas, length of the umbilical cord, gross pathological features of placentas and cords, mean birth weight of babies and placental/fetal ratios between women from assisted reproduction program and those who conceived naturally.

Preterm and premature rupture of membranes in pregnancies after in vitro fertilization.

Women conceiving by assisted reproduction are at higher risk for preterm and premature rupture of membranes. The aim of our study was to estimate and compare incidence of preterm premature rupture of membranes in singleton pregnancies of women who conceived by intrauterine insemination and in vitro fertilization, from 1999 to 2003. We investigated 87 women from the intrauterine insemination, and 102 from the in vitro fertilization program. There were no statistically significant differences in regard to preterm and premature rupture of membranes: p > 0.75 in two groups. The incidence of premature rupture of membranes was 2.30% (after intrauterine insemination) and 2.94% (after in vitro fertilization). There was no statistically significant differences in regard to preterm and premature rupture of membranes in women who conceived by insemination and in vitro fertilization. Estimated incidence of preterm and premature rupture of membranes was similar to the literature data and also similar to incidence after natural conception.

Preeclampsia and eclampsia in parturients from the in vitro fertilization program.

Women from in vitro fertilization program are at higher risk for developing pregnancy induced hypertension, so we analyzed the incidence of preeclampsia and eclampsia in women who conceived in an in vitro fertilization program. A seven-year study included 144 parturients from in vitro fertilization program. The control group consisted of 39,112 parturients from general population. We analyzed only women with singleton pregnancies. There were 2.08% parturients from the in vitro fertilization program, and 0.40% from the control group, with diagnosis of preeclampsia, with chi2=6.24; p<0.05. Eclampsia occurred in 0.69% women who conceived using in vitro fertilization, and in 0.06% parturients from the control group (chi2=2.05; p>0.10). Parturients from in vitro fertilization program are at statistically significantly higher risk for preeclampsia, but not for eclampsia, when compared with women from general population.

Histological characteristics of placentas from assisted reproduction programs.

Placentas from assisted reproduction programs are a poorly investigated research material. The aim of this investigation was to perform microscopic examination of placentas from assisted reproduction programs and to compare them with placentas from spontaneous pregnancies. The investigation comprised 12 placentas from assisted reproduction programs and 12 placentas from spontaneous pregnancies. We found a statistically significant increase of villous edema in investigated placentas (p = 0.001). We also found a statistically significantly increased incidence of microcalcifications in placentas from assisted reproduction programs (p = 0.04). There was no statistically significant difference between the two groups in regard to syncytial knots (X2 = 0.67, p > 0.25). Microscopic examination showed that placentas from assisted reproduction programs present with more frequent pathological findings. Further investigations of placentas from assisted reproduction programs could provide better understanding of different pathological conditions of pregnancies and labor in women with artificial insemination.

[Therapy of idiopathic sterility]. / Terapijski tretman idiopatskog steriliteta.

INTRODUCTION: During the period 1996-2000, we investigated 900 couples with infertility. In 71 (7.9%) couples no cause of sterility was revealed. These patients were divided according to age, parity and infertility duration. MATERIAL AND METHODS: We established the cumulative conception rate and cycle fecundity after three months without therapy, after three cycles of intrauterine insemination and after three cycles of in vitro fertilization (eventually intracytoplasmic sperm injection). Among patients with less than three years of infertility, cumulative conception rate was 34.8% after three months without therapy, 27.3% after three cycles of intrauterine insemination and 66.7% after three cycles of in vitro fertilization. RESULTS AND DISCUSSION: In patients with infertility longer than three years, cumulative conception rate without therapy was 12.5%, with intrauterine insemination 16.1% and with in vitro fertilization 40.5%. Differences regarding the age of patients were significant. Based on these findings, we proposed an optimal therapy regimen: three months therapy delay is desirable in patients under 30 years of age with infertility duration under three years. If there is no pregnancy in that period, intrauterine insemination is performed in three to four cycles. In case of intrauterine insemination failure in these women, in vitro fertilization and embryo transfer should be applied. In the group of women over 30 years of age, with infertility longer than three years, the possibility for occurrence of pregnancy with intrauterine insemination is slightly increased. If more than 4 follicles develop during preparations for intrauterine insemination, it is advisable to change the course to in vitro fertilization. In women older than 35, with primary or secondary infertility, in vitro fertilization should be performed from the very beginning.

[Endometriosis and pain]. / Endometrioza i bol.

INTRODUCTION: The main symptoms of endometriosis are pain, adnexal tumor and infertility. Pelvic pain and dysmenorrhea are cardinal symptoms as well as pain upon defecation, suprapubic pain (dysuria), pain during coitus and during gynecologic examination. Pain can be caused by fibrotic reaction of the adjacent tissue, adhesions, prostaglandins produced both in endometrium inside the uterus and ectopic endometrium, and also by increased macrophages in the peritoneal fluid. MATERIAL AND METHODS: 500 infertile patients underwent the procedure of laparoscopy in order to determine the cause of infertility. The control group comprised 200 fertile women. The presence of pain in the small pelvis was compared in two groups of patients: with or without endometriosis. Correlation of pain with the stage of disease and location of endometriotic implants in the small pelvis has also been investigated. RESULTS: Endometriosis was diagnosed by laparoscopy in 26% of infertile and 5% of fertile women. The difference was statistically significant (p < 0.001). Dysmenorrhea was present in 46.92% of infertile women with endometriosis and in 48.68% of women without endometriosis. The difference was not statistically significant. Dysmenorrhea was present in 30% of fertile women and in realtion to infertile women, the difference was statistically significant (p < 0.05), no matter if they have endometriosis or not. In relation to stages of endometriosis (the revized classification of the American Fertility Society), there is no significant difference concerning dysmenorrhea. Dysmenorrhea occurred in the first stage in 48%, in the second stage in 44.19%, in the third stage in 50% and in the fourth stage in 44.44%. The correlation coefficient ranged from -8.85 to -0.89. The correlation existed, it was high, but negative. Sensitivity, specificity and prognostic value of symptoms of dysmenorrhea have been estimated in relation to endometriosis with following results: sensitivity was 47%, specificity 51% and the prognostic value i.e. the possibility of occurrence in patients with dysmenorrhea was 25%. Localization of endometriotic foci did not affect occurrence of pain symptoms.

[Significance of maternal and paternal age in assisted reproduction programs]. / Znacaj godina starosti majke i oca u programu asistirane reprodukcije.

INTRODUCTION: Many infertile couples try to become parents spontaneously, neglecting the possibility to conceive artificially, so they seek medical help in their late reproductive age. MATERNAL AGE: Major aspects of maternal age in regard to assisted reproduction consider oocytes, ovaries and endometrium. Also, some habits and maternal diseases associated with aging may have an impact on fertility (smoking, atherosclerosis, previous gynecological operations etc.). Even though estimating the ovarian reserve is the most objective test in assessing female fertility, it has a limited predictive value in younger women. A short protocol of ovulation induction showed best results in women with poor ovarian reserve, but recent studies recommend low-dose gonadotropin-releasing hormone agonists in these cases. PATERNAL AGE: With aging, sperm parameters become worse, which points to the neglected role of the father in assisted reproduction. CONCLUSION: Thus, parental age plays an important role in assisted reproductive programs.