Influence of intracervical and intravaginal seminal plasma on the endometrium in assisted reproduction: a double-blind, placebo-controlled, randomized study.

OBJECTIVE: To investigate the effect of intracervical and intravaginal application of seminal plasma on the endometrium, as assessed by endometrial/subendometrial vascularization and endometrial volume between the day of oocyte retrieval and the day of embryo transfer in an in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycle. METHODS: This was a double-blind, placebo-controlled, randomized study including patients undergoing a first or second IVF/ICSI cycle. Homologous seminal plasma or placebo (sodium chloride) was injected into the cervix and posterior vaginal fornix just after follicle aspiration. Three-dimensional power Doppler examination was performed 30 min before oocyte retrieval and 30 min before embryo transfer. Main outcome measures were changes in vascularization flow index (VFI), flow index (FI) and vascularization index (VI) of the endometrium/subendometrium using VOCAL™ (Virtual Organ Computer-aided AnaLysis) and endometrial volume. RESULTS: One hundred patients agreed to participate in the study. Twenty-three patients were excluded, mainly as a result of canceled embryo transfer. Data were analyzed from 40 patients receiving seminal plasma and 37 receiving placebo. No significant differences between the two groups were seen in VFI, FI or VI of the endometrium or subendometrium or in endometrial volume on the day of oocyte pick-up and on the day of embryo transfer. CONCLUSION: Neither endometrial/subendometrial vascularization parameters nor endometrial volume seem to be affected by the application of seminal plasma in patients undergoing their first or second IVF/ICSI cycle.

Blood clots in the cumulus-oocyte complex predict poor oocyte quality and post-fertilization development.

Assessment of oocyte maturity and quality (morphological appearance) at the time of retrieval is difficult as the egg is obscured by a large cumulus mass that hinders adequate scoring. Since no data are available on the possible relationship between the cumulus-oocyte complex (COC) and oocyte morphology, this prospective intracytoplasmic sperm injection study was set up in 87 consecutive patients. COC were grouped according to expansion of both corona radiata and cumulus matrix. Special emphasis was placed on recording morphological anomalies of COC (inclusion of blood clots and amorphous clumps). For all mature ovae, quality was assessed and preimplantation development followed up to blastocyst stage if fertilized. The risk of not harvesting an oocyte was higher in COC with blood clots compared with normal cumulus matrices (P = 0.004). COC expansion did not allow for prediction of either nuclear status or quality of the egg. The presence of blood clots within the cumulus matrix was associated with reduced oocyte quality (dense central granulation), fertilization rate and blastocyst formation, compared with unaffected COC (P < 0.05). It may be postulated that COC showing blood inclusions derive from poor quality follicles, which has a detrimental effect on oocyte quality and further cleavage to blastocyst stage. Consequently, mechanical removal of blood clots cannot rescue the corresponding embryo.

Three-dimensional power Doppler in the diagnosis of ovarian torsion.

Recent advances in ultrasound technology have enabled the diagnosis of overall tissue vascularization by three-dimensional (3D) power Doppler. This case report describes 3D power Doppler characteristics of unilateral ovarian torsion 2 weeks after embryo transfer in a pregnant patient with bilateral hyperstimulated ovaries. Before laparoscopic treatment the twisted right ovary showed the following 3D power Doppler indices: mean grayness index, 15.66; vacularization index, 0.24; flow index, 21.99; vascularization flow index, 0.05. One hour after laparoscopic treatment 3D power Doppler indices of the untwisted ovary were as follows: mean grayness index, 25.61; vacularization index, 3.81; flow index, 42.800; vascularization flow index, 1.63. The resistance index of the ovarian vessels before and after laparoscopy showed no significant difference (5.1 vs. 5.2). The diagnosis of ovarian torsion can be better made with 3D power Doppler sonography than with two-dimensional Doppler sonography.

[Sonographic measurement of endometrium thickness as a predictive value for pregnancy through IVF]. / Die sonographische Endometriumdicke als Prediktionsfaktor für eine Schwangerschaft in einem IVF-Programm.

AIM: This prospective study was performed to evaluate the predictive value of endometrium thickness in patients undergoing IVF-ET. METHOD: Measurements of endometrium thickness as well as pattern assessments were performed in 936 cycles (722 patients) on the day of administering human chronic gonadotropin (HCG). RESULTS: The overall pregnancy rate was 31.1 % (291/936). The age of non pregnant patient was significantly higher (p < 0.029). There was a significant influence of oestradiol (p < 0.029), number of transferred embryos (p < 0.004), and embryo quality (p < 0.002) on the pregnancy rate. Overall, the mean (+/- SD) endometrium thickness was 11.16 mm (+/- 2.13). The mean (+/- SD) endometrium thickness of pregnant patients was 11.25 mm (+/- 2.19). The mean (+/- SD) endometrium thickness of non-pregnant patients was 11.12 mm (+/- 2.10). A stepwise logistic regression analysis showed no statistically significant correlation between endometrium thickness and pregnancy rate (p < 0.23). CONCLUSION: Sonographic measurement of endometrium thickness on the day of human chorionic treatment with gonadotropin is not useful in predicting IVF outcome.

First polar body morphology and blastocyst formation rate in ICSI patients.

BACKGROUND: It may be beneficial to identify, at a very early stage of development, concepti that will result in viable blastocysts by using a non-invasive technique. METHODS: Homogeneous groups in terms of first polar body (PB) morphology were analysed with regard to fertilization, embryo quality and blastocyst formation. The strategy was to transfer a maximum of two blastocysts with an adequate inner cell mass deriving from oocytes with identical first PBs in order to obtain information about the actual implantation potential. RESULTS: A significant relationship between first PB morphology and embryo quality was found. Fragmentation after 2 days was increased in embryos derived from oocytes with fragmented first PBs (P < 0.05) in comparison with those derived from oocytes with intact PBs. No similar correlation could be demonstrated for fertilization rate. Embryos in the intact first PB group showed an increased rate of blastocyst formation as compared with the fragmented first PB group (P < 0.05). In addition, a significant difference in implantation rate (48.6 versus 22.0%; P < 0.025) and ongoing pregnancy rate (68.4 versus 34.8%; P < 0.05) was observed for the intact versus fragmented groups respectively. CONCLUSION: In conclusion, the current study provides further evidence that preselection at a very early stage may be helpful in identifying a subgroup of preimplantation embryos with a good prognosis to form blastocysts and, consequently, to implant.

Prospective hatching of embryos developed from oocytes exhibiting difficult oolemma penetration during ICSI.

BACKGROUND: The hormonal milieu during ovarian stimulation is known to affect oolemma behaviour as well as zona pellucida thickness and structure. This led us to investigate whether a special subgroup of patients with oocytes where penetration of the oolemma is difficult during ICSI may benefit from assisted hatching. METHODS: A total of 77 couples (mean age: 32.9 +/- 4.6 years; range: 22-38) had oocytes that could hardly be penetrated by the ICSI pipette. Nineteen patients underwent two ICSI cycles, giving a total number of 96 cycles, which were randomly split into either the study group (n = 52) or the non-hatching group (n = 44). Hatching was done using a non-contact 1.48 mm wavelength diode laser. Implantation and pregnancy rates were recorded. RESULTS: The pregnancy rate was 36.6% (19/52) in the study group and 13.6% (6/44) in the non-hatching group (P < 0.05). In addition, a higher number (P < 0.05) of embryos implanted in the study group (23/106; 21.7%) than in the non-hatching group (9/92; 9.8%). CONCLUSIONS: Once oolema penetration during ICSI has proven difficult, prospective hatching of embryos considered for transfer may increase their implantation behaviour.

Reproducibility of three-dimensional ultrasound endometrial volume measurements in patients with postmenopausal bleeding.

OBJECTIVE: To evaluate the reproducibility of transvaginal three-dimensional (3D) endometrial volume measurement in patients with postmenopausal bleeding and to compare the reproducibility of this technique to that of two-dimensional (2D) endometrial thickness measurement. METHODS: In a prospective, blinded study, transvaginal ultrasound examinations were performed in 51 consecutive patients with postmenopausal bleeding. Three-dimensional volume and 2D thickness measurements were made and intraobserver and interobserver reproducibility of each technique were assessed. RESULTS: The intraobserver correlation of 3D endometrial volume measurement of the first observer was 0.97 and that of the second observer was 0.99. Thus, mean intraobserver correlation was 0.98. The mean interobserver correlation was 0.95 (0.95 vs. 0.96). There was no significant difference in reproducibility at different volume cut-offs. The mean intra- and interobserver correlation of endometrium volume measurements for five patients with endometrial carcinoma did not differ significantly from that for patients without carcinoma (0.98, 0.98 vs. 0.98, 0.95). The intraobserver correlation of 2D endometrial thickness measurements from the first observer was 0.71 and that from second observer 0.87. Thus, mean intraobserver correlation of the endometrial thickness measurements was 0.79. The mean interobserver correlation was 0.76 (0.84 vs. 0.70). CONCLUSIONS: Endometrial volume and thickness measurements by 3D and 2D ultrasound, respectively, show good reproducibility but the reproducibility of 3D ultrasound is better.

Laser assisted immobilization of spermatozoa prior to intracytoplasmic sperm injection in humans.

BACKGROUND: The conventional method of immobilization of spermatozoa prior to intracytoplasmic sperm injection (ICSI) is mechanical breakage of the tail by pressing it against the bottom of the injection dish. METHODS: This prospective self-controlled study was set up to evaluate the potential of a non-contact 1.48 microm wavelength diode laser in terms of immobilization. In addition, the fertilization rate and further development potential of such zygotes were investigated. The patients included in our study (n = 60) had oestradiol concentrations >2000 pg/ml, and thus a relatively high number of MII oocytes could be expected. Approximately half the oocytes were injected with laser treated spermatozoa (n = 262, study group) and the other half with mechanically immobilized spermatozoa (n = 252, control group). RESULTS: No significant differences between the two groups in terms of fertilization rate, early cleavage or blastocyst formation were observed. However, time required for identification, aspiration and injection of a potential spermatozoa was significantly shorter in the laser immobilized sperm group (P < 0.001). CONCLUSIONS: The application of a non-contact diode laser for sperm immobilization prior to ICSI is a potentially useful alternative to the conventional mechanical approach.

Acute puerperal inversion of the uterus--treatment by a new abdominal uterus preserving approach.

OBJECTIVE: Inversion of the uterus is still a rare (1, 2) but serious and life-threatening obstetric complication. It is said to be complete when the fundus uteri protrudes through the cervix and into the vagina. Within minutes a state of shock is reached due to pulling forces on the peritoneum as well as blood loss. METHODS: The vagina was entered by a longitudinal incision (3 m) below the contraction ring. Through this opening it was possible to advance two fingers (second and third finger of the left hand) into the vagina above the invaginated corpus uteri. The invaginated cavum uteri was loaded on these two fingers and, exerting counterpressure with the right hand, the inside was turned out. CONCLUSION: The present operative method guarantees easy reposition of the uterus in cases of failed vaginal manual repositioning. Furthermore, the cavum uteri remains intact and hysterectomy can be avoided.

Embryo fragmentation in vitro and its impact on treatment and pregnancy outcome.

OBJECTIVE: To determine the impact of embryo fragmentation on pregnancy, obstetric, and perinatal outcome. DESIGN: Retrospective analysis of embryo transfers that were homogeneous in regard to the degree of fragmentation. SETTING: Fertility center. PATIENT(S): A cohort of 460 fresh embryo transfers. INTERVENTION(S): A total of 164 pregnancies were analyzed for the incidence of antepartum complications during gestation, obstetric (multiple pregnancy, preterm delivery, cesarean section), and perinatal outcome (sex, birth weight, admission to neonatal intensive care unit, malformations). MAIN OUTCOME MEASURE(S): Implantation and clinical pregnancy rate, obstetric and perinatal outcome. RESULT(S): Embryo fragmentation and number of embryos per transfer showed a significant influence on clinical pregnancy and implantation rate. No such relation was found concerning complications, multiple pregnancy rate, incidence of cesarean section, gestation week, birth weight, and average time at the neonatology. On the other hand, pregnancies derived from bad-quality embryos had a significantly higher rate of malformations. CONCLUSION(S): The higher percentage of malformations found in bad-quality embryos may be due to a higher percentage of apoptotic features and chromosomal disorders. For ethical reasons, the transfer of embryos with >50% fragmentation should be considered only after consultation with the patient.

A prospective study on oocyte survival rate after ICSI: influence of injection technique and morphological features.

PURPOSE: To determine the influence of technical pitfalls and oocyte morphology on survival rate and cleavage behavior after ICSI. METHODS: A total of 2210 injection procedures was examined for morphological and technical deviations. Survival rate and cleavage behavior were evaluated. RESULTS: In 77.8% of all cases ICSI was unsuspicous. Out of 491 deviations from optimal injection deep penetration of the oocyte and abundant presence of cumulus cells showed significant correlation with degeneration rate (p < 0.001). Morphological anomalies associated with the periphery of the oocyte were rather related to degeneration than cytoplasmic anomalies (p < 0.001). Early embryonic development was not impaired by technical or morphological parameters. CONCLUSIONS: To conclude, these prospective data may be of prognostic value in regard of the number of embryos available for transfer and may help to improve treatment outcome.

Role of three-dimensional ultrasonographic measurement of endometrium volume as a predictor of pregnancy outcome in an IVF-ET program: a preliminary study.

OBJECTIVE: To evaluate the role of three-dimensional (3D) ultrasonographic measurement of the endometrium in predicting pregnancy in an IVF-ET program. DESIGN: Prospective study. SETTING: Center for assisted reproductive techniques. PATIENT(S): 65 women undergoing controlled ovarian hyperstimulation for IVF. INTERVENTION(S): Ultrasonographic examination on the day of hCG administration. MAIN OUTCOME MEASURE(S): Endometrial volume, endometrial thickness, and pregnancy rate. RESULT(S): The mean (+/-SD) endometrium volume (4.16 +/- 1.97 mL), endometrium thickness (11 +/- 2 mm), and estradiol level (1686.82 +/- 1057.10 pg/mL) in 21 pregnant women on the day of hCG administration did not differ statistically differ from the respective values in 44 nonpregnant women (4.53 +/- 1.79 mL; 11 +/- 2 mm, 1883.56 +/- 1147.21 pg/mL). Receiver-operating characteristic curves showed that the area under curve (AUC) was 0.57 for endometrial volume and 0.48 for endometrial thickness. Using a cut-off value of 2.5 mL for endometrial volume to predict pregnancy, results of the Fisher exact test were statistically significant. No significant cut-off value was found for endometrial thickness. CONCLUSION(S): Endometrial volume and thickness on the day of hCG administration did not predict occurrence of pregnancy. A minimum volume of 2.5 mL appeared to favor pregnancy. The predictive value of 3D ultrasonographic measurement of endometrial volume and thickness was better than that of 2D measurement.

Three-dimensional endometrial volume estimation as a predictor of pituitary down-regulation in an IVF-embryo transfer programme.

To examine the role of three-dimensional (3D) volume estimation in predicting pituitary down-regulation in an IVF-embryo transfer programme, 46 women were treated with buserelin acetate for down-regulation prior to and concomitantly with ovarian stimulation. Receiver operating characteristic (ROC) curve analysis was used for statistics. The area under the curve (AUC) provides a measure to show how good (AUC close to 1) or how poor (AUC close to 0.5) a test is. If down-regulation was defined as oestradiol <40, <60 or <80 pg/ml, the AUC of 3D-ultrasound was 0.57, 0.83 and 0.97 respectively. The highest sensitivity (100%) and specificity (93.2%) of 3D-ultrasound was achieved if down-regulation was defined as oestradiol <80 pg/ml (n = 44), with an endometrial volume of 1.9 ml. If down-regulation was defined as oestradiol <60 pg/ml (n = 42) the best combination of highest sensitivity (95.2%) and specificity (75. 0%) was obtained with an endometrial volume of 1.9 ml. The comparison of 3D volume calculation with endometrial thickness measurement revealed no significant difference in predicting down-regulation. 3D volume estimation provides a new tool for diagnosing relative hypo-oestrogenism or down-regulation, but it was not superior to two-dimensional ultrasound.