Cabergoline reduces the early onset of ovarian hyperstimulation syndrome: a prospective randomized study.

Prophylactic use of cabergoline has been associated with a decrease in the severity of ovarian hyperstimulation syndrome (OHSS). A prospective randomized study was designed to evaluate the potential of cabergoline to decrease the incidence of OHSS in high-risk patients undergoing assisted reproductive technology treatment; 166 patients with oestradiol concentrations over 4000 pg/ml on the day of human chorionic gonadotrophin (HCG) administration were evaluated. They all received 20 g routine preventive intravenous human albumin on the day of oocyte retrieval. They were then randomized into two groups: group A (n = 83) received 0.5 mg oral cabergoline per day for 3 weeks beginning on the day after oocyte retrieval, and group B (n = 83) received no medication. 'Early' OHSS was defined as being when the onset of the syndrome was initiated during the first 9 days after HCG administration, and 'late' OHSS was defined as being when the onset of the syndrome was initiated from 10 days after HCG administration. In group A, no patients progressed to 'early' OHSS and nine patients (10.8%) developed 'late' OHSS; in group B, 12 patients (15.0%) progressed to 'early' OHSS and three (3.8%) to 'late' OHSS. Although the risk of 'early' OHSS decreased significantly (P < 0.001), the risk of 'late' onset OHSS did not. The two groups presented no changes in pregnancy, implantation or miscarriages rates.

Location of the embryo-transfer catheter guide before the internal uterine os improves the outcome of in vitro fertilization.

The objective of this study was to assess whether positioning the embryo transfer (ET) catheter guide at the time of embryo expulsion, before or beyond the internal os, has an impact on IVF cycle outcome. We performed a retrospective study comparing IVF outcomes in relation to the ET guide position relative to the internal uterine os. We analyzed ultrasound-guided ETs in IVF-intracytoplasmic sperm injection (ICSI) cycles, performed with the tip of the ET catheter guide just before the internal os (group 1) and beyond the internal os (group 2). Implantation and pregnancy rates were significantly better in group 1 than in group 2, at 14.8% versus 11.8% and 57.3% versus 43.1, respectively. We conclude that passing the ET catheter guide beyond the internal os reduces implantation and pregnancy rates.

Embryos generated using testicular spermatozoa have higher developmental potential than those obtained using epididymal spermatozoa in men with obstructive azoospermia.

OBJECTIVE: To determine whether the injection of testicular spermatozoa results in more viable embryos (higher implantation rate) than injection of epididymal spermatozoa in cases of obstructive azoospermia. DESIGN: Retrospective analysis of 265 cases of testicular sperm aspiration (TESA) and percutaneous sperm aspiration (PESA), including 185 cases of obstructive azoospermia. SETTING: Private Infertility clinic. PATIENT(S): None, charts review. INTERVENTION(S): None, charts review. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate (PR), implantation rate. RESULT(S): Although fertilization rates were higher in the PESA group, implantation rates were significantly better in the TESA group. There was also a trend to higher ongoing PR and lower miscarriage rates in TESA cases. CONCLUSION(S): In cases of obstructive azoospermia, embryos generated using testicular spermatozoa have higher developmental potential than those obtained using epididymal spermatozoa.

A prospective, randomized and blinded comparison between 10,000 IU urinary and 250 microg recombinant human chorionic gonadotropin for oocyte maturation in in vitro fertilization cycles.

PURPOSE: To compare the efficacy and safety of u-hCG with r-hCG in IVF cycles. METHODS: A prospective, investigator-blind, randomized, comparative study. Patients (n = 100) < or =35 years with IVF indication were randomly assigned on the day of hCG administration for oocyte maturation to receive either u-hCG (10,000 IU) or r-hCG (250 microg). RESULTS: No statistical differences were found between groups in relation to total number of oocytes retrieved, percentage of mature oocytes, number of injected oocytes, fertilization rates and number of embryos transferred. The data indicate a possible trend toward a higher incidence of pregnancy in the r-hCG group. Adverse events, predominantly injection-site reactions, were significantly more common in the u-hCG group. CONCLUSIONS: r-hCG is at least as effective for inducing final stages of oocyte maturation as 10,000 IU u-hCG and is also associated with significantly better patient tolerance and thus higher patient acceptability.

The optimal time for intracytoplasmic sperm injection in the human is from 37 to 41 hours after administration of human chorionic gonadotropin.

Fertilization rates increased continuously with the time elapsed after administration of hCG, reaching a peak of 84% when intracytoplasmic sperm injection (ICSI) was performed >41 hours after hCG administration. However, the highest implantation rate, 24%, was achieved when ICSI was performed 37-41 hours after hCG administration.

Evidence of parthenogenetic origin of ovarian teratoma: case report.

This case report represents one of the few documented cases of parthenote embryo retrieval from an IVF patient with a history of ovarian teratomas. A 29-year-old woman presented at our centre with a history of primary infertility for 6 years due to male factor. She had undergone left oophorectomy 4 years before due to an ovarian teratoma. An ultrasound scan performed during basal evaluation revealed two complex images in the right ovary suggesting teratomas, measuring 2.5 x 2.4 and 1.7 x 1.3 cm. A significant extent of sonographically normal ovarian parenchyma was present, and the patient underwent the long leuprolide acetate protocol of ovarian stimulation with recombinant FSH for an IVF-ICSI cycle. She had 13 metaphase II (MII), four metaphase I (MI), two germinal vesicle (GV) oocytes and one 4-cell embryo retrieved. Eight out of nine injected oocytes were fertilized normally while one was unfertilized. Embryo transfer was carried out 72 h after retrieval. The 4-cell (parthenote) embryo recovered at oocyte retrieval continued to cleave in culture, developing into a 7-cell embryo by the next day. The embryo was morphologically normal, presenting an evident nucleus in each blastomere. Fluorescent in situ hybridization (FISH) returned two signals for the X chromosome in each blastomere that was analysed. Of the eight normally fertilized embryos, three were transferred, resulting in a normal singleton pregnancy and the birth of a healthy baby.

Impact of subserosal and intramural uterine fibroids that do not distort the endometrial cavity on the outcome of in vitro fertilization-intracytoplasmic sperm injection.

OBJECTIVE: To further evaluate the effects of intramural and subserosal uterine fibroids on the outcome of IVF-ET, when there is no compression of the endometrial cavity. DESIGN: Retrospective, matched-control study from January 2000 to October 2001. SETTING: Private IVF center. PATIENT(S): Two hundred forty-five women with subserosal and/or intramural fibroids that did not compress the uterine cavity (fibroid group) and 245 women with no evidence of fibroids anywhere in the uterus (control group). INTERVENTION(S): In vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) cycles. MAIN OUTCOME MEASURE(S): The type of fibroid (intramural, subserosal), number, size (cm), and location of intramural leiomyomas (fundal, corpus) were recorded. Outcomes of IVF-ICSI cycles were compared between the two groups. RESULT(S): There was no correlation between location and number of uterine fibroids and the outcomes of IVF-ICSI. Patients with subserosal or intramural fibroids <4 cm had IVF-ICSI outcomes (pregnancy, implantation, and abortion rates) similar to those of controls. Patients with intramural fibroids >4.0 cm had lower pregnancy rates than patients with intramural fibroids 4 cm and that such patients be submitted to treatment before they are enrolled in IVF-ICSI cycles. Whether or not women with fibroids > 4 cm would benefit from fibroid treatment remains to be determined.

Uterine cavity findings and hysteroscopic interventions in patients undergoing in vitro fertilization-embryo transfer who repeatedly cannot conceive.

OBJECTIVE: To assess hysteroscopic findings in patients undergoing IVF-ET who repeatedly failed to conceive despite transfer of good-quality embryos. DESIGN: Prospective, observational study. SETTING: Clinical research unit for reproductive medicine in a private clinic. PATIENT(S): Fifty-five patients with a normal uterine cavity on hysterosalpingography before the initial IVF-ET cycle and two previous failed IVF-ET attempts despite transfer of a minimum of two good-quality embryos on each occasion. INTERVENTION(S): Standard transvaginal ultrasonography and diagnostic and therapeutic hysteroscopy. MAIN OUTCOME MEASURE(S): Endometrial findings on transvaginal ultrasonography and hysteroscopy and outcome of the cycles after surgical hysteroscopy and antibiotic therapy. RESULT(S): Twenty-five (45%) patients had abnormal endometrial findings and underwent treatment to correct the lesions. All patients underwent a third IVF-ET cycle. Pregnancy (50% vs. 20%) and implantation (19% vs. 5.5%) rates were significantly higher in patients who were treated for uterine abnormalities than in patients who had normal uterine cavities on hysteroscopy. CONCLUSION(S): The incidence of pathologic findings on hysteroscopy is high in patients with repeated failures of IVF-ET. Evaluation of endometrial integrity by hysteroscopy is highly valuable and should be applied to all such cases.

Novel use of laser to assist ICSI for patients with fragile oocytes: a case report.

An inadvertent consequence of intracytoplasmic sperm injection (ICSI) is the degeneration of some of the microinjected oocytes. Most patients may not suffer any disadvantage through losing oocyte(s) during micromanipulation; however, in some circumstances, this can result in a reduction of the chances for pregnancy. This study reports a clinical pregnancy obtained by a novel approach using laser-assisted micro-opening of the zona pellucida prior to ICSI to secure a non-traumatic microinjection that avoids degeneration of oocytes. A total of 12 oocytes were obtained from the 36 year old patient in her third IVF treatment cycle, following two previously failed attempts where very high degeneration rates of oocytes after ICSI were recorded, together with suboptimal embryo quality. Five of the 11 matured (MII) oocytes were submitted to conventional ICSI and the other six MII oocytes first underwent laser-assisted opening of the zona pellucida (5-7 microm hole size was created with a 1.48 microm diode laser) before microinjection (LA-ICSI). Three of the five conventionally microinjected oocytes degenerated while one oocyte fertilized normally and developed to a good quality embryo. After the LA-ICSI procedure, one of the six oocytes degenerated and four oocytes fertilized normally; of these, two developed to excellent quality embryos, one to a good quality embryo and one to a poor quality embryo. The three best embryos (LA-ICSI group) were transferred to the patient on day 3. Rising serum human chorionic gonadotrophin concentrations were measured 12 days after transfer and on week 7 two implantation sites were detected, together with regular heart activity. The results of the present report suggest that laser-assisted ICSI may provide a safer approach to non-traumatic microinjection of oocytes than conventional ICSI, thereby minimizing the risk of degeneration and possibly also improving embryo quality. Therefore, it is suggested that laser-assisted ICSI might be applied in all cases associated with difficult zona pellucida penetration or/and fragile oolemma, or where patients have very few oocytes available, to improve the chances for pregnancy.

Heterotopic triplet pregnancy: report and video of a case of a ruptured tubal implantation with living embryo concurrent with an intrauterine twin gestation.

This report presents a case of triplet heterotopic gestation after intracytoplasmic sperm injection (ICSI)-IVF treatment, with a left ruptured ectopic tubal implantation with a living embryo and successful outcome of the concurrent intrauterine twin gestation. A couple whose infertility was caused by oligoasthenozoospermia was referred for ICSI treatment. Three good quality embryos were transferred at the request of the patient. Early gestational control was performed by ultrasound at weeks 5 and 7 of gestation. The patient reported to the centre during week 7 with severe abdominal pain and with signs of peritoneal irritation. Transvaginal ultrasound revealed an extra-uterine ruptured implantantion. During the concomitantly performed laparoscopic procedure, a living embryo was observed after opening the extra-uterine embryonic sac. Heartbeat activity was present and lasted for 5 min after surgical resection of the tubal implantation. The patient was discharged from hospital without complications. The intrauterine twin gestation was not affected and two healthy infants were born at week 38 of gestation. Heterotopic pregnancy should be ruled out in patients submitted to IVF-embryo transfer, although no predisposing factors are present in some cases. Precise diagnosis may be delayed due to some important characteristics of the IVF-embryo transfer treatment. Nevertheless, this condition should be diagnosed by ultrasound before tubal rupture to avoid obvious complications. Laparoscopy remains the gold standard for diagnosis and treatment in these cases. The presentation of the heterotopic pregnancy was recorded on video and may be viewed on the internet at www.rbmonline.com/Article/710.

Relationship between time period after vasectomy and the reproductive capacity of sperm obtained by epididymal aspiration.

BACKGROUND: It is not well defined whether the elapsed time after vasectomy has any influence on the outcome of IVF-ICSI using epididymal sperm. We analysed retrospectively the results of 151 ICSI cycles in which sperm of vasectomized men were used at different time periods after vasectomy. METHODS: Oocytes were obtained after a desensitizing ovarian stimulation protocol using GnRH agonist in association with recombinant FSH and HCG. Sperm were retrieved by percutaneous epididymal sperm aspiration. The cycles were split into three groups: < or =10 years after vasectomy (group 1, n = 47), 11-19 years after vasectomy (group 2, n = 79), and > or =20 years after vasectomy (group 3, n = 25). RESULTS: As might be expected, the mean age of men differed in the three groups (group 3 > group 2 > group 1), and the mean age of the women was also significantly higher in group 3 than in groups 1 and 2, although no differences were described between groups 2 and 3. All other laboratory and clinical parameters were similar in the three groups. Ongoing pregnancy and implantation rates (34, 25, 8% and 22, 15, 6% respectively) decreased significantly from group 1 to group 3. CONCLUSION: Pregnancy and implantation rates after ICSI with sperm from vasectomized men are negatively correlated with the time interval from vasectomy, which cannot be explained purely by male or female ageing.

ICSI and day 5 embryo transfers: higher implantation rates and lower rate of multiple pregnancy with prolonged culture.

This retrospective review study, carried out in a private IVF clinic, compared pregnancy and implantation rates with day 3 versus day 5 embryo transfers in a selected group of patients. Participants were patients who failed to achieve pregnancy in at least one previous attempt with embryo transfer on days 2 or 3, and had more than five oocytes fertilized. A total of 296 patients who had undergone day 3 (group A) transfers were compared with 154 who had undergone day 5 transfers (group B). Interventions were intracytoplasmic sperm injection (ICSI), day 3 and day 5 embryo transfer. Outcome measures were pregnancy, implantation, multiple gestation and blastocyst formation rates. Overall, 86.4% of embryos were at the six- to eight-cell stage at 72 h and 30% developed to blastocyst by day 5. The mean number of embryos transferred was 4.0 on day 3 and 3.0 on day 5. Pregnancy and implantation rates were 34.8 and 11.5% in group A, versus 45.3 and 18.5% in group B. Multiple gestation rate was 47.1% in group A and 28.5% in group B. Prolonging embryo culture in vitro to day 5 improved embryo selection and implantation rates. A significant decrease in high order gestations was achieved by reducing the number of embryos transferred, without compromising the pregnancy rates.

O papel da histeroscopia em infertilidade / The role of hysteroscopy in infertility

Os autores apresentam uma revisäo de vários trabalhos publicados na literatura no período de janeiro de 1978 a julho de 1997 sobre histeroscopia, em particular o seu papel na infertilidade. Discutem-se as principais indicaçöes da histeroscopia, (HSC) nos pacientes que consultam por infertilidade e além disso apresentam-se a relaçäo da HSC com a histerosalpingografia (HSG), Laparoscopia e Ultra-sonografia Transvaginal (USGTV) que säo exames utilizados na rotina da mulher infértil. Aspectos relativos ao diagnóstico e tratamento histeroscópico das doenças da cavidade uterina presentes nesse grupo de pacientes, tais como septo uterino, sinéquias uterinas, miomas submucosos, pólipos endometriais e endometrite säo comentados de maneira sumária. Os autores descrevem ainda as indicaçöes da HSC nas pacientes submetidas à Fertilizaçäo In vitro (FIV) e a outras Técnicas de Reproduçäo Assistida.

Gravidez com FSH-recombinante: relato de caso / Recombinant FSH and pregnancy: case report

OBJETIVO: relatar um caso de gravidez obtida após tratamento de fertilizaçäo "in vitro" usando FSH-recombinante. DESENHO: estudo restrospectivo de caso clínico. MATERIAL E MÉTODO: foi realizada técnica de fertilizaçäo in vitro (FIV), associada a técnica de injeçäo intracitoplasmática de espermatozóide (ICSI) em paciente de 42 anos de idade. Foram obtidos dois óvulos após induçäo da ovulaçäo com protocolo longo usando acetato de leuprolide e FSH-recombinante. Após a transferência dos embriöes o suporte da fase lútea foi feito com estradiol transdérmico e progesterona oleosa. RESULTADO: foram aspirados 2 oócitos M2 com 100 por cento de fertilizaçäo após o uso da ICSI. No 12§ dia pós transferência de 02 embriöes com 0 por cento de fragmentaçäo, foi constatada gravidez através de dosagem sérica de b-HCG e confirmada através de ultra-sonografia transvaginal realizada no 26§ dia pós transferência quando visualizou-se saco gestacional único e tópico com embriäo com comprimento crânio nádega de 2,8 mm, atividade cardíaca presente e vesícula vitelínica normal, compatível com gestaçäo única de 5 semanas de 3 dias. CONCLUSÃO: os autores relatam um caso de gravidez obtida através da técnica de FIV-ICSI em paciente de 42 anos onde foi utilizado FSH recombinante na induçäo da ovulaçäo.

Gravidez quádrupla e nascimento após injeçäo intracitoplasmática de espermatozóides (ICSI) totalmente imóveis / Quadruplets pregnancy after intracytoplasmic sperm injection (ICSI) of immobile sperm

OBJETIVO: relatar um caso de gravidez quadrigemelar após Injeçäo Intracitoplasmática de Espermatozóide (ICSI) com espermatozóides imóveis, obtidos através de Aspiraçäo direta do testículo (TESA), que resultou no nascimento de quatro crianças saudáveis. DELINEAMENTO: estudo retrospectivo de caso clínico. Local: Clínica e Centro de Pesquisa em Reproduçäo Humana Roger Abdelmassih. MÉTODO: Foi realizada técnica de Fertilizaçäo "in vitro" (FIV), associada a técnica de Injeçäo Intracitoplasmática de Espermatozóide (ICSI) em paciente de 37 anos de idade, utilizando espermatozóides totalmente imóveis recuperados por aspiraçäo direta do testículo. Os óvulos foram obtidos após induçäo da ovulaçäo com protocolo longo usando acetato de leuprolide e FSH altamente purificado associado com hMG (Pergonal, Serono laboratórios). Após a transferência dos embriöes, o suporte da fase lútea foi feito com estradiol transdérmico e progesterona oleosa. RESULTADOS: com a injeçäo de espermatozóides imóveis, 6 dos 7 oócitos injetados apresentaram fertilizaçäo e clivagem normais. No 17§ dia após transferência de 4 embriöes, foi constatada gravidez através de dosagem sérica de b-HCG. Através de ultra-sonografia foi constatada gestaçäo quadrigemelar com todos embriöes viáveis que resultou no nascimento de quatro crianças saudáveis através de TESA, resultando no nascimento de 4 crianças normais, demonstrando a viabilidade do tratamento proposto.

Incidência de lesöes oocitárias após a injeçäo intracitoplasmática de espermatozóides (ICSI) / Oocyte damage incidence after intracytoplasmatic sperm injection (ICSI)

OBJETIVO: Revisar na literatura e comparar os nossos resultados com as taxas de sobrevivência dos oócitos submetidos à técnica de injeçäo intracitoplasmática de espermatozóides (ICSI). DELINEAMENTO: Revisäo bibliográfica e estudo retrospectivo comparativo. MATERIAL E MÉTODOS: Analisar 554 ciclos realizados em nosso centro com a técnica ddo ICSI, comparando os resultados de lesäo oocitária pós injeçäo com os dados da literatura. RESULTADOS: Em 554 ciclos de ICSI realizados em nosso centro, foram injetados 3043 oócitos. Destes, apenas 90 oócitos degeneraram após a injeçäo do espermatozóide. A taxa de degeneraçäo observada foi de 3,0 po cento. CONCLUSÄO: Observamos que é necessário o aperfeiçoamento da técnica de injeçäo do espermatozóide, cuidado na quebra da membrana do oócito e material correto para realizar a técnica da microinjeçäo para evitar o aumento nas taxas de degeneraçäo dos oócitos, aumentando assim o número de embriöes a serem transferidos e futuras gestaçöes.

Gestaçäo por ovodoaçäo em paciente com 57 anos de idade: relato de caso / Ovum donation and pregnancy in a 57 years old patient: case report

OBJETIVO: Relatar um caso de ovodoaçäo, com gestaçäo, em paciente com 57 anos de idade. DELINEAMENTO: Estudo Retrospectivo de Caso Clínico. MATERIAL E MÉTODOS: Foi realizada a técnica de ovodoaçäo em paciente de 57 anos de idade, com conseqüente gravidez. Os óvulos foram obtidos de paciente do banco de doadoras da clínica, após induçäo de ovulaçäo com protocolo longo, usando-se Acetado de Leuprolide (Lupron, Abott, SÒo Paulo-Brasil) e FSH puro (Metrodin HP, Serono, MÚxico). A receptora fez uso de Acetato de Leuprolide e Estradiol transdérmico (Estraderm TTS 100, CIBA, SÄo Paulo-Brasil) até o dia da transferência dos embriöes e, posteriormente, suporte hormonal com Progesterona oleosa (Progesterone in oil, Steries Laboratories, Phoenix-Arizona-USA) e Estradiol transdêrmico. RESULTADO: Os autores relatam um caso de ovodoaçäo em paciente de 57 anos de idade e conseqüente gravidez. A paciente deu à luz de parto cesáreo com 38 1/2 semanas de gestaçäo, a um feto vivo do sexo masculino, medindo 49 cm., pesando 3.400 gr, no dia 19 de setembro de 1996. A paciente, por ocasiäo do parto, já havia completado 58 anos de idade.

Injeçäo intracitoplasmática de espermatozóides após tratamento da amostra seminal com soluçäo hipoosmótica de Swelling: relato de caso / Intracytoplasmatic sperm injection after semen washing with hypoosmotic swelling solution: case report

OBJETIVO: Relatar 2 casos onde foi utilizada a soluçäo hipoosmótica de Swelling para identificar espermatozóides imóveis porém vivos, em casos com astenospermia total. Estes espermatozóides foram injetados através da técnica de ICSI após identificaçäo de sua vitalidade. RESULTADOS: Ambos os casos foram injetados com espermatozóides imóveis pós tratamento com a soluçäo hipoosmótica de Swelling.Foram injetados 15 oócitos, e ocorreu a fertilizaçäo de 5 oócitos com clivagem e transferência de todos. Näo houve gravidez. CONCLUSÄO: O teste com soluçäo hipoósmotica de Swelling é indicado para identificar espermatozóides imóveis porém viáveis para injeçäo.