Transcervical tubal cannulation: a review.

Rapid progress has been made in the last 10 years regarding minimally invasive access to the human fallopian tube. Coaxial catheter systems are being used with hysteroscopy, fluoroscopy, ultrasonography, and tactile sensation to cannulate the fallopian tube transcervically with consistent success. Uterotubal obstruction viewed at the time of hysterosalpingogram can often be successfully cannulated with intrauterine pregnancies resulting. This review surveys all available published series of transcervical tubal cannulation with discussion of methodology, success in establishing patency, and the resultant pregnancy rates. It also describes how this technology has been applied to the intratubal deposition of gametes and embryos, direct visualization of the tubal epithelium, (falloposcopy), and contraception. Collectively, these techniques are defining tubal pathology more precisely, allowing us to prescribe the proper therapy.

Proximal tubal occlusion by hysterosalpingogram: a role for falloposcopy.

Eight infertility patients with proximal tubal occlusion by HSG and at least one other independent method underwent falloposcopy to evaluate the etiology of uterotubal occlusion. Patency was established in 9 of 12 tubes evaluated. Falloposcopy revealed 5 tubes with multiple or extensive intratubal lesions that would be unsuitable for unilocular tubal resection with subsequent reanastomosis. In addition, 5 tubes were visually normal or had only minor pathological changes (2 of these patients became pregnant). Only 2 of the tubes examined in a single patient would be considered candidates for microsurgical correction at laparotomy. Falloposcopy will become a useful adjunct in the evaluation of the patient with suspected tubal infertility. It provides information regarding the condition of the tubal mucosa that is unavailable by any other technique, adding precision to surgical techniques when they are deemed necessary while directing other patients to assisted reproductive technologies. However, falloposcopy is still in its infancy and data from larger studies are needed.

Fertility after the age of 40.

There is approximately a 50% decrease in the fertility rate of unselected women attempting pregnancy at age 40 or older compared with younger women and a two to three fold increased rate of spontaneous abortion. Approximately 45% of older women achieve a term outcome, however. Proper counseling of the older patient should include a realistic view of the following risks: a 30% to 50% reduced pregnancy potential, effect of pregnancy on other maternal illnesses, an increased risk of pre-eclampsia, hypertension, and diabetes, and an increased risk of chromosomal abnormalities, abortion, and stillbirth. Knowing these risks, additional testing for ovarian reserve may help to identify women with favorable indices in whom IVF, other forms of assisted reproduction, or surgery to restore fertility are most appropriate. Women with decreased ovarian reserve could be offered oocyte donation as an alternative to surgical correction for infertility, because pregnancy rates are excellent when donor oocytes are transferred to the uteri of women older than the age of 40. In short, age alone should no longer be a deterrent in the treatment of infertility.

Analysis of ectopic pregnancies resulting from in-vitro fertilization and embryo transfer.

The purpose of this study was to analyse the risk factors, stimulation characteristics, site and outcome of pregnancy and future fecundity of patients who develop ectopic pregnancies after in-vitro fertilization (IVF). Of 3145 transfer cycles between January 1981 and July 1989, 27 (3.3%) of the resulting 825 pregnancies were ectopic. There was a significantly greater incidence of a prior ectopic pregnancy in the study group compared to the controls. Compared to matched controls with intrauterine pregnancies, the study group had significantly higher peak oestradiol levels. Twenty-one ectopic pregnancies were ampullary, two were interstitial, one was abdominal, one was cervical and two were heterotopic. Sixteen of the patients subsequently underwent 40 IVF attempts with a pregnancy rate of 28% per transfer. We conclude that patients with a prior ectopic pregnancy are at risk for an IVF ectopic pregnancy. The subsequent IVF outcome of those who develop ectopic pregnancies after IVF is encouraging.

Ooplasmic transfusion: prophase germinal vesicle oocytes made developmentally competent by microinjection of metaphase II egg cytoplasm.

Approximately one fourth of all human oocytes collected for in vitro fertilization are of immature origin. Even when these oocytes undergo nuclear maturation, fertilization, and cleavage in vitro, transfer of such embryos rarely results in pregnancy reaching delivery. We hypothesized that human embryos derived from prophase I oocytes were developmentally incompetent because they lacked a factor(s) found in in vivo matured oocytes. Using micromanipulation techniques in monkeys, we removed ooplasm from metaphase II oocytes and injected it into prophase I oocytes. After nuclear maturation, oocytes were transferred to the fallopian tube for fertilization. After ooplasmic transfusion, prophase I oocytes resulted in a delivery rate of 13%. When metaphase II ooplasm was heated or exposed to ribonuclease A before microinjection into prophase I oocytes, it lost effectiveness in conferring developmental competence.

Comparison between laparoscopically and ultrasonographically guided transvaginal follicular aspiration methods in an in vitro fertilization program in the same patients using the same stimulation protocol.

Oocyte recovery from 43 patients undergoing ultrasound-guided transvaginal oocyte retrieval was compared to a previous laparoscopic oocyte retrieval cycle from the same patient. Gonadotropin stimulation in both cycles was performed using the same protocol. There were no statistically significant differences in the mean day of oocyte retrieval or the mean daily estradiol level up to the day of oocyte retrieval between laparoscopic and transvaginal cycles. The total number of follicles aspirated per cycle, preovulatory oocytes aspirated per cycle, and number of concepti of preovulatory origin transferred per cycle were not statistically different. The number of immature oocytes aspirated per cycle was statistically decreased in transvaginal retrieval cycles, which resulted in an increased total number of concepti transferred per transfer in laparoscopic retrieval cycles. Twelve pregnancies resulted from the transvaginal retrieval cycles (27.9%), seven of which are ongoing or delivered. Ultrasound-guided transvaginal follicular aspiration yields results comparable to laparoscopic retrieval in the same patients and should be the method of choice for oocyte pickup because of its many advantages.

Influence of fetal growth patterns on sonographic estimation of fetal weight.

Six published fetal weight estimating regression models proposed for clinical use were evaluated in 259 pregnant women who delivered within 72 h of an ultrasound evaluation performed with sector scanner. The patient sample included 89 (33.2%) fetal weights that were below the 10th or above the 90th percentile for menstrual age. The actual mean percent error (systematic error), standard deviation (random error), and the number of large errors of prediction for all equations were greatest in fetuses that were small- and large-for-gestational age. Whereas there were no significant differences between equations for the patient sample as a whole, equation AC,BPD (Shepard) had the smallest systematic error in intrauterine growth retarded, premature, and normal-term fetuses less than 4000 g. Conversely, the systematic error of the models that included femur length was smallest at the upper end of the weight scale and in macrosomic fetuses in general. In that regard, the accuracy of fetal weight prediction could be increased by selecting the appropriate model for the proper clinical indications. Although these findings can be explained by the limitations of the current regression models in estimating fetal soft tissue mass, a subtle effect of the use of the sector scanner on the results of this study cannot be completely excluded and requires further investigation.