Conventional IVF revisited: Is ICSI better for non-male factor infertility? Randomized controlled double blind study.

STUDY QUESTION: Is ICSI better than conventional IVF for non-male factor infertility? SUMMARY ANSWER: IVF should be the choice of assisted reproductive technique in non-male factor infertility cases. WHAT IS ALREADY KNOWN: Although total fertilization failure is a major concern for patients and professionals, the overall risk/benefit analysis favors conventional IVF in non-male factor infertility cases. However, according to the ESHRE EIM database pertaining to 1997-2012, the use of IVF has been continuously decreasing in favor of ICSI. STUDY DESIGN, SIZE, DURATION: Randomized controlled double-blind study involving 138 women undergoing ART in a private Center. PARTICIPANTS/MATERIALS, SETTING, METHODS: All couples with a female partner ≤42 years of age and without severe male factor (total progressive motile sperm with normal morphology >10.000) were included in the study. Exclusion criteria were: history of total fertilization failure, less than 6 cumulus oocyte complexes (COC) available for fertilization, prenatal genetic testing (PGT) cycles, unwillingness to participate and couples undergoing total cryopreservation for any indication. On the day of oocyte pick up, sibling COCs were randomly allocated to fertilization with IVF or denudation followed by ICSI to MII oocytes. The decision to transfer IVF or ICSI embryo(s) depended on embryo quality. Women receiving two embryos were given only IVF or ICSI embryos. Neither the clinician performing the transfer nor the patients were aware of the fertilization method used to generate the embryos transferred. Main outcome parameters were fertilization, clinical pregnancy, implantation and miscarriage rates. MAIN RESULTS AND THE ROLE OF CHANCE: Demographic variables, ovarian reserve and infertility etiology, duration of stimulation, total gonadotropin consumption, peak estradiol levels were similar for IVF-ET and ICSI-ET groups. Mean number of COCs (18.95 vs 19.24), number of embryos transferred (1,81 vs 1,81), the ratio of good quality embryos/total embryos (56.89 % and 55.97 %), clinical pregnancy rates (63 % vs 49 %), implantation rates (31 % vs 28 %), and abortion rates (12,5 % vs 8,1 %) were also similar. A total of 1306 COCs were allocated for IVF while 1331 COCs were denuded for ICSI. Fertilization rate per inseminated oocyte was significantly higher in ICSI group (56,20 % vs 63,78 %). There were ten cases of total fertilization failure, all in the IVF group. Although overall fertilization rate was higher for ICSI, it was similar in both groups when cases with total fertilization failure were excluded. LIMITATIONS, REASONS FOR CAUTION: The non-availability of live birth rates is a limitation. Randomization of sibling oocytes, not patients requires careful interpretation of pregnancy and implantation rates. WIDER IMPLICATIONS OF THE FINDINGS: Lower cost, ease of application and similar clinical outcome makes IVF the choice of fertilization method in non-male factor infertility cases.

Single-dose depot leuprolide is as efficient as daily short-acting leuprolide in ICSI cycles.

BACKGROUND: In this prospective randomized study, we aimed to compare the efficacy of a single depot (1.88 mg) reduced dose with a daily low dose (0.5 mg/day) of leuprolide for pituitary suppression as part of controlled ovarian hyperstimulation (COH) in an ICSI program. METHODS: The study population consisted of 103 patients randomized into two groups. Group 1 (n = 52) consisted of patients who had daily low-dose leuprolide injections. Group 2 (n = 51) consisted of patients who had the 1.88 mg single-dose leuprolide injection. RESULTS: The age of the patients, the number of metaphase II oocytes, the number and quality of embryos transferred were similar between the two groups. Although the length of gonadotrophin stimulation was significantly longer in group 2 (P < 0.01), the amount of gonadotrophins used was similar (P = 0.34). Leuprolide levels were significantly lower in group 2 within the first 8 h after injection (P < 0.05), but no difference was observed thereafter. Although LH levels on the day of hCG (P = 0.06) administration and estradiol levels on day 3 (P < 0.01) were lower in group 2, LH levels and progesterone levels 1 week after embryo transfer did not show any statistically significant difference. Clinical pregnancy rates per embryo transfer, implantation rates and first trimester abortion rates were also similar for both groups. CONCLUSIONS: A single reduced depot dose (1.88 mg) of leuprolide was found to be as effective as classical long multi-dose protocol for pituitary desensitization in COH for ICSI cycles.

Flushing the endometrium prior to the embryo transfer does not affect the pregnancy rate.

This study aimed to determine whether direct flushing of endometrial cavity with culture media just after cervical irrigation at the time of embryo transfer has any effect on pregnancy rates. A total of 240 women were prospectively randomised; one group of patients (group 1) underwent intrauterine direct flushing of endometrial cavity with culture media just after cervical irrigation at the time of embryo transfer as detected by transabdominal ultrasound and the other group of patients (group 2) had cervical flushing but did not undergo intrauterine flushing. Pregnancy (positive human chorionic gonadotrophin) rates were 57.5% and 62.9% for group 1 and group 2, respectively. Clinical pregnancy (positive fetal heart rate) rates were 45.2% and 51.4% for group 1 and group 2, respectively. Implantation rates were 20.0% and 21.2% for group 1 and group 2, respectively. Ongoing pregnancy (>12 weeks of pregnancy) rates were 47.9% and 47.2% for group 1 and group 2, respectively. There were no significant differences in pregnancy rates, clinical pregnancy rates, implantation rates and ongoing pregnancy rates between the two groups. In conclusion, even direct flushing of media into the uterine cavity neither improves nor adversely affects the pregnancy rate.

Endometrial polyps smaller than 1.5 cm do not affect ICSI outcome.

This study aimed to determine whether the presence of endometrial polyps discovered during ovarian stimulation affects the outcomes of intracytoplasmic sperm injection (ICSI) cycles. This retrospective descriptive study was conducted in a private assisted reproductive technology unit. Medical records of ICSI cycles performed between January 2003 and December 2004 were reviewed. Patients were divided into three groups: patients with endometrial polyps discovered during ovarian stimulation (group 1, n=15), patients who underwent hysteroscopic polyp resection prior to their ICSI cycle (group 2, n=40) and patients without polyps (group 3, n=956). Main outcome measures were clinical pregnancy rates and implantation rates. Age of the patients, age of the husbands, body mass index, total amount of gonadotrophins used, length of stimulation, peak oestradiol concentrations, peak endometrial thickness and number of embryos replaced were not significantly different between the groups, nor were the pregnancy and implantation rates. Only one patient (12.5%) from the first group experienced miscarriage within 12 weeks of pregnancy. In conclusion, endometrial polyps discovered during ovarian stimulation do not negatively affect pregnancy and implantation outcomes in ICSI cycles.

Public opinion regarding oocyte donation in Turkey: first data from a secular population among the Islamic world.

INTRODUCTION: We aimed to reveal the general attitudes of Turkish people toward various aspects of oocyte donation. METHODS: This descriptive study was carried out in two separate districts of a large Turkish city. Four hundred participants were chosen by cluster sampling methods. The questionnaires were performed by 4th year medical students face to face with the participants. RESULTS: The participants consisted of 232 women (58%) and 168 men (42%); 65% were married, 5% were divorced; 64% had children, 15 (4%) had infertility problems, 263 (66%) were graduates of high school or university; 269 (67%) considered themselves religious. Only less than one-third of the respondents actually knew what oocyte donation meant. Approval of oocyte donation was high in our study sample. Only 61 (15%) respondents showed complete objection to oocyte donation and more men were in favour than women. Less than half of the participants thought that their religion would prevent oocyte donation if they needed it. More than half of the participants would prefer the use of oocyte donation treatment rather than adoption of a child. CONCLUSION: This is the first report on the attitudes towards oocyte donation from a country having a secular constitution and whose population is mainly Muslim. The most important conclusion to be drawn from the present study is the fact that most of the participants did not have any objection to oocyte donation treatments.

Bone resorption starts at 14 days of treatment with gonadotropin-releasing hormone agonist in in vitro fertilization cycles.

The effect of gonadotropin-releasing hormone agonist (GnRH-a) use on bone turnover was investigated in a prospective cohort study of female patients undergoing in vitro fertilization (IVF) treatment. In 46 couples diagnosed with male-factor infertility, the women underwent a long step-down ovulation induction protocol. Urinary cross-linked N-telopeptide (uNTx) level was used to demonstrate bone turnover rate and was measured at the first day of GnRH-a administration, the first day of gonadotropin administration, the day after human chorionic gonadotropin injection and 12 days after embryo transfer. Urinary NTx levels (mean+/-standard deviation (SD)) were 71+/-34, 81+/-40, 81+/-50 and 83+/-47 nmol BCE/mmol creatinine (BCE, bone collagen equivalents), respectively. There was no statistically significant difference between the four measurements (p = 0.28). In 19 women GnRH-a was administered for > or = 14 days. Urinary NTx values of this group and the remaining 27 patients after GnRH-a treatment were 96.2+/-40.7 and 71.5+/-36.8 nmol BCE/mmol creatinine (mean+/-SD), respectively. The difference between these groups was statistically significant (p=0.038). These findings suggest that < 14 days' use of GnRH agonist in IVF patients has no effect on bone metabolism. To our knowledge, this is the first study demonstrating that the effect of agonists on bone metabolism starts as soon as estradiol suppression has started.

Plexiform neurofibroma during and after pregnancy.

Neurofibromatosis is a genetic disease that affects multiple organ systems, and has a wide range of clinical features. Neurofibromatosis in pregnancy is encountered with a frequency of 1:2434 to 1:18,500 deliveries. Plexiform neurofibromas are rare subcutaneous nodules or amorphous overgrowth of subcutaneous tissues, which may affect the underlying bone, and produce deformities. We present a patient with a giant plexiform neurofibroma of the thigh which got larger in pregnancy, and shrunk a bit in the postpartum period.

Brain metastasis of ovarian cancer after negative second-look laparotomy.

We present a case of ovarian carcinoma that had brain metastasis seven months after having a negative second-look laparotomy and 13 months after the onset of diagnosis. Despite intense multidisciplinary treatment with surgery, chemotherapy and radiotherapy, the patient died seven months after second-look laparotomy.