Use of three-dimensional ultrasound imaging in the diagnosis of prenatal-onset skeletal dysplasias.

OBJECTIVE: Recognition of prenatal-onset skeletal dysplasias has improved with advances in ultrasound imaging. Skeletal abnormalities can be recognized by two-dimensional (2D) ultrasound, but generating a precise diagnosis can be challenging. We aimed to determine whether three-dimensional (3D) imaging conferred any advantages over 2D imaging in these cases. METHODS: We studied five women with fetuses of 16-28 gestational weeks referred for abnormal ultrasound skeletal findings. First 2D and then 3D sonography was performed and the results compared. RESULTS: The pregnancies resulted in the following skeletal dysplasias: thanatophoric dysplasia, achondrogenesis II/hypochondrogenesis, achondroplasia, chondrodysplasia punctata (rhizomelic form) and Apert's syndrome. For all five fetuses, the correct diagnosis was made in the prenatal period by analysis of the 2D images. In each case the 3D images confirmed the preliminary diagnosis and for many findings it improved the visualization of the abnormalities. CONCLUSION: The 3D imaging had advantages over the 2D imaging when it came to evaluation of facial dysmorphism, relative proportion of the appendicular skeletal elements and the hands and feet. Most importantly, the patient and referring physician appreciated the 3D images of the abnormal findings more readily which aided in counseling and management of the pregnancy.

IVF-patients with nonmale factor "to ICSI" or "not to ICSI" that is the question?

PURPOSE: Intracytoplasmic sperm injection (ICSI) guarantees high fertilization rates and could theoretically lead to higher implantation rates as well. Furthermore injection into oocyte creates a hole in the zona pellucida similar to the procedure of assisted hatching. We were therefore interested to assess such a potential benefit for infertile IVF patients without male factor. MATERIALS AND METHODS: Open randomized prospective study according to the rules "Good Clinical Practice" with informed consent of the patients and institutional review board approval. Ninety-one consecutively seen patients with tubal infertility or hostile cervical mucus were randomized to undergo either ICSI (44 patients) or IVF (45 patients). In two patients fertilization of oocytes failed and so a repeated ICSI had to be performed. All these patients were stimulated with the same protocol, using the gonadotropin releasing hormone-agonist (GnRH-a) buserelin acetate in an ultrashort flair-up protocol together with pure follicle stimulating hormone (rFSH). The two study groups did not differ in terms of age, BMI, and all baseline hormone levels. RESULTS: The total pregnancy rate was 42% in the normal IVF group with 33% ongoing pregnancies. The ICSI group had a total pregnancy rate of 39% with 23% ongoing pregnancies. The implantation rate per transferred embryo was higher for normal IVF but not significant (18% versus 11%). The variables, fertilization rate, age, body mass index, baseline hormone levels, endometrial thickness, embryo score, and the highest grade embryo per transfer were very similar in both groups. CONCLUSION: ICSI should be applied only when conventional IVF fails, that is, for male factor patients and for patients with unexplained infertility.

Cumulus assessment by three-dimensional ultrasound for in vitro fertilization.

OBJECTIVE: To correlate the appearances of intrafollicular cumulus-like structures using three-dimensional (3D) ultrasound technology with the recovery of mature oocytes. MATERIALS AND METHODS: A prospective, observational study using 3D ultrasound examination was performed in 50 women undergoing in vitro fertilization (IVF) after ovarian stimulation. Examination was performed on the day of human chorionic gonadotropin (hCG)-ovulation induction. Estradiol-17-beta (E2) levels were measured on the same day. The ovaries were examined for the presence of cumuli in all follicles greater than 15 mm in diameter. Only cumuli demonstrable in all three planes, or in a computer-animated 3D reconstruction, were recorded as 'visible'. The number, maturity, and fertilization rate of retrieved oocytes were compared with the pre-ovulatory assessment of cumuli by 3D ultrasound. STATISTICS: Correlation coefficients (Pearson) between the variables were calculated and stepwise regression analyses performed. RESULTS: A total of 262 cumuli were visualized within 318 follicles from which 296 mature oocytes were retrieved and 218 fertilized. There was a significant correlation between the number of detected cumuli and the number of retrieved oocytes (r2 = 0.83; P < 0.0001), mature oocytes (r2 = 0.78; P < 0.0001), and the number of the fertilized oocytes (r2 = 0.65; P < 0.0001). There was a marked correlation between E2 and the number of follicles and the number of fertilized oocytes. CONCLUSIONS: Cumulus visualization by 3D ultrasound appears to be an indicator for mature oocytes and successful fertilization. Follicles in which the cumulus cannot be visualized in all three planes are unlikely to contain mature oocytes or oocytes in which fertilization is achieved.

The effect of smoking on oocyte quality and hormonal parameters of patients undergoing in vitro fertilization-embryo transfer.

PURPOSE: The aim of the present study was to investigate the influence of smoking on different parameters such as oocyte count, embryo score, and basal hormone values within the scope of in vitro fertilization-embryo transfer (IVF-ET). METHODS: Eight hundred thirty-four women undergoing IVF-ET treatment were classified as smokers or nonsmokers on the basis of questionnaires. Additionally, we divided them into three groups according to their stimulation protocol--"combined stimulation" [I; clomiphene citrate plus human menopausal gonadotropin (hMG)], "ultrashort" [II; gonadotropin releasing hormone agonist (GnRHa) plus hMG or follicle-stimulating hormone (FSH)], and "long downregulation protocol" (III)--and further classified again as smokers or nonsmokers within the groups. RESULTS: In general, smoking patients were significantly (P = 0.0195) younger than nonsmokers and showed a significantly (P = 0.0379) lower embryo score and a tendency (P = 0.0931) to produce fewer oocytes. There was no significant difference concerning the number of normally or pathologically fertilized and transferred oocytes and embryos suitable for cryopreservation. Women who smoked had significantly (P = 0.0112) higher basal 17-beta-estradiol (E2), luteinizing hormone (LH) (P = 0.0001), and dehydroepian-drosteronesulfate (DHEAS) (P = 0.0039) levels, but their basal human prolactin (HPRL) levels were significantly (P = 0.0033) lower than those of nonsmokers. According to the stimulation protocol used, we found the following results. Smoking patients in group I showed a significantly (P = 0.023) lower embryo score and produced fewer oocytes (P = 0.0113), with fewer of them being fertilized (P = 0.0072) and transferred (P = 0.0067). Women who smoked had significantly (P = 0.0002) higher basal LH levels, but their HPRL levels were significantly (P = 0.031) lower than those of nonsmokers. Furthermore, they had a thinner endometrium on the day of embryo transfer (P = 0.0366). In group II we measured significantly elevated basal E2 levels (P = 0.0089) and higher LH values (P = 0.0092) in smokers. Group III showed a trend (P = 0.0565) toward lower HPRL values in smokers. CONCLUSIONS: Although the fertilization rate of oocytes and the pregnancy rate were not significantly different between smokers and nonsmokers, we found significantly alterated hormonal parameters and negatively influenced oocyte parameters, particularly after clomiphene stimulation. So we might consider using only GnRHa protocols for smoking patients. Additionally, we advise our patients to stop smoking before an IVF-ET treatment because of the complex effects of smoking on the reproductive and hormonal system.

Psychotherapeutic counseling and pregnancy rates in in vitro fertilization.

PURPOSE: Since the Austrian propagation bill of July 1, 1992, was passed into law, Austrian physicians are committed to offer psychological counseling to women before performing assisted reproductive techniques, unless refused by the patient. The acceptance of psychotherapeutic counseling (PSITCO) and its influence on pregnancy rate were carefully reviewed. METHODS: The study comprised 1156 consecutive patients (mean age, 33.3 years) and 1736 in vitro fertilization (IVF) cycles. In a consent form for follicle puncture, the patients were interviewed about PSITCO as follows. Several methods of psychological support during IVF-embryo transfer treatment were offered to patients especially psychotherapy, hypnotherapy, and relaxation and physical perception exercises. RESULTS: Forty-two and three-tenths percent of patients rejected PSITCO, 17.8% had already received PSITCO, and 10.4% were willing to undergo PSITCO. The acceptance of PSITCO had no relevance on pregnancy rate. The cumulative calculation of pregnancy rates showed that up to 56.4% of women who had undergone PSITCO conceived. In patients who were planning to undergo PSITCO, the pregnancy rate was 41.9%. Concerning the cumulative pregnancy rate, this study showed that patients who accepted or underwent PSITCO had a higher pregnancy rate than those who did not avail themselves of this possibility. CONCLUSIONS: These results should encourage sterility specialists to consider psychological therapy as an essential aspect of IVF. Solely a written declaration of the patient stating his/her awareness of the possibility to undergo PSITCO is, in our opinion, insufficient.

Smoking and in vitro fertilization: a meta-analysis.

PURPOSE: Including our own data and seven relevant publications from the literature, this meta-analysis aimed to establish the influence of the status of female smokers on the clinical pregnancy rate after the first attempt at in vitro fertilization-embryo transfer (IVF-ET). METHODS: We started to collect information about our own patient's smoking habits in January 1996 to evaluate prospectively the influence on IVF success. Information regarding 799 patients (607 nonsmokers and 192 smokers) was obtained. Additionally we retrieved seven relevant publications from the unabridged MEDLINE 1982-1996. They were recalculated to first cycles, because from a biometrical point of view, only the results of the first IVF cycle are really well comparable, as the number of necessary IVF cycles always correlates with the number of pregnancies. These data were compared in the nonparametric sign test according to Dixon-Mood and calculated as relative success ratios, defined as the quotient of the probability of IVF-ET success of nonsmokers divided by that of smokers for each publication. RESULTS: This meta-analysis, based on a total of 2314 first IVF-ET treatments, showed that almost twice as many IVF-ET cycles were needed for smokers as for nonsmokers to become pregnant. For the success quotient, we obtained a ratio of 1.79, with an associated 95% confidence interval of from 1.24 to 2.59. The total analysis shows, with a P value of less than 0.01, significantly higher pregnancy rates (21%) in nonsmokers compared to smokers (14%). CONCLUSIONS: Based on the analyzed data there exists--from a statistical point of view--a significant negative effect on the chances of success for smokers to become pregnant compared to nonsmokers.