Gamete intra-fallopian transfer or intrauterine insemination after controlled ovarian hyperstimulation for treatment of infertility due to endometriosis.

We compared the effectiveness of gamete intra-Fallopian transfer (GIFT) and intrauterine insemination (IUI) after controlled ovarian hyperstimulation (COH) in the treatment of infertility due to endometriosis. This was a retrospective study carried out at a tertiary teaching medical center. A total of 127 consecutive patients with endometriosis were treated with GIFT or IUI after COH between June 1990 and December 1998. Patients were divided into two groups. Group 1 (n = 97) included patients with stages 1 and 2 endometriosis, and group 2 (n = 30) included patients with stages 3 and 4 endometriosis. Laparoscopic conservative surgery for endometriosis was performed prior to IUI for patients in both group 1 and group 2. In group 1, 55 patients underwent 95 cycles of IUI after COH and 42 patients underwent 57 cycles of GIFT. In group 2, 14 patients underwent 16 cycles of IUI after COH, while 16 patients underwent 22 cycles of GIFT. The stimulation protocol for both GIFT and IUI was mid-luteal pituitary down-regulation with a gonadotropin releasing hormone agonist (GnRH-a) followed by gonadotropins. In group 1, the pregnancy rates (GIFT = 50.9%, IUI = 29.4%) and the delivery rates (GIFT = 28.1%, IUI = 14.7%) per cycle were significantly higher in GIFT compared to IUI (p = 0.009 and p = 0.05, respectively). There was no significant differences in the pregnancy rate (GIFT 69%, IUI 50.9%, respectively) or the delivery rate (GIFT 38.1%, IUI 25.5%) per patient. In group 2, there was no significant difference in the pregnancy rate (GIFT 54.5%, IUI 31.3%) or the delivery rate (GIFT 40.9%, IUI 12.5%) per cycle, but the difference in the pregnancy rate (GIFT 75%, IUI 35.7%) and the delivery rate (GIFT 56.3%, IUI 14.3%) per patient was significantly higher in GIFT compared to IUI (p = 0.04 and p = 0.02, respectively). We conclude that, when the same stimulation protocol is used in the early stages of endometriosis, a few cycles of IUI can achieve similar results to GIFT, and therefore should be used first. In advanced stages of endometriosis GIFT appears to be more effective.

Intracytoplasmic sperm injection for treatment of non-obstructive azoospermia.

Four cases from a tertiary care teaching medical center were studied to assess the potential of sperm extraction, fertilization and the establishment of pregnancy in couples with non-obstructive azoospermia. Four couples with non-obstructive azoospermia underwent intracytoplasmic sperm injection after testicular sperm extraction. Multiple small biopsies were obtained from each testis under general anesthesia in search for sperm, and to establish a histologic diagnosis. The histopathology includes incomplete maturation arrest, hypospermatogenesis, germ cell hypoplasia and incomplete tubular sclerosis. Testicular sperm extraction resulted in the retrieval of immotile sperm from three patients, and a few motile sperm from one patient. Of 60 oocytes which were injected with testicular sperm, 32 (53.3%) fertilized and 27 of these (84.4%) cleaved. Twelve embryos were transferred to three patients and the remaining 15 embryos were cryopreserved. In one patient, no embryos resulted. One clinical pregnancy was established and a normal female infant, weighing 7 lbs 11 oz, was delivered vaginally in August 1996. This study shows that sperm can be extracted from patients with non-obstructive azoospermia when multiple biopsies are obtained. Fertilization, cleavage, clinical pregnancy and delivery of normal babies can be achieved using intracytoplasmic injection of extracted sperm.

Testicular sperm extraction and intracytoplasmic sperm injection: a simplified method for treatment of obstructive azoospermia.

OBJECTIVE: To assess the effectiveness of a simple method of testicular sperm extraction for the treatment of obstructive azoospermia. DESIGN: Retrospective study. SETTING: Teaching tertiary medical center. PATIENT(S): Seventeen men with obstructive azoospermia. INTERVENTION(S): The patients underwent 19 cycles of intracytoplasmic sperm injection (ICSI) using testicular sperm. In 5 cycles, testicular sperm extraction was performed after failed microepididymal sperm aspiration. In 14 cycles, testicular sperm extraction was performed in the office under local anesthesia from the outset. The outcome was compared with ICSI cycles using ejaculated sperm (95 cycles) and epididymal sperm (12 cycles fresh and 9 cycles frozen-thawed). MAIN OUTCOME MEASURE(S): Clinical pregnancy and implantation rates. RESULT(S): There were no differences in the fertilization, cleavage, implantation, or clinical pregnancy rates among ICSI cycles using testicular, epididymal (fresh or frozen-thawed), or ejaculated sperm. CONCLUSION(S): When used in conjunction with ICSI, testicular sperm extraction from small excisional biopsy is a simple and cost-effective method for the treatment of obstructive azoospermia.

Elevated progesterone levels in the late follicular phase do not predict success of in vitro fertilization-embryo transfer.

OBJECTIVE: To examine the effects of subtle elevation in P levels in late follicular phase on the outcome of IVF-ET cycles, using GnRH agonist (GnRH-a) and hMG +/- FSH protocol. DESIGN: A retrospective analysis of data. PATIENTS: Fifty-four patients who completed 63 IVF-ET cycles were treated with midluteal GnRH-a, followed by hMG +/- pure FSH. Depending on serum P levels on the day of hCG administration, patients were divided in two groups. In group 1, P levels were < or = 0.9 ng/mL (conversion factor to SI unit, 3.180) and in group 2, the levels were > 0.9 ng/mL. RESULTS: Luteinizing hormone levels, on the day of hCG administration, as measured by RIA, were suppressed completely. In cycles with subtle P rise (71%), we observed a significantly higher serum E2 concentration, greater number of mature follicles, and greater number of oocytes retrieved. There were no differences between the two groups in fertilization rate, number of embryos transferred, clinical pregnancy rate, implantation rate, and miscarriage or delivery rates. CONCLUSIONS: We conclude that in IVF-ET cycles, when pretreated with GnRH-a, P levels may increase on the day of hCG administration despite LH suppression and such elevation may not affect adversely the final outcome.

Fertilization and pregnancy achieved by intracytoplasmic injection of sperm retrieved from testicular biopsies.

OBJECTIVE: To determine if intracytoplasmic sperm injection using testicular sperm is effective in the treatment of infertile couples with obstructive azoospermia. DESIGN: Case report. SETTING: Tertiary care teaching medical center. METHODS: Intracytoplasmic sperm injection was performed in two patients using testicular sperm after microsurgical epididymal sperm aspiration failed. RESULTS: In both cases fertilization and embryos resulted. One patient conceived and delivered triplets. There was no evidence of chromosomal abnormality or congenital malformation. CONCLUSIONS: Intracytoplasmic sperm injection using sperm extracted from testicular biopsy appears to be effective in the treatment of infertile couples with obstructive azoospermia when microsurgical sperm aspiration fails.

Selection of human spermatozoa by a hyperosmotic two-layer Percoll gradient.

OBJECTIVE: To investigate whether a hyperosmotic Percoll solution improves the spermatozoal recovery rate of a two-layer Percoll gradient. DESIGN: A total of 49 semen samples were prepared by both the conventional two-layer Percoll gradient and a hyperosmotic Percoll gradient. SETTING: In vitro fertilization laboratory of a tertiary care, university-affiliated hospital. PATIENTS: Semen samples were obtained from patients attending semen analysis. MAIN OUTCOME MEASURES: The number of spermatozoa recovered, percentage motility, percentage normal morphology, and their survival at 24 hours were assessed after preparation by both Percoll gradients. RESULTS: The hyperosmotic Percoll gradient resulted in a significantly higher total and motile sperm recovery rate. The degree of increase in total sperm recovery was significantly higher in abnormal semen samples compared with normal semen samples. Percentage normal morphology of sperm samples prepared by hyperosmotic Percoll was improved compared with conventional Percoll but was only significant in abnormal semen samples. However, percentage motility of sperm samples prepared by the hyperosmotic Percoll was significantly lower than those prepared by conventional Percoll gradients. CONCLUSIONS: The hyperosmotic two-layer Percoll gradient improved motile sperm recovery but also recovered more immotile sperm, leading to a decrease in percentage motility. This technique may allow us to recover more spermatozoa when we come across samples of low sperm concentration.