Hysteroscopy-assisted laparoscopic salpingectomy for interstitial pregnancy without cornual resection.

OBJECTIVE: To illustrate a novel surgical management technique for interstitial ectopic pregnancies (IP). DESIGN: Video description of the case, demonstration of the surgical technique, reevaluation at the 6-week postoperative follow-up, and review of the advantages of this surgical technique for IP. SETTING: Tertiary referral center. PATIENT(S): A 42-year-old gravida 2 para 1-0-0-1, underwent a successful in vitro fertilization (IVF) cycle with a single embryo transfer and had an early ultrasound diagnosis of IP with cardiac activity. After failed medical management with a single dose of methotrexate, she was referred to us for surgical management. Transvaginal ultrasound revealed fluid in the cul-de-sac and confirmed a right interstitial ectopic pregnancy with an estimated gestational age of 6 weeks. The myometrium at the periphery of the implantation site was 1-1.5 mm, and the "interstitial line sign" was seen. After counseling for possible treatment modalities, the patient opted for surgical management, planning for further IVF treatment. Her preoperative ß-human chorionic gonadotropin level (ß-hCG) was 3241 IU/L. Her surgical history was significant for a previous myomectomy via laparotomy and an elective lower transverse C-section. INTERVENTION(S): Hysteroscopy assisted by multipuncture video laparoscopy surgery was performed. Hysteroscopic resection was not feasible as the ectopic was not visualized as described previously. Using normal saline as the distension media and with the hysteroscope aimed at the right ostium, the hydrostatic pressure was increased transiently to dissect the ectopic pregnancy and facilitate the next surgical step. Laparoscopically, the ectopic pregnancy was milked with atraumatic graspers and mobilized from the cornua into the tube creating enough proximal length for salpingectomy. Right salpingectomy was achieved using high-frequency bipolar with no complications. MAIN OUTCOME MEASURE(S): Hysteroscopy-assisted laparoscopy technique allows for several advantages, including a short operative time and minimal blood loss. No sutures were required and the myometrial architecture was left undisrupted. RESULT(S): The postoperative course was uncomplicated, and the patient was discharged on the same day of surgery. The patient's ß-hCG level dropped from 3,241 to 139 IU/L after 48 hours. Two weeks later, the ß-hCG level was 3 IU/L. A follow-up ultrasound was performed six weeks postoperatively confirming the integrity of the myometrium without defects and proportional wall thickness on both sides. The patient was referred back to her infertility specialist to resume IVF treatment with no remarkable delay. CONCLUSION(S): In select cases and the presence of a proficient laparoscopic surgeon, early diagnosed IP can be removed safely using the described novel technique. While an interval conception of 3-6 months is recommended after conventional surgical procedures for IP, this technique can be comparable to salpingectomy.

Prospective controlled study to evaluate laboratory and clinical outcomes of oocyte vitrification obtained in in vitro fertilization patients aged 30 to 39 years.

OBJECTIVE: To determine whether the process of oocyte vitrification affects oocyte viability in in vitro fertilization (IVF) patients between 30 and 39 years of age. DESIGN: Prospective controlled study. SETTING: Private IVF practice. PATIENT(S): A total of 30 women assigned and 22 qualified. INTERVENTION(S): Denudation of oocytes, cryopreservation of oocytes using vitrification method in a medium with 15% ethylene glycol (EG), 15% dimethylsulfoxide (DMSO), and 0.5 M sucrose. MAIN OUTCOME MEASURE(S): Oocyte survival, fertilization, day-3 embryo quality, blastocyst formation, clinical pregnancy, implantation, and live-birth rates. RESULT(S): After denudation of oocytes, mature sibling oocytes were randomly allocated to the fresh and vitrified groups. The survival rate was 79.6% after vitrification/warming. Overall, no statistically significant differences were found in fertilization, day-3 embryo quality, or blastocyst formation rates between the fresh and vitrified groups. The positive ß-human chorionic gonadotropin, clinical pregnancy rate, and implantation rate were 13 (59.0%) of 22, 10 (45.4%) of 22, and 16 (30.1%) of 53 for the vitrified group. The overall efficiency in achieving a live birth was 11 (5.9%) of 186 per vitrified oocyte. CONCLUSION(S): The impact of vitrification can be reduced to a minimal level, making it possible to achieve high pregnancy and implantation rates in this age group of IVF patients.

Clinical evaluation of the efficiency of an oocyte donation program using egg cryo-banking.

OBJECTIVE: To evaluate the efficiency of oocyte donation cycles using egg "cryo-banking." DESIGN: Study conditions for vitrified/warmed oocytes for 20 non-autologous recipients (from 10 donors) were set prospectively, and outcomes of it were later compared retrospectively to nine fresh donations cycles. SETTING: Private assisted reproductive technology program. PATIENT(S): Ten donors and 20 infertile recipients. INTERVENTION(S): Oocytes were vitrified 3 to 4 hours after collection and cryo-stored. Intracytoplasmic sperm injection was performed 3 hours after warming, and embryos were in vitro cultured for 5 days. Two or three blastocysts were transferred per patient. MAIN OUTCOME MEASURE(S): Oocyte survival, fertilization, development, clinical pregnancy, and implantation rates. RESULT(S): A total of 153 oocytes were warmed and 134 survived. A total of 117 fertilized and 68% developed to blastocyst stage. A total of 47 embryos were transferred (2.35 embryos per recipient) and 26 implanted. Fifteen patients achieved ongoing pregnancies initially, and two additional pregnancies were obtained after transfer of supernumerary vitrified/warmed embryos. Nine of the 10 donors from the current study had previous fresh donations cycles from where seven clinical pregnancies were established in nine recipients, providing the base for comparison. CONCLUSION(S): Oocyte donation using vitrified/warmed oocytes can provide high pregnancy and implantation rates, and thus can be considered as efficient treatment procedure with additional benefits to recipients.

Exposure of preimplantation embryos to platelet-activating factor increases birth rate.

PROBLEM: Platelet-activating factor (PAF) plays a significant role in fertility. Preimplantation stage embryos produce PAF (ePAF) which is required for development. PAF's mechanism of action is receptor-mediated and its presence has been reported in the developing mouse and human embryo. Exposure of preimplantation stage mouse embryos results in higher implantation rates. However, the effect of such treatment on live-birth rates and birth weights has not been reported. Therefore, the objective the study was to determine the effect of exposing preimplantation mouse embryos to PAF on subsequent birth rate and weight. DESIGN: Two-cell stage preimplantation stage mouse embryos exposed to PAF (10(-7) M) for 15 min prior to intraoviductal transfer. METHODS: Preimplantation stage embryos were recovered from eCG/hCG primed BDF1 female mice. Embryos were exposed to synthetic PAF (10(-7) M) for 15 min. PAF-treated embryos were transferred to the oviducts of pseudopregnant female CD-1 female mice. Superovulated and cultured BDF1 embryos not treated with PAF served as in vitro controls and naturally ovulated embryos with no collection/culture served as in vivo controls. Embryos were permitted to develop to term (18-21 days). The number of pups born per litter and litter weights subsequently were recorded. RESULTS: A total of 160 BDF1 mouse embryos were collected, treated, and transferred (20 per CD-1 recipient) as described. There was a significant (P < 0.05) increase in the number of pups born to the PAF treatment group (56/80; 70%) as compared to the control group (44/80; 55%). There was also a significant difference (P < 0.05) in litter birth weights between the PAF (1.31 g/litter) and controls groups (1.25 g/litter). There was a significant difference (P < 0.05) in birth weights between the PAF treatment group and the in vivo group (1.51 g/litter). There was a significant difference in birth weights between the in vitro-control and in vivo groups (1.51 g/litter). There were no observational malformaties to pups born in any group. CONCLUSIONS: Brief exposure of preimplantation stage embryos to PAF will result in a significant increase of delivery rates (pups/litter) as well as birth weights. However, the increase of birth weight was significantly below that found naturally. Additional studies are warranted to elucidate the mechanism of PAF's action in the preimplantation stage embryo and subsequent uterine development.

Platelet-activating factor significantly enhances intrauterine insemination pregnancy rates in non-male factor infertility.

OBJECTIVE: To determine the efficacy of treating semen specimens with platelet-activating factor (PAF) before IUI. DESIGN: Prospective randomized double-blinded study of PAF treatment of sperm for patients with a history of infertility undergoing IUI. SETTING: Private infertility center. INTERVENTION(S): Patients had ovulation induction therapy with clomiphene citrate (CC) or gonadotropin, two IUIs per month with PAF treatment. MAIN OUTCOME MEASURE(S): Clinical pregnancy rates. RESULT(S): There was a significant difference in IUI pregnancy rates per cycle between control (10/56; 17.9%) and PAF (14/47; 29.8%) treatment groups in the normal male study arm. There was a significant difference in cumulative IUI pregnancy rates between control (10/35; 28.6%) and PAF (14/26; 53.9%) patient groups in the normal male study arm. There was no significant difference in IUI pregnancy rates per cycle between control (12/124; 9.7%) and PAF (14/119; 11.8%) treatment groups in the male factor study arm. There was no significant difference in cumulative IUI pregnancy rates between control (12/46; 26.1%) and PAF (14/38; 36.8%) patient groups in the male factor study arm. There was a significant difference in overall cumulative IUI pregnancy rates between control (21/81; 25.9%) and PAF (27/64; 42.2%) patient groups. CONCLUSION(S): The inclusion of PAF into the IUI sperm wash procedure significantly improves pregnancy rates. However, the significant improvement can only be shown to affect men presenting with normal semen parameters.

Cryopreservation of metaphase II human oocytes effects mitochondrial membrane potential: implications for developmental competence.

BACKGROUND: Current outcome results with embryos derived from thawed MII human oocyes are significantly lower than with embryos cryopreserved at the pronuclear stage. Here, we investigated whether freezing-thawing was associated with changes in oocyte mitochondrial polarity (DeltaPsim) that could influence competence by altering ATP levels or the ability of the cytoplasm to regulate intracellular Ca2+. METHODS: Fresh and thawed uninseminated and unfertilized MII oocytes were stained with the DeltaPsim-specific probe JC-1 to detect clusters of high-polarized mitochondria (J-aggregate positive) and with the Ca2+- specific probe Fluo-4 to measure changes in intracellular levels of this cation. ATP content per oocyte was measured directly and cortical granules were visualized with a cortical granule-specific probe. RESULTS: A significant difference between fresh and thawed MII oocytes existed for pericortical J-aggregate fluorescence and for the ability of the cytoplasm to increase free Ca2+ in response to ionophore exposure. No significant difference in ATP contents was measured and cryopreservation was not associated with an apparent release of cortical granules. CONCLUSION: Irreversible loss of high DeltaPsim in thawed oocytes may be associated with defects in Ca2+ signalling after insemination and could have downstream consequences for normal embryogenesis.

Fertilization potential of human sperm is correlated with endogenous platelet-activating factor content.

PURPOSE: Platelet-activating factor (PAF) is a potent signaling phospholipid that is found in mammalian sperm and has a positive correlation with fertility. Whereas PAF is present in human sperm, there are no relational reports on its content and the cells fertilization potential. Therefore, the study objective was to determine if PAF content in capacitated-induced sperm is related to fertilization potential as determined by the sperm penetration assay (SPA). METHODS: Endogenous sperm lipids were measured for PAF content by a specific radioimmunoassay following insemination of zona pellucida-free hamster ova. Data were analyzed by regression analysis and Student's t test. RESULTS: Regression analysis revealed a positive and significant relation (R2 = 0.806; P < 0.05) between PAF content in human sperm and SPA outcome (pass: > or = 5.0; fail: < 5.0, penetrations/ova). Patients that passed (22.61 +/- 5.21 picomoles/10(6)) the SPA had significantly (P < 0.01) higher PAF levels in their sperm than patients that failed (12.91 +/- 1.76 picomoles/10(6) cells) the test. CONCLUSIONS: PAF content in capacitated-induced sperm has a significant and positive relationship with fertilization potential. Fertilization potential may be predicted by measuring PAF levels in capacitation-induced human sperm. Determining PAF content in capacitated human sperm may be a beneficial diagnostic tool for the infertility specialist.