Speciality
Spotlight

 




 

Obstetric
& Gynaecology


 

 




Infertility

   
   

  • Effective of the Postcoital Test: Randomised Controlled Trial

    SG Oei, et al ( Saint Joseph Hosp, Veldhoven, The Netherlands; Leiden Univ. Med Ctr, The Netherlands; Flinders University of
    South Australia, Adelaide) BMJ 317: 502-505, 1998.

       


    Background – Observational studies have shown that the diagnostic and prognostic power of the postcoital test (PCT) is limited, as is its ability to assess and treat cervical hostility to sperm. Infertility investigations, with and without the PCT, were compared to determine the usefulness of such testing in routine fertility evaluations.

        


    Conclusions – The PCT does not appear to be essential in standard infertility evaluations. The use of tests that appear to be unnecessary and that offer little chance of changing the scope of diagnostic possibilities needs to be re-examined.

        


    The treatment of infertile couples with poor PCT findings is the same as that of infertile couples with unexplained infertility. In both groups, controlled ovarian hyperstimulation followed by intrauterine insemination is performed to increase the chance of conception. Infertile couples in which the female partner ovulates and has patent oviducts and the male partner has sufficient sperm to fertilize an egg are treated with controlled ovarian hyperstimulation and intrauterine insemination, whether they have a normal or abnormal PCT. Therefore, as shown in this study, it is no longer necessary to perform the PCT as part of the diagnostic evaluation of the infertile couple because pregnancy rates are the same whether or not the test is performed.

       

  • SR Lincoln, et al (Univ of Tenessee, Memphis) 

    Screening for Hypothyroidism in Infertile women


    J Reprod Med 44: 455-457, 1999.


       


    Background – Previous research has suggested that infertility is closely associated with hypothyroidism. However, the incidence of hypothyroidism in infertile women is estimated to be less than 1%, and many clinicians question the value of including routine screening for hypothyroidism as part of the infertility assessment. The frequency of increased thyroid stimulating hormone (TSH) in patients with a history of infertility seen at reproductive endocrinology and infertility centers was investigated.

       


    Conclusions – The prevalence of increased TSH was 2.3% in this group of women with infertility of at least 1 year’s duration. Most women with a diagnosis of hypothyroidism had ovulatory dysfunction. When their hypothyroidism was treated, 64% were able to become pregnant. Thus infertile women with ovulatory dysfunction should be screened for hypothyroidism.

        


    Many clinicians measure TSH and prolactin levels in all women with a history of infertility who wish to conceive in this study, fewer than 1% of infertile women with normal ovulatory cycles had an elevated TSH level. None of these women conceived after being treated with levothyroxine. However, 7 of 11 women with evidence of ovulatory dysfunction and elevated TSH levels conceived after being treated with levothyroxine. Thus, it appears cost-effective to measure TSH levels in infertile women without regular ovulatory cycles so as to detect and treat subclinical hypothyroidism. 

       


    The benefit of measuring TSH, as well as prolactin, in infertile women with regular ovulatory cycles remain to be established. If either of these assays is abnormal in women with regular ovulatory menstrual cycles, treatment with bromocriptine or levothyroixne has not been shown to improve fecundity.

       

  • Efficacy of Treatment for Unexplained Infertility

    DS Guzick, et al (Univ of Rochester, NY; State Univ of New York, Buffalo; Fertility Physicians of Northern California, Palo Alto;
    et al ) Fertil Steril 70: 207-213, 1998.

       


    Clomiphene citrate (CC) plus IUI is a cost-effective treatment for couples with unexplained infertility. If this approach fails, effective treatment options are hMG plus IUI and assisted reproduction.

       


    This review of the literature regarding various methods of therapy for unexplained infertility provides very useful data. The number of pregnancies per cycle compared with expectant management is increased several-fold with the use of CC plus IUI of separated sperm. A higher pregnancy rate can be achieved with the use of hMG plus IUI, but the cost of therapy is also increased. Complications with the use of hMG are greater than with CC and the former also requires frequent sonographic and hormonal monitoring to prevent hyperstimulation. Thus, it seems appropriate to treat unexplained infertility initially with CC and IUI, if the woman is younger than age 40. Such therapy can be performed in the office of most gynecologists without extensive monitoring. If pregnancy fails to occur after 4 to 6 treatment cycles, the couple may be referred for treatment with hMG plus IUI or
    IVF.

       

  • DS
    Guzick, for the National Cooperative Reproductive Medicine Network (Univ of Rochester, NY; et al ) Efficacy of
    Superovulation and Intrauterine Insemination in the treatment of Infertility.


    N Engl J Med 340:177-183, 1999


        


    Both superovulation and intrauterine insemination are often used to treat infertility. A large, randomized, controlled clinical trial compared the efficacy of these 2 methods of treating infertility.

       


    Conclusion : For achieving pregnancy in infertile couples in which the women had no identifiable infertility factor and the man had motile sperm, the combination of superovulation and intrauterine insemination was superior to either technique alone and to intracervical insemination. The pregnancy rate for the combination of these 2 techniques was 33%.

        


    The results of this prospective randomzied clinical trial indicate that treatment of unexplained infertility with superovulation and intrauterine insemination yields a significantly higher pregnancy rate than doses intracervical insemination with or without superovulation. The pregnancy rate per treatment cycle with superovulation and intrauterine insemination was 9% in this study. With 4 treatment cycles, one third of the couples receiving this treatment regimen conceived. Unfortunately 20% of the pregnancies occurring after use of hMG were multiple gestations. The cost of superovulation and intrauterine insemination is substantially less than in vitro fertilization. 

       

  • Intrauterine Insemination Treatment in Subfertility: An analysis of factors affecting outcome.

    S Nuojua-Huttunen, et al (Oulu Infertility Clinic, Finland; Oulu Univ Hosp, Finland.; Univ of
    Oulu, Finland)

    Hum Reprod 14: 698-703, 1999

        


    Conclusions – Clomiphene citrate human menopausal gonadotrophin/IUI is effective and cost-efficient for selected patients with subfertility. This approach is most beneficial for women younger than 40 years, with infertility 6 years or less in duration, who do not have endometriosis.

        


    Controlled ovarian stimulation (COH) followed by IUI of the partner’s sperm is an effective method of treating the couple with unexplained infertility. The results of this study indicate that prognostic factors for a successful outcome of COH and IUI include female age younger than 40 years, duration of infertility less than 6 years, and no known cause of infertility. In addition, the pregnancy rate was about 3-fold higher if 2 or more follicles more than 16mm in diameter were present at the time of human chorionic gonadotrophin administration than if there was only a single preovulatory follicle. If each of these factors is present, the pregnancy rate per treatment cycle of COH and IUI is about 15%.

       

  • MM
    Biljan, et al (McGill Univ, Montreal). 

    Prospective Randomized Double-blind Trial of the Correlation between Time of Administration and Antiestrogenic Effects of Clomiphene Citrate on Reproductive End Organs.


    Fertil Steril 71:633-638, 1999


       


    Authors have studied twenty three women with unexplained infertility and 45 cycles of clomiphene citrate and intrauterine insemination.

       


    In the group receiving the drug in the first 5 days, the gonadotropins and E2 levels, as well as uterine artery pulsatility index, were significantly higher than in the control group.

        


    The authors conclude that more rapid follicular growth, a longer clomiphene citrate-free period before intrauterine insemination, and higher pregnancy rates resulted with clomiphene citrate begun on day 1 of the menstral cycle rather than on day 5.

       


    Jr. Mishell comments that a small prospective randomised trial does shows that results are best when the treatment is started on day 1 of the cycle.

       


    This result shows that additional randomized trials need to be performed to allow clinicians to decide the optimal treatment regimen for unexplained infertility.

       

  • American Society for Reproductive Medicien (Birmingham, Ala Assisted Reproductive Technology in the United States: 1996
    Results Generated from the American Soceity for Reproductive Medicine/Society for Assisted Reproductive Technology Registry. 


    Fertile Steril 71:798-807, 1999


        


    A total of 65863 cycles of ART treatment were initiated in 1996. Of these, it was found that in vitro fertilisation (IVF) with 26% pregnancy per retrieval, gamete intrafallopian transfer with 29% deliveries per retrieval, zygote intrafallopian transfer with 30.9% deliveries per retrieval. In addition it was found that after embryo transfer, pregnancy rate of 16.8% deliveries per transfer with donor oocyte cycles it was 39.1% deliveries per transfer and from cryopreserved embroys the overall success rate was 20.8% and surrogative uterus 31.3% of deliveries per embryo transfer. This information should be made available to all infertile couples considering the use of assisted reproduction.

       

  • Human Chorionic Gonadotrophin Concentrations in Early Pregnancy After In-Vitro Fertilization.

    S Bjercke, et al (Rikshospitalet, Oslo, Norway)

    Hum Reprod 14:1642-1646, 1999

        


    Authors conclude that a discriminatory HCG value on day 12 after IVF and embryo transfer cycles may be useful for predicting pregnancy outcomes. This marker may help clinicians identify at-risk pregnancies and implement a more intensive surveillance policy in this population.

       


    Editorial comments by Jr.D.R.Mishell: When the HCG level in this study was more than 55 IU/L, there was a 90% chance of having a viable pregnancy. When the level was less than 55 IU/L, 60% of the pregnancies in this study did not reach viability. Clinicians who perform IVF may wish to measure HCG 12 days after embryo transfer so as to provide women with a rough prognosis of having a viable pregnancy before the gestational age when the more sensitive parameters of fetal viability using sonographic imaging can be performed.

       

  • A Randomized comparison of the Method of Sperm Preparation for
    IUI.


    Dodson W.C. et atl (Univ Hosp. Hershey, Philadelphia)

    Fertil steril 70:574-575, 1998

       


    Authors found that despite differences in sperm recovery, no method of sperm preparation provided better cycle fecundity than the others. In multiple tube swim-up specimens, the percentage recovery of sperm was lower. The double centrifugation preparation had the lowest percentage of normal forms. The treatment groups did not differ in cycle fecundity.

         

  • F
    Parazzini, for the Gruppo Italiano per lo Studio dell’Endometriosi (Universita di Milano, Milano, Italy et al) 

    Ablation of Lesions or
    No Treatmetn in Minimal-Mild Endometriosis in Infertile Women : A Randomized Trial


    Hum Reprod 14:1332-1334, 1999.


       


    The results of this randomized controlled trial differ from that reported by a Canadian group. In the Canadian randomized trial, surgical treatment of minimal to mild endometriosis resulted in a significantly higher pregnancy rate than occurred in those women who had only a diagnostic laparoscopy. Other studies comparing surgical treatment of minimal or mild endometriosis with no treatment or treatment with danazol also reported conflicting results, with some showing a benefit with respect to fertility and other showing no benefits. Because the effects of surgical treatment of minimal to mild endometriosis on fertility are inconsistent, support for such treatment remains
    weak.

       

  • M
    Rubinstein, et al (CERT Med Inst, Buenos Aires, Argentina) Low-Dose Aspirin Treatment Improves Ovarian Responsiveness,
    Uterine and Ovarian Blood Flow Velocity, Implantation, and Pregnancy Rates in Patients Undergoing In Vitro Fertilization: A Prospective, Randomized, Double-blind placebo-controlled assay.


    Fertil Steril 71:825-829, 1999


        


    It was found that low dose aspirin treatmetn significantly improved the number of follicles, number of oocytes retrieved, serum E2 levels on the day of human chorionic gonadotropin administration, implantation rate, and pregnancy rate in patients undergoing IVF. 

        

  • In-Vitro Fertilization Treatment for Severe Male Factor: The Fertilization Potential of Immotile Spermatozoa Obtained by Testicular Extraction.



    A Shulman, et al (Chaim Sheba Med Ctr, tel Hashomer, Israel).

    Hum Reprod 14:749-752, 1999.

        


    Authors conclude that immotile testicular spermatozoa recently released from the Sertoli cells can effectively fertilize mature oocytes, producing a normal pregnancy. Testicular sperm retrieval is recommended for patients with totally immotile spermatozoa from the ejaculate. However, if all available spermatozoa are still immotile, those retrieved from the testes should be injected.

        

  • Fertilization and Pregnancy Outcome with Intracytoplasmic Sperm Injection for Azoospermic Men.

    GD Palermo, et al (New York Hosp-Cornell Med Ctr; Population Council, New York) 


    Hum Reprod 14:741-748, 1999.


        


    Spermatozoa retrieval was done by microsurgical epididymal aspiration or testicular biopsy.

        


    Conclusions : Fertilization and pregnancy rates with epididymal spermatozoa were greater in the partners of men with obstructive azoospermia than in those of men with nonobstructive azoospermia, in whom spermatozoa were obtained from the testes. The current findings also indicate that cryopreservation can be used routinely for subsequent pregnancy attempts in the partners of men with obstructive
    azoospermia.

       

  • Live Birth From a Zygote Cryopreserved for 8 Years

    KJ Go, et al (Pennsylvania Hosp, Philadelphia)

    Hum Reprod 13:2970-2971, 1998.

       


    Authors have reported normal pregnancy after thawing embryo cryoprserved for 8 years.

       


    Editorial comments : There are no studies to determine the maximum duration of time that a human embryo may be frozen and then develop normally after thawing and uterine transfer. In several countries, legislation limits the duration of time that cryopreserved embryos can be maintained before they are discarded. In the United Kingdom, this time limit is 5 years. This case report questions the need for these arbitrary limits on duration of frozen embryo storage.

        

  • Trends in Contraceptive Use in the United States: 1982-1995

    LJ Piccinino, et al (Natl Ctr for heatlh Statistics, Hyattsville, Md) 


    Fam Plann Perspect 30:4-10 &46, 1998.


        


    Editorial comments: Nationwide surveys of contraceptive use in the United States are performed periodically with the planning and funding of US government agencies. Surveys were performed in1982, 88, and 95, and this study summarizes the changes that have occurred with contraceptive use during these years. Between 1982 and 1995, the use of contraceptives by women of reproductive age increased so that, in 1995, only about 5% of women who were sexually active and not wishing to conceive were using no method of contraception. Sterilization is the most common method of pregnancy prevention in the United States followed by use of oral contraceptives and the male condom. Use of the condom has increased markedly in the United States during this period. Relatively few women use each of 3 very effective methods, the IUD, progestin injections, and progestin implants. Less than 1 million women used each of these methods in 1995.

         

  • P F Kaplan, D J Austin and R Freund 

    Subcutaneous human menopausal gonadotropin administration for controlled ovarian hyperstimulation with intrauterine insemination cycles.

    Am J Obstet Gynecol 2000; 182:1421-6

       


    Objective : This study was undertaken to determine the feasibility of administering human menopausal gonadotropin subcutaneously for controlled ovarian hyperstimulation with intrauterine insemination.

           


    Study Design: This was a prospective nonrandomized matched group comparison. Study patients undergoing controlled ovarian hyperstimulation with intrauterine insemination infertility treatment between June 1998 and March 1999 self-administered human menopausal gonadotropin subcutaneously for ovulation induction. Cycles were analyzed for duration of human menopausal gonadotropin treatment, total number of ampules of human menopausal gonadotropin used, peak serum estradiol level, number of mature follicles (=15mm), cycle fecundity, and acceptability of the subcutaneous route of human menopausal gonadotropin administration. Age-matched historical control subjects who followed the same protocol except of the route of human menopausal gonadotropin administration, which was instead intramuscular, were used for comparison.

         

    Results: Study and control cycles did not differ with respect to duration of human menopausal gonadotropin treatment, total number of ampules of human menopausal gonadotropin used, peak serum estradiol level, number of mature follicles or cycle fecundity rate. Two study patients were switched from subcutaneous to intramuscular administration because of minor local injection site reactions.

       


    Conclusion: Subcutaneous human menopausal gonadotropin administration for controlled ovarian hyperstimulation with intrauterine insemination treatment cycles was generally well tolerated and yielded stimulation parameters and pregnancy rates similar to those associated with the intramuscular route. Patients subjectively preferred subcutaneous human menopausal gonadotropin administration because of the ability to self-administer the injections, the use of a smaller injection needle, and reduced muscular pain at the injection site.

         

  • M. Fujisawa, T. Shirakawa, et al (Division of Urology, Department of Organ Therapeutics, et al)

    Y-Chromosome Microdeletion and Phenotype in
    Cytogenetically Normal Men With Idiopathic
    Azoospermia

    Fertil Steril, September 2001; Vol. 76(3): 491-5

           

    Objective : To determine the prevalence of microdeletions of the long arm of chromosome Y within the AZFa, AZFb, and AZFc subregions in patients with idiopathic azoospermia, and then correlate the microdeletions with clinical phenotypes to determine the most important subregion for screening.

           

    Patient(s) : Among 89 consecutive azoospermic patients, those whose infertility was related to known hereditary, endocrine, or obstructive causes or a cytogenetic abnormality were excluded; 54 remaining patients were studied using a polymerase chain reaction (PCR).

          

    Of these patients, 33 had Sertoli cell only syndrome, 10 had maturation arrest, and 11 had hypospermatogenesis.

          

    Conclusion(s) : Cytogenetically azoospermic patients should be examined for microdeletions before undertaking assisted reproduction. AZFc may be the most important subregion to screen.

          

    In addition, intact AZFa and AZFb subregions may be important for the presence of germ cells.

          

  • R.
    Luboshitzky, G. Qupti, et al (Endocrine Institute, Haemek Medical Center, et al)

    Increased 6-Sulfatoxymelatonin Excretion in Women with Polycystic Ovary Syndrome

    Fertil Steril, September 2001; Vol. 76(3): 506-10

            

    Objective : To determine melatonin production in hyperandrogenic women.

            

    Design : Controlled prospective study.

           

    Setting : Outpatients in an academic medical center.

           

    Patient(s) : Twenty-two women with polycystic ovary syndrome (PCOS), 20 women with idiopathic hirsutism, and 15 age-matched individuals who had similar body mass indexes as controls.

           

    Intervention(s) : Fasting blood samples and 24-hour urinary samples were obtained from all participants.

           

    Main Outcome Measure(s) : All participants provided serum samples for the measurement of LH, FSH, testosterone, E2, DHEAS, 17 a-hydroxyprogesterone (17-OHP), and insulin levels, as well as urinary 6-sulfatoxymelatonin (aMT6s).

            

    Result(s) : Women with PCOS had higher aMT6s, testosterone, LH/FSH ratio, and insulin values than either women with idiopathic hirsutism or control women. Testosterone inversely correlated with aMT6s in PCOS. Regression analysis revealed that only testosterone was an important determinant of aMT6s in PCOS.

            

    Conclusion(s) : Women with PCOS have increased melatonin production.

            

    Comments : Because hyperinsulinemia has been suggested to play a role in the pathogenesis of androgen excess in PCOS (19, 20), insulin should be considered as a potential candidate involved in the modulation of melatonin in PCOS.

             

    Insulin was shown to stimulate androgen synthesis in ovarian thecal cells, decrease free androgen levels, and potentiate ACTH-stimulated adrenal androgens (20).

          

    In conclusion, women with ovarian hyperandorgenism have increased melatonin production, whereas melatonin secretion is normal in women who are hyperandorgenic due to idiopathic hirsutism.

            

  • T.
    Mukaida, S. Nakamura, et al (Hiroshima HART Clinic, Hiroshima, and Osaka HART Clinic, Osaka, Japan)

    Successful Birth After Transfer of Vitrified Human Blastocysts With Use of a Cryoloop Containerless Technique

    Fertil Steril, September 2001, Vol. 76(3) pg. 618-20

           

    Objective : Clinical application of vitrification for the cryopreservation of human blastocysts.

           

    Design : Clinical trial of vitrification of human blastocysts.

           

    Setting : Private assisted reproductive technology clinic.

           

    Patient(s) : Supernumerary blastocysts after fresh blastocyst transfer were vitrified for subsequent transfer.

          

    Intervention(s) : Culture of pronuclear embryos to the blastocyst stage in sequential media and subsequent vitrification of supernumerary blastocysts using a cryoloop technique 

            

    Main Outcome Measure(s) : Clinical outcome after transfer of vitrified blastocysts.

           

    Result(s): A total of 60 vitrified blastocysts from 21 patients were warmed, and the survival rate at 2 hours after warming was 63%. Six clinical pregnancies were achieved after 19 transfers. One healthy baby was born, four pregnancies are ongoing, and one ended in miscarriage.

           

    Conclusion(s) : Human blastocysts can be successfully vitrified by suspension on a small nylon loop and a direct plunge into liquid nitrogen. A delivery and ongoing pregnancies prove the safety of this method. This report documents the first successful pregnancy and delivery achieved by blastocyst vitrification using the cryoloop containerless technique.

           

    Comments : Vitrification would be a preferred method of cryopreservation to the slow-cooling method because of the lack of ice crystal formation and handiness. The authors have already reported a simple vitrification method using an ethylene glycol-based solution for four-to eight-cell human embryos frozen in conventional cryostraws. 

           

    Moreover the success of vitrification procedures has recently been increased by techniques that substantially reduce the volume of vitrification solution. Among such techniques, the cryoloop must be a most refined strategy. 

            

    A major difference between the cryoloop and the conventional straw for vitrification is the cooling and warming rate. The cryoloop enables ultrarapid cooling and warming. In the present study, this may have prevented intracellular ice formation because the authors have observed that human blastocysts are dehydrated and concentrated more slowly than earlier stage embryos, suggesting that intracellular ice is more likely to form. Furthermore, the technique using the cryoloop is easier and simpler than that using the cryostraw.

            

    With the development of sequential culture media, based upon the physiology of the human reproductive tract and the changing physiology of the developing of the developing embryos, it is possible to grow viable blastocysts easily in vitro. Because of the resulting high implantation rates, blastocyst transfer will be a reliable approach in ART. In this report, the authors have shown for the first time that vitrification using the cryoloop is a clinically useful method for the cryopreservation of human blastocysts.

            

  • Richard J Paulson, Robert C Milligan and Rebecca Z Sokol (Los Angeles, California)

    The lack of influence of age on male fertility.

    Am J Obstet Gynecol, 2001; 184: 818-24

     

    Objective: This study was undertaken to determine the effect of male aging on sperm quality as determined by semen analysis, the fertilization rate of human oocytes in vitro, and live birth rates.

     

    Study Design: Retrospective analysis correlating outcome measures with male age was performed for 558 oocyte donation cycles in 441 couples. The oocyte donation model was chosen because it controls for oocyte quality and endometrial receptivity, which allows variations in sperm quality as a function of male age to be the only dependent variable. Outcome measures analyzed were semen analysis, fertilization rates in vitro, pregnancy rates, live birth rates, and cumulative live birth rates by life-table analysis.

     

    Results: There was a negative correlation between male age and total sperm count, but there was no correlation between male age and any of the other parameters in the semen analysis. There was no association between male age and the fertilization rate of donated oocytes in vitro, pregnancy rates, or live birth rates. Recipient couples were grouped by quartiles of male age, and cumulative live birth rates were the same in the 4 groups.

     

    Conclusion: Whereas male aging is associated with a significant decline in total sperm count, this change is not reflected in a decreased fertilization rate or a decreased live birth rate in the oocyte donation model.          

                                       

  • Marsha J gorrill, Karen Sadler-Fredd, et al   

    Multiple gestations in assisted reproductive technology: Can they be avoided with blastocyst transfers?     

    Am J Obstet Gynecol, June 2001; 184: 1471-7                    

                                                              

    Objective: Blastocysts are advanced-stage embryos with high implantation potential; theoretically, limited numbers of blastocysts can be used for embryo transfer to achieve good pregnancy rates with low multiple pregnancy rates. Clinical outcomes of a  
    newly implemented blastocyst transfer program were evaluated.                         

                                                                          

    Study Design: This study is a retrospective analysis of 553 blastocyst transfer cycles performed by a university-based in vitro   
    fertilization program; risk factors associated with multiple gestations were analyzed.                                

                                                        

    Results : An average of 2.2 embryos were used for embryo transfer. The overall clinical pregnancy rate per embryo transfer was 45.1%; multiple gestation, twin
    and triplet rates were 40.9%, 36.5%, and 4.3%, respectively. Multiple gestations increased   
    significantly (1) when embryo transfer was done on day 5, (2) when
    ³2 blastocysts were present on day 5, and (3) when maternal age was £ 30 years.                                                         

                                           

    Conclusion: In spite of a conservative approach to the number of blastocysts used for embryo transfer, the overall multiple    
    pregnancy rate was high, and triplet pregnancies did occur.             

              

  • Hillary
    Klonoff-Cohen, Elaine Chu, Loki Natarajan and William Sieber   

    A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer.         

    Fert. & Ster. Vol.76(4), October 2001, pg.675-87.          

                                        

    Objective: To evaluate whether baseline or procedural stress during in vitro fertilizaiton (IVF) or gamete intrafallopian transfer (GIFT) affects pregnancy or live birth delivery rates.        

                              

    Patients: One hundred and fifty-one women completed two questionnaires.          

                                  

    Discussion: Psychological stress may diminish success rates, possibly by one of the following mechanisms: hypothalamus dysfunction either by neurotransmitting alterations, catecholamine depletion, or interference with hypothalamic receptors for neurotransmitters. The exact mechanism by which stress interferes with the hypothalamus-pituitary-gonadal reaction is not clearly understood. Progesterone and cortisol, the neuroendocrine correlates of stress, may provide potential pathways through which stress could affect IVF outcome. Future studies should measure the plasma and follicular levels of stress hormones such as prolactin and cortisol to clarify the role of these hormonal mechanisms, to determine the neuroendocrine and physiologic pathways that could meditate an effect on reproductive outcomes (decreased numbers of oocytes, poor quality of embryo).

                                         

    This research determined that success rates for IVF or GIFT may, in part, be affected by psychological stress that results in disruption of the reproductive function. Clinicians and women can now identify which stage(s) in the IVF and GIFT attempt are important; it appears that the baseline (rather than during the procedure) is the most critical time for monitoring and decreasing stress levels. This can possibly be achieved through counseling, support groups, educational booklets, handouts and suggested readings.               

                                                                         

  • Annette
    Kaushce, Gayle M Jones, et al       

    Sex ratio and birth weights of infants born as a result of blastocyst transfers compared with early cleavage stage embryo transfers. 

    Fert.& Ster., vol.76(4), Oct.2001,pg.688-93        

             

    Objective: To analyze the birth weights and sex ratio of infants born as a result of blastocyst transfer and compare them with data resulting from the transfer of early-cleavage stage embryos.        

                     

    Design: Retrospective analsysis.        

                     

    Setting: Monash IVF (private in vitro fertilization clinic).     

                         

    Patient(s): One hundred twenty five infertile patients who became pregnant after IVF procedures involving blastocyst transfer. 

                           

    Conclusion(s): There is no evidence of abnormal fetal growth or a shift in the sex ration for infants born as a result of blastocyst transfer when compared with the case of births resulting from early cleavage stage embryo transfers within our unit or all other assisted conception units in Australia and New Zealand.                
             

                                                                                                                                                         

  • Sharon A Kidd, Brenda Eskenazi, et al                     

    Effects of male age on semen quality and fertility: a review of the literature                  

    Fert. & Ster., vol.75(2), Feb.2001, pg.237                          

                                                                

    Objective: To review the literature on the association between male age and semen quality (semen volume, concentration, motility and morphology) and fertility status (pregnancy rate and time to
    pregnancy/subfecundity).       

                                                                       

    Methods : Review of English language-published research over the last 20 years from January 1, 1980, through December 31, 1999, using MEDLINE and Biosis databases. Studies with insufficient numbers of subjects, case reports, case series, or anecdotal data were excluded.                                                

                                                                                    

    Conclusion: The weight of the evidence suggests that increased male age is associated with a decline in semen volume, sperm motility and sperm morphology but not with sperm concentration.       

                                                                                                                                                       

  • Lynn M Wallock, Tsunenobu Tamura, et al 

    Low seminal plasma folate concentrations are associated with low sperm density and count in male smokers and nonsmokers.         

    Fert. & Ster., vol.75(2), Feb.2001, pg.252         

                                    

    Total seminal plasma folate concentrations were on average 1.5 times higher than blood plasma folate concentrations in all men. Seminal plasma non-methlytetrahydrofolate levels correlated significantly with sperm density and total sperm count. Seminal plasma of smokers contained a proportionally lower concentration of non-methyltetrahydrofolate compared with nonsmokers.

                        

    Seminal plasma total folate and 5-methyltetrahydrofolate concentrations reflect folate nutriture. The non-methyltetrahydrofolate fraction of seminal plasma may be important for male reproduction function.  

                              

    Folates in the seminal fluid appear to be important for normal reproductive functioning.                           

                                                                             

  • Philip
    F Brook, John A Radford, et al

    Isolation of germ cells from human testicular
    tissue for low temperature storage and
    autotrnsplantation.

    Fert & Ster, vol.75(2), Feb,2001, pg.
    269-74        

                        

    Objective: To develop a new protocol for conserving
    fertile potential in men undergoing sterilizing
    chemotherapy by low temperature banking of germ
    cells which can be returned to the patient’s
    testes after thawing.  

                         

    Design: Isolation of human and murine germ cells for
    comparing cellular viability after cooling to liquid
    nitrogen temperatures by the use of different
    cryoprotective agents and for infusion into the
    testis.               

                                          

    After isolation using a two-step enzymatic
    disaggregation protocol, 66% to 87% of germ cells
    from human and murine specimens, respectively, were
    still viable. Cell survival was similar in four
    commonly used cryoprotective agents after cooling to
    liquid nitrogen temperatures. Semniferous tubules
    infused by back flow with dye solution via the rete
    testis were filled with an efficiency of 55%.

                                                         

  • Mohammed F M Mitwally and Robert F Casper                   

    Use of an aromatase inhibitor for induction of ovulation in patients with an inadequate response to clomiphene citrate                 

    Fert & Sterl. Vol.75(2), Feb.2001, pg.305-9       

                     

    Objective : To use aromatase inhibition for induction of ovulation in women in whom clomiphene citrate (CC) treatment was unsuccessful.                 

                                              

    Two tertiary-referral infertility clinics associated with the Division of Reproductive Sciences, University of Toronto.   

                                  

    Patients: Twelve patients with anovulatory polycsytic ovary syndrome (PCOS) and 10 patients with ovulatory infertility, all of whom had previously received CC with an inadequate outcome (no ovulation and/or endometrial thickness of ? 0.5cm) 

                                      

    Interventions The aromatase inhibitor letrozole was given orally in a dose of 2.5mg on days 3-7 after menses.          

                                                       

    Conclusion: Oral administration of the aromatase inhibitor letrozole is effective for ovulation induction in anovulatory infertility and for increased follicle recruitment in ovulatory infertility. Letrozole appears to avoid the unfavourable effects on the endometrium frequently seen with antiestrogen use for ovulation induction.                                     

                                                                                                    

    In women with World Health Organization type II anovulatory infertility, the treatment of first choice for the induction of ovulation is an antiestrogen, most commonly clomiphene citrate (CC). However, 20% -25% of women are resistant to CC and do not ovulate. In addition, clinical data have revealed a discrepancy between ovulation and conception rates during CC treatment and a higher than expected incidence of miscarriage in conception cycles. These observations have been attributed to the antiestrogenic mechanism of action of CC, which involves long-lasting estrogen receptor (ER) depletion. It also appears that CC accumulates in the body because of its long half-life. As a result, CC may have a negative effect on the quality and quantity of cervical mucus, on endometrial development, and on other as yet undetermined fertility factors.      

                                                     

  • David t Vandermolen, Valerie S Ratts, et al       

    Metformin increases the ovulatory rate and pregnancy rate from clomiphene citrate in patients with  
    polycystic ovary syndrome who are resistant to clomiphene citrate alone.   

    Fert.&Ster. Vol.75(2), Feb.2001, gp.310  

                                 

    Participants received placebo or metformin 500mg three times daily, for 7 weeks. Information on reproductive steroids, gonadotropins, and oral glucose tolerance testing was obtained at baseline and after treatment. Metformin or placebo was continued and CC treatment was begun at 50mg daily for 5 days. Serum P level ? 4ng/mL was considered to indicate ovulation. With ovulation, the daily CC dose was not changed, but with anovulation it was increased by 50mg for the next cycle. Patients completed the study when they had had six ovulatory cycles, became pregnant, or experienced anovulation while receiving 150mg of CC.           

                          

    Results : In the metformin and placebo groups, 9 of 12 participants (75%) and 4 of 15 participants (27%) ovulated, and 6 of 11 participants (55%) and 1 of 14 participants (7%) conceived, respectively. Comparisons between the groups were significant.

                                      

    Conclusion : In anovulatory women with PCOS who are resistant to CC, metformin use significantly increased the ovulation rate and pregnancy rate from CC treatment.           

                                                                                        

    In addition to increased ovulatory response, women who received metformin and CC had a conception rate after ovulation of 21%. This rate is consistent with normal cycle fecundity.       

                              

    75% of participants ovulated in response to CC plus,
    metformin.     

                                            

    Thus, our results provide a rationale for metformin and CC treatment of obese CC resistant women with PCOS before proceeding to ovulation induction with gonadotropins or to
    IVF-ET.                                      

                                                              

  • Uma Deve Gordon, Robert F Harrison, et al      

    A randomized prospective assessor-blind evaluation of luteinzing hormone dosage and in vitro fertilization outcome.       

    Fert & Ster. Feb. 2001, 75: 324-31 

                  

    Objective : To determine the effect of exogenous LH dosage on IVF outcome.  

                   

    Patients: Infertile normogonadotropic women undergoing their first cycle of IVF were studied. 

               

    Main Outcome Measure(s): Dose and duration of gonadotropin stimulation, follicle and oocyte numbers implantation rate, and pregnancy rate. 

                 

    Conclusions: Although the residual endogenous LH after down-regulation was adequate for ovarian response and E2 synthesis, the addition of exogenous LH improved implantation. An FSH/LH ratio of 75/75 IU per ampoule appeared to be the optimum dose.        

                               

    To date, although pregnancies have been reported in hypogonadal women treated with rhFSH and rhLH, no pregnancies have been documented with rhFSH alone in hypogonadotropic
    hypogonadism.  

                               

    A third explanation may be direct effect of LH on the
    endometrium.             

                                                                          

  • Firouz
    Khamsi, Yalcin Yavas, et al 

    Intracytoplasmic sperm injection increased fertilization and good-quality embryo formation in patients with non-male factor indications for in vitro fertilization: a prospective randomized study.

    Fert & Ster. Feb.2001, 75: 342-7

       


    Objective : To compare the fertilization rate and formation of good-quality embryos with conventional and ICSI in patients with non-male factor infertility.

       


    Patients: Thirty-five patients with non-male factor infertility

       


    Intervention: Retrieved sibling oocytes were randomly assigned to conventional IVF or ICSI. Of sibling oocytes assigned to ICSI, ONLY metaphase II oocytes were injected with sperm.



    Main Outcome Measures:: Fertilization rate and formation of good-quality embryos per retrieved oocyte.



    Results : Per retrieved oocyte, ICSI resulted in better fertilization rate compared with conventional IVF (17.3% [134 of 188] vs 57.2% [107 of 187]). Per retrieved oocyte, ICSI also resulted in better formation of good-quality embryos at 48 horus after retrieval compared with conventional IVF (64.4% [121 of 188] vs. 47.1% [88 of 187].

               
       

    Conclusion: In IVF patients with non-male factor infertility, subjecting some sibling oocytes to ICSI increased the fertilization rate and formation of good-quality embryos per retrieved oocyte. It also avoided the problem of total fertilization failure in almost all cases.

      


    Many IVF centers have extended ICSI treatment to patients other than those with male factor infertility. These centres usually perform ICSI on some but not all of the retrieved oocytes because, based on their clinical experience, they may avoid cases of total failure of fertilization.

      


    The rate of total fertilization failure with conventional IVF was 14.3%.

      


    Regardless of the cause of infertility (excluding male factor infertility), success of IVF was more certain if half of the oocytes were subjected to ICSI.

      


    It was previously reported that the greater the diameter of the oocyte cumulus complex the better the chance of fertilization and development.

      


    Routine testing for antisperm antibodies was not performed, but it may have been relevant to fertilization with ICSI.

       


    Hardening of the zona pellucida at different stages may also be an important factor in failure of fertilization despite healthy spermatozoa. Finally, there may be problems in oocytes related to the type of ovarian stimulation and the culture conditions rather than an intrinsic abnormality of the ovaries.

      

  • Jan
    W.A, de Vries, Sjoerd Repping, et al 

    Absence of deleted in azoospermia (DAZ) genes in spermatozoa of infertile men with somatic DAZ deletions.

    Fert.& Ster. Vol.75, 2001, 476-9

     

    Objective: To determine the presence or absence of the deleted in azoospermia (DAZ) gene clusters in the Y-bearing spermatozoa in semen of severely oligozoospermic men or in testicular biopsy samples of azoospermic men with somatic DAZ deletions.

      

    Patients: Nineteen patients attending clinics for therapeutic intracytoplasmic injection of sperm.

     

    Intervention: Peripheral blood lymphocytes were used to obtain somatic DNA for analysis using the polymerase chain reaction. Analysis of chromosomes X and Y and the detection of the DAZ gene clusters were carried out with the fluorescence in situ hybridization technique in spermatozoa remaining after intracyclic plasmic sperm injection.

     

    Main Outcome Measures: Presence or absence of the DAZ gene clusters in matched somatic DNA and Y-bearing spermatozoa.

     

    Results: Seven patients appeared to have a somatic DAZ deletion. Three colour fluoresence in situ hybridization showed that all Y-bearing spermatozoa examined from these men carried the same deletion.

      

    Conclusion: The DAZ deletions present in the seven men would all have been transmitted if they had fathered sons through artificial fertilization techniques using the sperm cells examined in this study.

       

  • Basak
    Balaban, Bulent Urman, et al

    Blastocyst-stage transfer of poor-quality cleavage-stage embryos results in higher implantation
    rates.


    Fert.& Ster. Vol.75(3), March 2001, 75: 514-8

      

    Objective: To determine the feasibility and success of blastocyst-stage embryo transfers in patients having only fair and poor quality cleavage-stage embryos on day 3.

      

    Design: Prospective case study with historic controls.

      

    Patients: A total of 158 day 5 embryo transfer cycles in patients with grade 3 and grade 4 cleavage-stage embryos. Control group consisted of 162 day 3 transfer cycles performed with embryos of similar quality.

      

    Main Outcome Measure(s): The percentage of cycles that culminated in the transfer of at least one blastocyst and implantation and pregnancy rate related to the day of transfer.

       

    Conclusions: Transfer of fair and poor quality embryos at the blastocyst stage is feasible and is associated with higher implantation rates as compared to transfer of similar quality embryos on day 3.

       

  • Phillippe
    Terriou, Christophe Sapin, et al

    Embryo score is a better predictor of pregnancy than the number of transferred embryos or female age.

    Fert.&Ster. Vol.75(3), March 2001, pg.525

      

    Objective: To compare the value of 17 IVF variables, including a new mean score of transferred embryos (MSTE), in predicting pregnancy rate.

      

    Design: Retrospective study

      

    Patients: Women who underwent 10,000 embryo transfers.

    Main Outcome Measures : Duration of infertility, type of infertility , female age, rank of IVF attempt, type of ovarian treatment, progesterone level, sperm count, sperm motility, sperm morphology, number of retrieved oocytes, number of mature oocytes, maturation rate, number of embryos obtained, fertilization rate, number of transferred embryos, cumulative embryo score (CES), mean score of transferred embryos (MSTE), and pregnancy rate.

      

    Results: Outcome of IVF-ET was significantly correlated with female age, type of infertility, number of retrieved oocytes, number of mature oocytes, maturation rate, embryos obtained, fertilization rate, transferred embryos, CES, and MSTE. Multivariate analysis demonstrated that MSTE was a better predictor of pregnancy than the number of transferred embryos and female
    age.

       

    Conclusion: Embryo quality is the best predictor of pregnancy. The embryo score described herein should be used in IVF-ET programs to choose the best embryos for transfer.

       

  • Hongxia Li, Steven T Nakjima, et al

    Differences in hormonal characteristics of conceptive versus nonceptive menstrual cycels.

    Fert.&Ster. Vol.7r5(3), March 2001, pg. 549

      

    Objective: To determine the hormonal characteristics of a fecund menstrual cycle.



    Design: Prospective observational study.

       

    Setting: Clinical research center.

      

    Results: The mean peak value of periovulatory urinary FSH was significantly higher in conceptive cycles than in nonconceptive cycles. The mean serum E2 concentration was significantly higher on day 0 (day of peak urinary FSH concentration) in conceptive cycles than in nonconceptive cycles; but mean peak values of serum E2 did not differ significantly. No other significant differences were observed in serum and urinary hormone profiles between conceptive and nonconceptive cycles.

      

    Conclusions: A lower,broader peak of FSH in urine was observed in nonconceptive cycles compared with conceptive cycles. Urinary FSH measurements may be useful in predicting less fecund ovulatory cycles and may identify some types of reduced female fertility.

         

  • Anne Ego, Damien Subtil, et al

    Survival analysis of fertility after ectopic pregnancy

    Fert. & Ster. Vol.75(3), March 2001, pg.560-6

      

    Objective: To evaluate the reproductive outcome after ectopic pregnancy and to assess the contribution of risk factors to future fertility.

      

    Setting: Register of ectopic pregnancies established in an urban area around Lille, France.

     

    Patients: Three hundred and twenty eight women treated between April 1994 and March 1997 who had not been using an IUCD at the time of the ectopic pregnancy and were trying to become pregnant.

     

    Conclusion: More than half of the women treated for ectopic pregnancy spontaneously conceived and had a normally progressive pregnancy at 1 year. Fertility depends more on established patient characteristics than characteristics of ectopic pregnancy itself or treatment thereof.

      

  • Ben W J Mol, John A Collins, et al

    Cost-effectiveness of hysterosalpingography, laparoscopy and Chlamydia antibody testing in subfertile couples.

    Fert.& Ster. Vol.75(3), March 2001, pg.571-80

      

    Objective: To evaluate the cost-effectiveness analysis of hysterosalpingography (HSG), laparoscopy, and Chlamydia antibody testing (CAT) in subfertile couples

       

    Design: Cost-effectiveness analysis

      

    Setting: Decision analytic framework

      

    Patients: Data of >2000 subfertile couples in the Canadian Infertility Treatment Evaluation Study. Results of CA-125 measurements and CAT were simulated from baseline characteristics.



    Interventions: Expectant management was considered to be the reference strategy (strategy 1). In strategy 2 and 3, IVF was offered either immediately or after 2.5 years. In strategy 4, the decision to offer or delay treatment was based on the couple’s chance of spontaneous conception. Nine strategies incorporated combination of CAT, CA-125 measurement, HSG and laparoscopy.



    Results: The strategy starting with CAT was the most cost-effectiveness in couples whose 3 year chance of conception was > 14%, whereas the strategy starting with HSG was the most cost-effective in couples with worse fertility prospects.



    Conclusions: The diagnostic work-up to detect tubal pathology in subfertile couples should start with CAT in couples with relatively good fertility prospects and immediate HSG in couples with relatively poor fertility prospects.

       

  • Rebecca C Taylor, Jonathan Berkowitz and Peter F McComb

    Role of laparoscopic salpingostomy in the treatment of hydrosalpinx

    Fert.& Ster. Vol.75(3), March 2001, pg. 594-600

       

    Results: The overall IUP and EP rates were 24.5% and 16.5% respectively. Analysis of historical variables, assigned independently, demonstrated a significantly higher IUP rate with a positive history of gonorrhea and a significantly higher EP rate with a positive history of pelvic inflammatory disease, lack of history of intrauterine device (IUD) usage, or the performance of a bilateral procedure. The logistic regression model to predict intrauterine pregnancy had an overall predictive value of 77.5% and included the following significant variables: secondary infertility, positive history of gonorrhea, and the operative finding of moderate periadnexal adhesions. The logistic regression model to predict ectopic pregnancy had an overall predictive value of 89.0% and included the following significant variables: previous ectopic pregnancy, negative history of IUD use, positive history of PID, a bilateral procedure, and perihepatic adhesions.

         

  • M Ludwig, H Riethmuller-Winzen et al

    Health of 227 children born after controlled ovarian stimulation for in vitro fertilization using the luteinizing hormone-releasing hormone antagonist cetrorelix.

    Fert.& Ster. Vol.75(1), Jan. 2001, pg.18-22

      

    Objective: To summarize data from completed phase II and III clinical trials on children born after controlled ovarian stimulation using the luteinizing hormone-releasing hormone antagonist
    cetrorelix.

      

    Design: All children born after ovarian stimulation in patients treated for infertility who were in prospective studies until March 23, 1999

      

    Patients: Children born after IVF or IVF plus
    ICSI.

      

    Interventions: Controlled ovarian stimulation with cetrorelix in a multiple-dose or single/dual-dose protocol.

      

    Main Outcome Measures: Outcome of pregnancy and, in deliveries, the date of birth, number and sex of children born, birth weight, body length, and abnormalities were recorded. At approximately 1 year of age and 2 years of age, body weight and length and abnormalities in physical and mental development were recorded.

     

    Results: Two hundred nine and 18 children were born after fresh and frozen embryo transfers, respectively. Of the pregnancies, 76.25 resulted in live birth and ectopic pregnancy occurred in 3.4% (8 of 21); one heterotopic pregnancy and four induced abortions were recorded. The malformation rate among all live births, stillbirths and aborted fetuses was 3.1%.

      

    Conclusions: Use of cetrorelix in controlled ovarian stimulation does not harm the subsequently born children.

       

  • R.F. Harrison, S Jacob, et al

    A prospective randomized clinical trial of differing starter doses of recombinant follicle-stimulating hormone (follitropin -b) for first time in vitro fertilization and intracytoplasmic sperm injection treatment cycles.

    Fert.&Ster. Vol.75(1), jan.2001, pg.23

      

    Objective: Comparison of the efficacy of differing starter doses of recombinant follicle stimulating hormone (rFSH) for IVF and intracytoplasmic sperm injection cycles when the treatment is administered both subcutaneously and intramuscularly.

     

    Design: Single center 1-year prospective randomized study.

     

    Patients: 345 couples in first cycle

     

    Interventions: Treatment with subcutaneous or intramuscular rFSH, followed by E2 and ultrasound follicle tracking, with later oocyte collection and zygote transfer.

     

    Main Outcome Measure: Ovarian response and other clinically dependent variables.

     

    Results: Intramuscular administration was significantly more likely to result in a need for increased dosage than was subcutaneous administration.

     

    Conclusion: In the main study total dosage used, the ICSI metaphase II oocyte numbers were significantly lower and there was a trend toward a need for a dosage increase on day 5 when 150 IU rFSH was the starter dosage, as compared to a starting dosage of 200 IU. Otherwise, there is little advantage to using the higher dosage.

       

  • The North American Ganirelix Study Group: Margo Fluker, James Grifo, et al

    Efficacy and safety of ganirelix acetate versus leuprolide acetate in women undergoing controlled ovarian hyperstimulation.

    Fert.&Ster. Vol.75(1), Jan.2001, pg.38-45

     

    Objective: To assess the efficacy, safety, and local tolerance of ganirelix acetate for the inhibition of premature luteinizing hormone (LH) surges in women undergoing controlled ovarian hyperstimulation
    (COH).

     

    Design: Phase III, multicenter, open-label randomized trial

     

    Setting: In vitro fertilization (IVF) centers in North America

     

    Patient(s): Healthy female partners (n=313) in subfertile couples for whom COH and IVF or intracycloplasmic sperm injection were indicated.

     

    Interventions: Patients were randomized to receive one COH cycle with ganirelix or the reference treatment, a long protocol of leuprolide acetate in conjunction with follitropin-B for injection.

     

    Outcome measures: Number of oocytes retrieved, pregnancy rates, endocrine variables, and safety variables.

     

    Results: The mean number of oocytes retrieved per attempt was 11.6 in the ganirelix group and 14.1 in the leuprolide group. Fertilization rates were 62.4% and 61.9% in the ganirelix and leuprolide groups, respectively, and implantation rates were 21.1% and 26.1%. Clinical and ongoing pregnancy rates per attempt were 35.4% and 30.8% in the ganirelix group and 38.4% and 36.4% in the leuprolide acetate group. Fewer moderate and severe injection site reactions were reported with ganirelix.(11.9% and 0.6%) than with leuprolide (24.4% and 1.1%).

     

    Conclusions: Ganirelix is effective, safe and well tolerated. Compared with leuprolide acetate, ganirelix therapy has a shorter duration and fewer injections but produces a similar pregnancy rate.

       

  • Melissa D, Kahsar-Miller, et al

    Prevalence of polycystic ovary syndrome (PCOS) in first-degree relatives of patients with PCOS.

    Fert. & Ster. Vol.75(1), Jan.2001, pg.53-8

      

    Objective: To determine the rate of clinically evident polycystic ovary syndrome (PCOS) among first-degree female relatives within families with a proband affected by PCOS.

      

    Design: Clinical and biochemical evaluation of the mothers and sisters of 93 patients with PCOS. The diagnosis of PCOS was established by: (1) a history of oligomenorrhea, (2) clinical evidence (i.e. hirsutism) or biochemical evidence (i.e. elevated total for free T) of hyperandrogenism, and (3) the exclusion of related disroders.

     

    Setting: Tertiary care university

     

    Patients: Patients with PCOS and their mothers and sisters.



    Interventions: Interview, physical examination, and hormonal testing on blood samples were performed for all subjects.

       

    Main Outcome Measures: The presence of hirsutism and hyperandrogenemia was determined in the mothers and sisters of the patients with PCOS.

     

    Results: Of the 78 mothers and 50 sisters evaluated clinically, 19(24%) and 16(32%) were affected with PCOS, respectively. A higher rate of PCOS was observed when only premenopausal women not taking hormones (i.e. Untreated) were considered (i.e. 35% of mothers and 40% of sisters), consistent with amelioration of symptoms with hormonal therapy or aging. These rates of PCOS are significantly higher than that observed in general population (approximately 4%) and suggest the involvement of a major genetic component in the disorder.

      

    Conclusion: The rates of PCOS in mothers and sisters of patients with PCOS were 24% and 32%, respectively, although the risk was higher when considering untreated premenopausal women only.

       

  • Thomas G Matkov, Michael Zenni, et al

    Preoperative semen analysis as a predictor of seminal improvement following varicocelectomy.

    Fert. & Ster. Vol.75(1), Jan.2001, pg.63

      

    Objective: To determine the predictive role of preoperative semen analysis on both seminal improvement and pregnancy rates following varicocelectomy

     

    Design: Retrospective data analysis.

     

    Patients: One hundred ten consecutive patients who underwent varicocelectomies. Seminal improvement data were available for 84 patients, and pregnancy data were available for 58
    patients.

     

    Interventions: Stratification of patients based on preoperative total motile sperm count (TM). Varicocelectomy was performed on all patients.

     

    Main Outcome Measures: TMs, pregnancy rates, and conception techniques following varicocelectomy of each preoperative group.

     

    Results: Men with mild to moderate oligoasthenospermia (TM > 5 million) had significantly better seminal improvement following varicocelectomy. While preoperative stratification showed no difference in pregnancy rates (when assisted reproductive techniques were included), men who achieved a postoperative TM > 20 million were more likely to achieve conception by less invasive techniques (natural and intrauterine insemination vs. in vitro fertilization
    [IVF])

     

    Conclusions: Varicocelectomy may be the most cost-effective initial intervention in males with TM>5 million. Patients with TM <5 million and concomitant female factor infertility may be better initial candidates for
    IVF.

      

  • R.P. Dickey, S.N. Taylor, et al (The Fertility Institute of New Orleans, Louisiana)

    Relationship of follicle numbers and estradiol levels to mulitple implantation in 3,608 intrauterine insemination cycles.

    Fert.& Ster. Vol.75(1), Jan.2001, pg. 69-78

     

    Objective: To determine the relationship of follicle numbers and estradiol (E2) levels to multiple implantations in human menopausal gonadotropin (hMG) and clomiphene citrate (CC) cycles.

     

    Design: Fifteen-year prospective study.

     

    Patients: Women who underwent 3608 cycels of husband or donor intrauterine insemination
    (IUI).

     

    Results: Triplet and higher-order implantations – but not twin implantations – were related to age, E2 levels and number of follicles ³ 12mm and ³ 15mm, but not number of follicles ³ 18mm, in hMG and CC+hMG cycles. For patients less than 35 years old, three or more implantations tripled when six or more follicles were ³12mm, in CC, hMG, and CC+hMG cycles, and when E2 was ³ 1000 pg mL in hMG and CC+hMG cycles. For patients 35 or older pregnancy rates in hMG and CC+hMG cycles doubled when six or more follicles were ³ 12mm, or E2 levels were >1000pg mL, whereas 3 or more implantations were not significantly increased.

     

    Conclusions: Withholding hCG or IUI in CC, hMG, and CC+hMG cycles when six or more follicles are ³ 12mm may reduce triplet and higher-order implantations by 67% without significantly reducing pregnancy rates for patients under 35 years of age.

      

  • M Aboulghar, R Mansour, G.Serour et al (The Egyptian IVF-ET Center, Maadi, Cairo, Egypt).

    Controlled ovarian hyperstimulation and intrauterine insemination for treatment of unexplained infertility should be limited to a maximum of three trials.

    Fert.& Ster. Vol.75(1), Jan.2001, pg.88

     

    Objective: To investigate the opitmum number of cycles of controlled ovarina hypertstimulation and intrauterine insemination in the treatment of unexplained infertility.

     

    Design: Observational prospective study.

     

    Setting: In vitro fertilization embryo transfer center

     

    Patients: Five hundred ninety-four couples with unexplained infertility

     

    Interventions: Controlled ovarian hyperstimulation (COH), intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection
    (ICSI).

     

    Conclusions: In unexplained infertiity, the cycle fecundity in the first three trials of COH and IUI was higher than in cycles 4-6, with a statisically significant difference. Patients should be offered IVF or ICSI if they fail to conceive after three trials of COH and
    IUI.

       

  • Bolumar F, and the European Study Group on Infertility and Subfecundity (Univ Miguel Hernandez, Alicante, Spain; et al)

    Body Mass Index and Delayed Conception: A European Multicenter Study on Infertility and Subfecundity

    Am J Epidemiol 151: 1072-1079, 2000

       

    Introduction: Subfertility, which is defined as the inability to conceive after 9.5 months of unprotected intercourse.

       

    Results: An increased risk of delayed conception was also observed among women whose BMI was less than 20 kg/m2. The adjusted fecundability ratio was 0.52 for female smokers whose BMI was 30 kg/m2 or greater. After adjustment for risk factors, 47% of women who were obese and 19% of lean women needed over 12 months to conceive, compared with 12% of normal-weight women.

        

  • Behre HM, Kuhlage J, et al (Inst of Reproductive Medicine of the Univ, Munster, Germany)

    Prediction of Ovulation by Urinary Hormone Measurements With the Home Use ClearPlanâ Fertility Monitor: Comparison With Transvaginal Ultrasound Scans and Serum Hormone Measurements

    Hum Reprod 15: 2478-2482, 2000

      

    Methods: Data on a total of 149 cycles were analyzed.

      

    Findings: During the 2 days of CPFM peak fertility, ovulation was detected in 91.1% of the cycles. In none of the cycles did ovulation occur before CPFM peak fertility or the serum LH surge day.

      

    Editor’s Comments: The home urinary test to predict ovulation described in this report measures both estrone glucuronide and
    LH.

        

  • Jeanty P, Besnard S, et al (Women’s Health Alliance, Nashville, Tenn)

    Air-Contrast Sonohysterography as a First Step Assessment of Tubal Patency

    J Ultrasound Med 19: 519-527, 2000

      

    Methods: Air-contrast sonohysterography was performed to assess tubal patency in 114 women with infertility.

      

    Results: Cervical stenosis prevented introduction of the balloon catheter in 5 patients. Air-contrast sonohysterographic and laparoscopic assessments of tubal patency agreed in 17 patent tubes and in 6 closed or nonvisualized tubes.

       

    Conclusion: Air-contrast sonohysterography is a comfortable, safe, rapid, and accurate first-line procedure for assessing tubal patency in women with infertility. The procedure was comfortable even for patients with closed tubes, as the air simply refluxed around the balloon catheter. (With hysterosalpingography, the resistance to pushing the piston of the syringe is greatly increased when tubes are closed, and this increased pressure is painful.) Additionally, air-contrast sonohysterography can identify other uterine abnormalities, such as synechiae, polyps, and endoluminal fibroids.

         

      



 

 

Speciality Spotlight

 

 

Infertility
   
   

  • Effective of the Postcoital Test: Randomised Controlled Trial
    SG Oei, et al ( Saint Joseph Hosp, Veldhoven, The Netherlands; Leiden Univ. Med Ctr, The Netherlands; Flinders University of South Australia, Adelaide) BMJ 317: 502-505, 1998.
       
    Background – Observational studies have shown that the diagnostic and prognostic power of the postcoital test (PCT) is limited, as is its ability to assess and treat cervical hostility to sperm. Infertility investigations, with and without the PCT, were compared to determine the usefulness of such testing in routine fertility evaluations.
        
    Conclusions – The PCT does not appear to be essential in standard infertility evaluations. The use of tests that appear to be unnecessary and that offer little chance of changing the scope of diagnostic possibilities needs to be re-examined.
        
    The treatment of infertile couples with poor PCT findings is the same as that of infertile couples with unexplained infertility. In both groups, controlled ovarian hyperstimulation followed by intrauterine insemination is performed to increase the chance of conception. Infertile couples in which the female partner ovulates and has patent oviducts and the male partner has sufficient sperm to fertilize an egg are treated with controlled ovarian hyperstimulation and intrauterine insemination, whether they have a normal or abnormal PCT. Therefore, as shown in this study, it is no longer necessary to perform the PCT as part of the diagnostic evaluation of the infertile couple because pregnancy rates are the same whether or not the test is performed.
       

  • SR Lincoln, et al (Univ of Tenessee, Memphis) 
    Screening for Hypothyroidism in Infertile women
    J Reprod Med 44: 455-457, 1999.
       
    Background – Previous research has suggested that infertility is closely associated with hypothyroidism. However, the incidence of hypothyroidism in infertile women is estimated to be less than 1%, and many clinicians question the value of including routine screening for hypothyroidism as part of the infertility assessment. The frequency of increased thyroid stimulating hormone (TSH) in patients with a history of infertility seen at reproductive endocrinology and infertility centers was investigated.
       
    Conclusions – The prevalence of increased TSH was 2.3% in this group of women with infertility of at least 1 year’s duration. Most women with a diagnosis of hypothyroidism had ovulatory dysfunction. When their hypothyroidism was treated, 64% were able to become pregnant. Thus infertile women with ovulatory dysfunction should be screened for hypothyroidism.
        
    Many clinicians measure TSH and prolactin levels in all women with a history of infertility who wish to conceive in this study, fewer than 1% of infertile women with normal ovulatory cycles had an elevated TSH level. None of these women conceived after being treated with levothyroxine. However, 7 of 11 women with evidence of ovulatory dysfunction and elevated TSH levels conceived after being treated with levothyroxine. Thus, it appears cost-effective to measure TSH levels in infertile women without regular ovulatory cycles so as to detect and treat subclinical hypothyroidism. 
       
    The benefit of measuring TSH, as well as prolactin, in infertile women with regular ovulatory cycles remain to be established. If either of these assays is abnormal in women with regular ovulatory menstrual cycles, treatment with bromocriptine or levothyroixne has not been shown to improve fecundity.
       

  • Efficacy of Treatment for Unexplained Infertility
    DS Guzick, et al (Univ of Rochester, NY; State Univ of New York, Buffalo; Fertility Physicians of Northern California, Palo Alto; et al ) Fertil Steril 70: 207-213, 1998.
       
    Clomiphene citrate (CC) plus IUI is a cost-effective treatment for couples with unexplained infertility. If this approach fails, effective treatment options are hMG plus IUI and assisted reproduction.
       
    This review of the literature regarding various methods of therapy for unexplained infertility provides very useful data. The number of pregnancies per cycle compared with expectant management is increased several-fold with the use of CC plus IUI of separated sperm. A higher pregnancy rate can be achieved with the use of hMG plus IUI, but the cost of therapy is also increased. Complications with the use of hMG are greater than with CC and the former also requires frequent sonographic and hormonal monitoring to prevent hyperstimulation. Thus, it seems appropriate to treat unexplained infertility initially with CC and IUI, if the woman is younger than age 40. Such therapy can be performed in the office of most gynecologists without extensive monitoring. If pregnancy fails to occur after 4 to 6 treatment cycles, the couple may be referred for treatment with hMG plus IUI or IVF.
       

  • DS Guzick, for the National Cooperative Reproductive Medicine Network (Univ of Rochester, NY; et al ) Efficacy of Superovulation and Intrauterine Insemination in the treatment of Infertility.
    N Engl J Med 340:177-183, 1999
        
    Both superovulation and intrauterine insemination are often used to treat infertility. A large, randomized, controlled clinical trial compared the efficacy of these 2 methods of treating infertility.
       
    Conclusion : For achieving pregnancy in infertile couples in which the women had no identifiable infertility factor and the man had motile sperm, the combination of superovulation and intrauterine insemination was superior to either technique alone and to intracervical insemination. The pregnancy rate for the combination of these 2 techniques was 33%.
        
    The results of this prospective randomzied clinical trial indicate that treatment of unexplained infertility with superovulation and intrauterine insemination yields a significantly higher pregnancy rate than doses intracervical insemination with or without superovulation. The pregnancy rate per treatment cycle with superovulation and intrauterine insemination was 9% in this study. With 4 treatment cycles, one third of the couples receiving this treatment regimen conceived. Unfortunately 20% of the pregnancies occurring after use of hMG were multiple gestations. The cost of superovulation and intrauterine insemination is substantially less than in vitro fertilization. 
       

  • Intrauterine Insemination Treatment in Subfertility: An analysis of factors affecting outcome.
    S Nuojua-Huttunen, et al (Oulu Infertility Clinic, Finland; Oulu Univ Hosp, Finland.; Univ of Oulu, Finland)
    Hum Reprod 14: 698-703, 1999
        
    Conclusions – Clomiphene citrate human menopausal gonadotrophin/IUI is effective and cost-efficient for selected patients with subfertility. This approach is most beneficial for women younger than 40 years, with infertility 6 years or less in duration, who do not have endometriosis.
        
    Controlled ovarian stimulation (COH) followed by IUI of the partner’s sperm is an effective method of treating the couple with unexplained infertility. The results of this study indicate that prognostic factors for a successful outcome of COH and IUI include female age younger than 40 years, duration of infertility less than 6 years, and no known cause of infertility. In addition, the pregnancy rate was about 3-fold higher if 2 or more follicles more than 16mm in diameter were present at the time of human chorionic gonadotrophin administration than if there was only a single preovulatory follicle. If each of these factors is present, the pregnancy rate per treatment cycle of COH and IUI is about 15%.
       

  • MM Biljan, et al (McGill Univ, Montreal). 
    Prospective Randomized Double-blind Trial of the Correlation between Time of Administration and Antiestrogenic Effects of Clomiphene Citrate on Reproductive End Organs.
    Fertil Steril 71:633-638, 1999
       
    Authors have studied twenty three women with unexplained infertility and 45 cycles of clomiphene citrate and intrauterine insemination.
       
    In the group receiving the drug in the first 5 days, the gonadotropins and E2 levels, as well as uterine artery pulsatility index, were significantly higher than in the control group.
        
    The authors conclude that more rapid follicular growth, a longer clomiphene citrate-free period before intrauterine insemination, and higher pregnancy rates resulted with clomiphene citrate begun on day 1 of the menstral cycle rather than on day 5.
       
    Jr. Mishell comments that a small prospective randomised trial does shows that results are best when the treatment is started on day 1 of the cycle.
       
    This result shows that additional randomized trials need to be performed to allow clinicians to decide the optimal treatment regimen for unexplained infertility.
       

  • American Society for Reproductive Medicien (Birmingham, Ala Assisted Reproductive Technology in the United States: 1996 Results Generated from the American Soceity for Reproductive Medicine/Society for Assisted Reproductive Technology Registry. 
    Fertile Steril 71:798-807, 1999
        
    A total of 65863 cycles of ART treatment were initiated in 1996. Of these, it was found that in vitro fertilisation (IVF) with 26% pregnancy per retrieval, gamete intrafallopian transfer with 29% deliveries per retrieval, zygote intrafallopian transfer with 30.9% deliveries per retrieval. In addition it was found that after embryo transfer, pregnancy rate of 16.8% deliveries per transfer with donor oocyte cycles it was 39.1% deliveries per transfer and from cryopreserved embroys the overall success rate was 20.8% and surrogative uterus 31.3% of deliveries per embryo transfer. This information should be made available to all infertile couples considering the use of assisted reproduction.
       

  • Human Chorionic Gonadotrophin Concentrations in Early Pregnancy After In-Vitro Fertilization.
    S Bjercke, et al (Rikshospitalet, Oslo, Norway)
    Hum Reprod 14:1642-1646, 1999
        
    Authors conclude that a discriminatory HCG value on day 12 after IVF and embryo transfer cycles may be useful for predicting pregnancy outcomes. This marker may help clinicians identify at-risk pregnancies and implement a more intensive surveillance policy in this population.
       
    Editorial comments by Jr.D.R.Mishell: When the HCG level in this study was more than 55 IU/L, there was a 90% chance of having a viable pregnancy. When the level was less than 55 IU/L, 60% of the pregnancies in this study did not reach viability. Clinicians who perform IVF may wish to measure HCG 12 days after embryo transfer so as to provide women with a rough prognosis of having a viable pregnancy before the gestational age when the more sensitive parameters of fetal viability using sonographic imaging can be performed.
       

  • A Randomized comparison of the Method of Sperm Preparation for IUI.
    Dodson W.C. et atl (Univ Hosp. Hershey, Philadelphia)
    Fertil steril 70:574-575, 1998
       
    Authors found that despite differences in sperm recovery, no method of sperm preparation provided better cycle fecundity than the others. In multiple tube swim-up specimens, the percentage recovery of sperm was lower. The double centrifugation preparation had the lowest percentage of normal forms. The treatment groups did not differ in cycle fecundity.
         

  • F Parazzini, for the Gruppo Italiano per lo Studio dell’Endometriosi (Universita di Milano, Milano, Italy et al) 
    Ablation of Lesions or
    No Treatmetn in Minimal-Mild Endometriosis in Infertile Women : A Randomized Trial
    Hum Reprod 14:1332-1334, 1999.
       
    The results of this randomized controlled trial differ from that reported by a Canadian group. In the Canadian randomized trial, surgical treatment of minimal to mild endometriosis resulted in a significantly higher pregnancy rate than occurred in those women who had only a diagnostic laparoscopy. Other studies comparing surgical treatment of minimal or mild endometriosis with no treatment or treatment with danazol also reported conflicting results, with some showing a benefit with respect to fertility and other showing no benefits. Because the effects of surgical treatment of minimal to mild endometriosis on fertility are inconsistent, support for such treatment remains weak.
       

  • M Rubinstein, et al (CERT Med Inst, Buenos Aires, Argentina) Low-Dose Aspirin Treatment Improves Ovarian Responsiveness, Uterine and Ovarian Blood Flow Velocity, Implantation, and Pregnancy Rates in Patients Undergoing In Vitro Fertilization: A Prospective, Randomized, Double-blind placebo-controlled assay.
    Fertil Steril 71:825-829, 1999
        
    It was found that low dose aspirin treatmetn significantly improved the number of follicles, number of oocytes retrieved, serum E2 levels on the day of human chorionic gonadotropin administration, implantation rate, and pregnancy rate in patients undergoing IVF. 
        

  • In-Vitro Fertilization Treatment for Severe Male Factor: The Fertilization Potential of Immotile Spermatozoa Obtained by Testicular Extraction.
    A Shulman, et al (Chaim Sheba Med Ctr, tel Hashomer, Israel).
    Hum Reprod 14:749-752, 1999.
        
    Authors conclude that immotile testicular spermatozoa recently released from the Sertoli cells can effectively fertilize mature oocytes, producing a normal pregnancy. Testicular sperm retrieval is recommended for patients with totally immotile spermatozoa from the ejaculate. However, if all available spermatozoa are still immotile, those retrieved from the testes should be injected.
        

  • Fertilization and Pregnancy Outcome with Intracytoplasmic Sperm Injection for Azoospermic Men.
    GD Palermo, et al (New York Hosp-Cornell Med Ctr; Population Council, New York) 
    Hum Reprod 14:741-748, 1999.
        
    Spermatozoa retrieval was done by microsurgical epididymal aspiration or testicular biopsy.
        
    Conclusions : Fertilization and pregnancy rates with epididymal spermatozoa were greater in the partners of men with obstructive azoospermia than in those of men with nonobstructive azoospermia, in whom spermatozoa were obtained from the testes. The current findings also indicate that cryopreservation can be used routinely for subsequent pregnancy attempts in the partners of men with obstructive azoospermia.
       

  • Live Birth From a Zygote Cryopreserved for 8 Years
    KJ Go, et al (Pennsylvania Hosp, Philadelphia)
    Hum Reprod 13:2970-2971, 1998.
       
    Authors have reported normal pregnancy after thawing embryo cryoprserved for 8 years.
       
    Editorial comments : There are no studies to determine the maximum duration of time that a human embryo may be frozen and then develop normally after thawing and uterine transfer. In several countries, legislation limits the duration of time that cryopreserved embryos can be maintained before they are discarded. In the United Kingdom, this time limit is 5 years. This case report questions the need for these arbitrary limits on duration of frozen embryo storage.
        

  • Trends in Contraceptive Use in the United States: 1982-1995
    LJ Piccinino, et al (Natl Ctr for heatlh Statistics, Hyattsville, Md) 
    Fam Plann Perspect 30:4-10 &46, 1998.
        
    Editorial comments: Nationwide surveys of contraceptive use in the United States are performed periodically with the planning and funding of US government agencies. Surveys were performed in1982, 88, and 95, and this study summarizes the changes that have occurred with contraceptive use during these years. Between 1982 and 1995, the use of contraceptives by women of reproductive age increased so that, in 1995, only about 5% of women who were sexually active and not wishing to conceive were using no method of contraception. Sterilization is the most common method of pregnancy prevention in the United States followed by use of oral contraceptives and the male condom. Use of the condom has increased markedly in the United States during this period. Relatively few women use each of 3 very effective methods, the IUD, progestin injections, and progestin implants. Less than 1 million women used each of these methods in 1995.
         

  • P F Kaplan, D J Austin and R Freund 
    Subcutaneous human menopausal gonadotropin administration for controlled ovarian hyperstimulation with intrauterine insemination cycles.
    Am J Obstet Gynecol 2000; 182:1421-6
       
    Objective : This study was undertaken to determine the feasibility of administering human menopausal gonadotropin subcutaneously for controlled ovarian hyperstimulation with intrauterine insemination.
           
    Study Design: This was a prospective nonrandomized matched group comparison. Study patients undergoing controlled ovarian hyperstimulation with intrauterine insemination infertility treatment between June 1998 and March 1999 self-administered human menopausal gonadotropin subcutaneously for ovulation induction. Cycles were analyzed for duration of human menopausal gonadotropin treatment, total number of ampules of human menopausal gonadotropin used, peak serum estradiol level, number of mature follicles (=15mm), cycle fecundity, and acceptability of the subcutaneous route of human menopausal gonadotropin administration. Age-matched historical control subjects who followed the same protocol except of the route of human menopausal gonadotropin administration, which was instead intramuscular, were used for comparison.
         
    Results: Study and control cycles did not differ with respect to duration of human menopausal gonadotropin treatment, total number of ampules of human menopausal gonadotropin used, peak serum estradiol level, number of mature follicles or cycle fecundity rate. Two study patients were switched from subcutaneous to intramuscular administration because of minor local injection site reactions.
       
    Conclusion: Subcutaneous human menopausal gonadotropin administration for controlled ovarian hyperstimulation with intrauterine insemination treatment cycles was generally well tolerated and yielded stimulation parameters and pregnancy rates similar to those associated with the intramuscular route. Patients subjectively preferred subcutaneous human menopausal gonadotropin administration because of the ability to self-administer the injections, the use of a smaller injection needle, and reduced muscular pain at the injection site.
         

  • M. Fujisawa, T. Shirakawa, et al (Division of Urology, Department of Organ Therapeutics, et al)
    Y-Chromosome Microdeletion and Phenotype in Cytogenetically Normal Men With Idiopathic Azoospermia
    Fertil Steril, September 2001; Vol. 76(3): 491-5
           
    Objective : To determine the prevalence of microdeletions of the long arm of chromosome Y within the AZFa, AZFb, and AZFc subregions in patients with idiopathic azoospermia, and then correlate the microdeletions with clinical phenotypes to determine the most important subregion for screening.
           
    Patient(s) : Among 89 consecutive azoospermic patients, those whose infertility was related to known hereditary, endocrine, or obstructive causes or a cytogenetic abnormality were excluded; 54 remaining patients were studied using a polymerase chain reaction (PCR).
          
    Of these patients, 33 had Sertoli cell only syndrome, 10 had maturation arrest, and 11 had hypospermatogenesis.
          
    Conclusion(s) : Cytogenetically azoospermic patients should be examined for microdeletions before undertaking assisted reproduction. AZFc may be the most important subregion to screen.
          
    In addition, intact AZFa and AZFb subregions may be important for the presence of germ cells.
          

  • R. Luboshitzky, G. Qupti, et al (Endocrine Institute, Haemek Medical Center, et al)
    Increased 6-Sulfatoxymelatonin Excretion in Women with Polycystic Ovary Syndrome
    Fertil Steril, September 2001; Vol. 76(3): 506-10
            
    Objective : To determine melatonin production in hyperandrogenic women.
            
    Design : Controlled prospective study.
           
    Setting : Outpatients in an academic medical center.
           
    Patient(s) : Twenty-two women with polycystic ovary syndrome (PCOS), 20 women with idiopathic hirsutism, and 15 age-matched individuals who had similar body mass indexes as controls.
           
    Intervention(s) : Fasting blood samples and 24-hour urinary samples were obtained from all participants.
           
    Main Outcome Measure(s) : All participants provided serum samples for the measurement of LH, FSH, testosterone, E2, DHEAS, 17 a-hydroxyprogesterone (17-OHP), and insulin levels, as well as urinary 6-sulfatoxymelatonin (aMT6s).
            
    Result(s) : Women with PCOS had higher aMT6s, testosterone, LH/FSH ratio, and insulin values than either women with idiopathic hirsutism or control women. Testosterone inversely correlated with aMT6s in PCOS. Regression analysis revealed that only testosterone was an important determinant of aMT6s in PCOS.
            
    Conclusion(s) : Women with PCOS have increased melatonin production.
            
    Comments : Because hyperinsulinemia has been suggested to play a role in the pathogenesis of androgen excess in PCOS (19, 20), insulin should be considered as a potential candidate involved in the modulation of melatonin in PCOS.
             
    Insulin was shown to stimulate androgen synthesis in ovarian thecal cells, decrease free androgen levels, and potentiate ACTH-stimulated adrenal androgens (20).
          
    In conclusion, women with ovarian hyperandorgenism have increased melatonin production, whereas melatonin secretion is normal in women who are hyperandorgenic due to idiopathic hirsutism.
            

  • T. Mukaida, S. Nakamura, et al (Hiroshima HART Clinic, Hiroshima, and Osaka HART Clinic, Osaka, Japan)
    Successful Birth After Transfer of Vitrified Human Blastocysts With Use of a Cryoloop Containerless Technique
    Fertil Steril, September 2001, Vol. 76(3) pg. 618-20
           
    Objective : Clinical application of vitrification for the cryopreservation of human blastocysts.
           
    Design : Clinical trial of vitrification of human blastocysts.
           
    Setting : Private assisted reproductive technology clinic.
           
    Patient(s) : Supernumerary blastocysts after fresh blastocyst transfer were vitrified for subsequent transfer.
          
    Intervention(s) : Culture of pronuclear embryos to the blastocyst stage in sequential media and subsequent vitrification of supernumerary blastocysts using a cryoloop technique 
            
    Main Outcome Measure(s) : Clinical outcome after transfer of vitrified blastocysts.
           
    Result(s): A total of 60 vitrified blastocysts from 21 patients were warmed, and the survival rate at 2 hours after warming was 63%. Six clinical pregnancies were achieved after 19 transfers. One healthy baby was born, four pregnancies are ongoing, and one ended in miscarriage.
           
    Conclusion(s) : Human blastocysts can be successfully vitrified by suspension on a small nylon loop and a direct plunge into liquid nitrogen. A delivery and ongoing pregnancies prove the safety of this method. This report documents the first successful pregnancy and delivery achieved by blastocyst vitrification using the cryoloop containerless technique.
           
    Comments : Vitrification would be a preferred method of cryopreservation to the slow-cooling method because of the lack of ice crystal formation and handiness. The authors have already reported a simple vitrification method using an ethylene glycol-based solution for four-to eight-cell human embryos frozen in conventional cryostraws. 
           
    Moreover the success of vitrification procedures has recently been increased by techniques that substantially reduce the volume of vitrification solution. Among such techniques, the cryoloop must be a most refined strategy. 
            
    A major difference between the cryoloop and the conventional straw for vitrification is the cooling and warming rate. The cryoloop enables ultrarapid cooling and warming. In the present study, this may have prevented intracellular ice formation because the authors have observed that human blastocysts are dehydrated and concentrated more slowly than earlier stage embryos, suggesting that intracellular ice is more likely to form. Furthermore, the technique using the cryoloop is easier and simpler than that using the cryostraw.
            
    With the development of sequential culture media, based upon the physiology of the human reproductive tract and the changing physiology of the developing of the developing embryos, it is possible to grow viable blastocysts easily in vitro. Because of the resulting high implantation rates, blastocyst transfer will be a reliable approach in ART. In this report, the authors have shown for the first time that vitrification using the cryoloop is a clinically useful method for the cryopreservation of human blastocysts.
            

  • Richard J Paulson, Robert C Milligan and Rebecca Z Sokol (Los Angeles, California)
    The lack of influence of age on male fertility.
    Am J Obstet Gynecol, 2001; 184: 818-24
     
    Objective: This study was undertaken to determine the effect of male aging on sperm quality as determined by semen analysis, the fertilization rate of human oocytes in vitro, and live birth rates.
     
    Study Design: Retrospective analysis correlating outcome measures with male age was performed for 558 oocyte donation cycles in 441 couples. The oocyte donation model was chosen because it controls for oocyte quality and endometrial receptivity, which allows variations in sperm quality as a function of male age to be the only dependent variable. Outcome measures analyzed were semen analysis, fertilization rates in vitro, pregnancy rates, live birth rates, and cumulative live birth rates by life-table analysis.
     
    Results: There was a negative correlation between male age and total sperm count, but there was no correlation between male age and any of the other parameters in the semen analysis. There was no association between male age and the fertilization rate of donated oocytes in vitro, pregnancy rates, or live birth rates. Recipient couples were grouped by quartiles of male age, and cumulative live birth rates were the same in the 4 groups.
     
    Conclusion: Whereas male aging is associated with a significant decline in total sperm count, this change is not reflected in a decreased fertilization rate or a decreased live birth rate in the oocyte donation model.          
                                       

  • Marsha J gorrill, Karen Sadler-Fredd, et al   
    Multiple gestations in assisted reproductive technology: Can they be avoided with blastocyst transfers?     
    Am J Obstet Gynecol, June 2001; 184: 1471-7                    
                                                              
    Objective: Blastocysts are advanced-stage embryos with high implantation potential; theoretically, limited numbers of blastocysts can be used for embryo transfer to achieve good pregnancy rates with low multiple pregnancy rates. Clinical outcomes of a   newly implemented blastocyst transfer program were evaluated.                         
                                                                          
    Study Design: This study is a retrospective analysis of 553 blastocyst transfer cycles performed by a university-based in vitro    fertilization program; risk factors associated with multiple gestations were analyzed.                                
                                                        
    Results : An average of 2.2 embryos were used for embryo transfer. The overall clinical pregnancy rate per embryo transfer was 45.1%; multiple gestation, twin and triplet rates were 40.9%, 36.5%, and 4.3%, respectively. Multiple gestations increased    significantly (1) when embryo transfer was done on day 5, (2) when ³2 blastocysts were present on day 5, and (3) when maternal age was £ 30 years.                                                         
                                           
    Conclusion: In spite of a conservative approach to the number of blastocysts used for embryo transfer, the overall multiple     pregnancy rate was high, and triplet pregnancies did occur.             
              

  • Hillary Klonoff-Cohen, Elaine Chu, Loki Natarajan and William Sieber   
    A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer.         
    Fert. & Ster. Vol.76(4), October 2001, pg.675-87.          
                                        
    Objective: To evaluate whether baseline or procedural stress during in vitro fertilizaiton (IVF) or gamete intrafallopian transfer (GIFT) affects pregnancy or live birth delivery rates.        
                              
    Patients: One hundred and fifty-one women completed two questionnaires.          
                                  
    Discussion: Psychological stress may diminish success rates, possibly by one of the following mechanisms: hypothalamus dysfunction either by neurotransmitting alterations, catecholamine depletion, or interference with hypothalamic receptors for neurotransmitters. The exact mechanism by which stress interferes with the hypothalamus-pituitary-gonadal reaction is not clearly understood. Progesterone and cortisol, the neuroendocrine correlates of stress, may provide potential pathways through which stress could affect IVF outcome. Future studies should measure the plasma and follicular levels of stress hormones such as prolactin and cortisol to clarify the role of these hormonal mechanisms, to determine the neuroendocrine and physiologic pathways that could meditate an effect on reproductive outcomes (decreased numbers of oocytes, poor quality of embryo).
                                         
    This research determined that success rates for IVF or GIFT may, in part, be affected by psychological stress that results in disruption of the reproductive function. Clinicians and women can now identify which stage(s) in the IVF and GIFT attempt are important; it appears that the baseline (rather than during the procedure) is the most critical time for monitoring and decreasing stress levels. This can possibly be achieved through counseling, support groups, educational booklets, handouts and suggested readings.               
                                                                         

  • Annette Kaushce, Gayle M Jones, et al       
    Sex ratio and birth weights of infants born as a result of blastocyst transfers compared with early cleavage stage embryo transfers. 
    Fert.& Ster., vol.76(4), Oct.2001,pg.688-93        
             
    Objective: To analyze the birth weights and sex ratio of infants born as a result of blastocyst transfer and compare them with data resulting from the transfer of early-cleavage stage embryos.        
                     
    Design: Retrospective analsysis.        
                     
    Setting: Monash IVF (private in vitro fertilization clinic).     
                         
    Patient(s): One hundred twenty five infertile patients who became pregnant after IVF procedures involving blastocyst transfer. 
                           
    Conclusion(s): There is no evidence of abnormal fetal growth or a shift in the sex ration for infants born as a result of blastocyst transfer when compared with the case of births resulting from early cleavage stage embryo transfers within our unit or all other assisted conception units in Australia and New Zealand.                          
                                                                                                                                                         

  • Sharon A Kidd, Brenda Eskenazi, et al                     
    Effects of male age on semen quality and fertility: a review of the literature                  
    Fert. & Ster., vol.75(2), Feb.2001, pg.237                          
                                                                
    Objective: To review the literature on the association between male age and semen quality (semen volume, concentration, motility and morphology) and fertility status (pregnancy rate and time to pregnancy/subfecundity).       
                                                                       
    Methods : Review of English language-published research over the last 20 years from January 1, 1980, through December 31, 1999, using MEDLINE and Biosis databases. Studies with insufficient numbers of subjects, case reports, case series, or anecdotal data were excluded.                                                
                                                                                    
    Conclusion: The weight of the evidence suggests that increased male age is associated with a decline in semen volume, sperm motility and sperm morphology but not with sperm concentration.       
                                                                                                                                                       

  • Lynn M Wallock, Tsunenobu Tamura, et al 
    Low seminal plasma folate concentrations are associated with low sperm density and count in male smokers and nonsmokers.         
    Fert. & Ster., vol.75(2), Feb.2001, pg.252         
                                    
    Total seminal plasma folate concentrations were on average 1.5 times higher than blood plasma folate concentrations in all men. Seminal plasma non-methlytetrahydrofolate levels correlated significantly with sperm density and total sperm count. Seminal plasma of smokers contained a proportionally lower concentration of non-methyltetrahydrofolate compared with nonsmokers.
                        
    Seminal plasma total folate and 5-methyltetrahydrofolate concentrations reflect folate nutriture. The non-methyltetrahydrofolate fraction of seminal plasma may be important for male reproduction function.  
                              
    Folates in the seminal fluid appear to be important for normal reproductive functioning.                           
                                                                             

  • Philip F Brook, John A Radford, et al
    Isolation of germ cells from human testicular tissue for low temperature storage and autotrnsplantation.
    Fert & Ster, vol.75(2), Feb,2001, pg. 269-74        
                        
    Objective: To develop a new protocol for conserving fertile potential in men undergoing sterilizing chemotherapy by low temperature banking of germ cells which can be returned to the patient’s testes after thawing.  
                         
    Design: Isolation of human and murine germ cells for comparing cellular viability after cooling to liquid nitrogen temperatures by the use of different cryoprotective agents and for infusion into the testis.               
                                          
    After isolation using a two-step enzymatic disaggregation protocol, 66% to 87% of germ cells from human and murine specimens, respectively, were still viable. Cell survival was similar in four commonly used cryoprotective agents after cooling to liquid nitrogen temperatures. Semniferous tubules infused by back flow with dye solution via the rete testis were filled with an efficiency of 55%.
                                                         

  • Mohammed F M Mitwally and Robert F Casper                   
    Use of an aromatase inhibitor for induction of ovulation in patients with an inadequate response to clomiphene citrate                 
    Fert & Sterl. Vol.75(2), Feb.2001, pg.305-9       
                     
    Objective : To use aromatase inhibition for induction of ovulation in women in whom clomiphene citrate (CC) treatment was unsuccessful.                 
                                              
    Two tertiary-referral infertility clinics associated with the Division of Reproductive Sciences, University of Toronto.   
                                  
    Patients: Twelve patients with anovulatory polycsytic ovary syndrome (PCOS) and 10 patients with ovulatory infertility, all of whom had previously received CC with an inadequate outcome (no ovulation and/or endometrial thickness of ? 0.5cm) 
                                      
    Interventions The aromatase inhibitor letrozole was given orally in a dose of 2.5mg on days 3-7 after menses.          
                                                       
    Conclusion: Oral administration of the aromatase inhibitor letrozole is effective for ovulation induction in anovulatory infertility and for increased follicle recruitment in ovulatory infertility. Letrozole appears to avoid the unfavourable effects on the endometrium frequently seen with antiestrogen use for ovulation induction.                                     
                                                                                                    
    In women with World Health Organization type II anovulatory infertility, the treatment of first choice for the induction of ovulation is an antiestrogen, most commonly clomiphene citrate (CC). However, 20% -25% of women are resistant to CC and do not ovulate. In addition, clinical data have revealed a discrepancy between ovulation and conception rates during CC treatment and a higher than expected incidence of miscarriage in conception cycles. These observations have been attributed to the antiestrogenic mechanism of action of CC, which involves long-lasting estrogen receptor (ER) depletion. It also appears that CC accumulates in the body because of its long half-life. As a result, CC may have a negative effect on the quality and quantity of cervical mucus, on endometrial development, and on other as yet undetermined fertility factors.      
                                                     

  • David t Vandermolen, Valerie S Ratts, et al       
    Metformin increases the ovulatory rate and pregnancy rate from clomiphene citrate in patients with   polycystic ovary syndrome who are resistant to clomiphene citrate alone.   
    Fert.&Ster. Vol.75(2), Feb.2001, gp.310  
                                 
    Participants received placebo or metformin 500mg three times daily, for 7 weeks. Information on reproductive steroids, gonadotropins, and oral glucose tolerance testing was obtained at baseline and after treatment. Metformin or placebo was continued and CC treatment was begun at 50mg daily for 5 days. Serum P level ? 4ng/mL was considered to indicate ovulation. With ovulation, the daily CC dose was not changed, but with anovulation it was increased by 50mg for the next cycle. Patients completed the study when they had had six ovulatory cycles, became pregnant, or experienced anovulation while receiving 150mg of CC.           
                          
    Results : In the metformin and placebo groups, 9 of 12 participants (75%) and 4 of 15 participants (27%) ovulated, and 6 of 11 participants (55%) and 1 of 14 participants (7%) conceived, respectively. Comparisons between the groups were significant.
                                      
    Conclusion : In anovulatory women with PCOS who are resistant to CC, metformin use significantly increased the ovulation rate and pregnancy rate from CC treatment.           
                                                                                        
    In addition to increased ovulatory response, women who received metformin and CC had a conception rate after ovulation of 21%. This rate is consistent with normal cycle fecundity.       
                              
    75% of participants ovulated in response to CC plus, metformin.     
                                            
    Thus, our results provide a rationale for metformin and CC treatment of obese CC resistant women with PCOS before proceeding to ovulation induction with gonadotropins or to IVF-ET.                                      
                                                              

  • Uma Deve Gordon, Robert F Harrison, et al      
    A randomized prospective assessor-blind evaluation of luteinzing hormone dosage and in vitro fertilization outcome.       
    Fert & Ster. Feb. 2001, 75: 324-31 
                  
    Objective : To determine the effect of exogenous LH dosage on IVF outcome.  
                   
    Patients: Infertile normogonadotropic women undergoing their first cycle of IVF were studied. 
               
    Main Outcome Measure(s): Dose and duration of gonadotropin stimulation, follicle and oocyte numbers implantation rate, and pregnancy rate. 
                 
    Conclusions: Although the residual endogenous LH after down-regulation was adequate for ovarian response and E2 synthesis, the addition of exogenous LH improved implantation. An FSH/LH ratio of 75/75 IU per ampoule appeared to be the optimum dose.        
                               
    To date, although pregnancies have been reported in hypogonadal women treated with rhFSH and rhLH, no pregnancies have been documented with rhFSH alone in hypogonadotropic hypogonadism.  
                               
    A third explanation may be direct effect of LH on the endometrium.             
                                                                          

  • Firouz Khamsi, Yalcin Yavas, et al 
    Intracytoplasmic sperm injection increased fertilization and good-quality embryo formation in patients with non-male factor indications for in vitro fertilization: a prospective randomized study.
    Fert & Ster. Feb.2001, 75: 342-7
       
    Objective : To compare the fertilization rate and formation of good-quality embryos with conventional and ICSI in patients with non-male factor infertility.
       
    Patients: Thirty-five patients with non-male factor infertility
       
    Intervention: Retrieved sibling oocytes were randomly assigned to conventional IVF or ICSI. Of sibling oocytes assigned to ICSI, ONLY metaphase II oocytes were injected with sperm.

    Main Outcome Measures:: Fertilization rate and formation of good-quality embryos per retrieved oocyte.

    Results : Per retrieved oocyte, ICSI resulted in better fertilization rate compared with conventional IVF (17.3% [134 of 188] vs 57.2% [107 of 187]). Per retrieved oocyte, ICSI also resulted in better formation of good-quality embryos at 48 horus after retrieval compared with conventional IVF (64.4% [121 of 188] vs. 47.1% [88 of 187].
                   
    Conclusion: In IVF patients with non-male factor infertility, subjecting some sibling oocytes to ICSI increased the fertilization rate and formation of good-quality embryos per retrieved oocyte. It also avoided the problem of total fertilization failure in almost all cases.
      
    Many IVF centers have extended ICSI treatment to patients other than those with male factor infertility. These centres usually perform ICSI on some but not all of the retrieved oocytes because, based on their clinical experience, they may avoid cases of total failure of fertilization.
      
    The rate of total fertilization failure with conventional IVF was 14.3%.
      
    Regardless of the cause of infertility (excluding male factor infertility), success of IVF was more certain if half of the oocytes were subjected to ICSI.
      
    It was previously reported that the greater the diameter of the oocyte cumulus complex the better the chance of fertilization and development.
      
    Routine testing for antisperm antibodies was not performed, but it may have been relevant to fertilization with ICSI.
       
    Hardening of the zona pellucida at different stages may also be an important factor in failure of fertilization despite healthy spermatozoa. Finally, there may be problems in oocytes related to the type of ovarian stimulation and the culture conditions rather than an intrinsic abnormality of the ovaries.
      

  • Jan W.A, de Vries, Sjoerd Repping, et al 
    Absence of deleted in azoospermia (DAZ) genes in spermatozoa of infertile men with somatic DAZ deletions.
    Fert.& Ster. Vol.75, 2001, 476-9
     
    Objective: To determine the presence or absence of the deleted in azoospermia (DAZ) gene clusters in the Y-bearing spermatozoa in semen of severely oligozoospermic men or in testicular biopsy samples of azoospermic men with somatic DAZ deletions.
      
    Patients: Nineteen patients attending clinics for therapeutic intracytoplasmic injection of sperm.
     
    Intervention: Peripheral blood lymphocytes were used to obtain somatic DNA for analysis using the polymerase chain reaction. Analysis of chromosomes X and Y and the detection of the DAZ gene clusters were carried out with the fluorescence in situ hybridization technique in spermatozoa remaining after intracyclic plasmic sperm injection.
     
    Main Outcome Measures: Presence or absence of the DAZ gene clusters in matched somatic DNA and Y-bearing spermatozoa.
     
    Results: Seven patients appeared to have a somatic DAZ deletion. Three colour fluoresence in situ hybridization showed that all Y-bearing spermatozoa examined from these men carried the same deletion.
      
    Conclusion: The DAZ deletions present in the seven men would all have been transmitted if they had fathered sons through artificial fertilization techniques using the sperm cells examined in this study.
       

  • Basak Balaban, Bulent Urman, et al
    Blastocyst-stage transfer of poor-quality cleavage-stage embryos results in higher implantation rates.
    Fert.& Ster. Vol.75(3), March 2001, 75: 514-8
      
    Objective: To determine the feasibility and success of blastocyst-stage embryo transfers in patients having only fair and poor quality cleavage-stage embryos on day 3.
      
    Design: Prospective case study with historic controls.
      
    Patients: A total of 158 day 5 embryo transfer cycles in patients with grade 3 and grade 4 cleavage-stage embryos. Control group consisted of 162 day 3 transfer cycles performed with embryos of similar quality.
      
    Main Outcome Measure(s): The percentage of cycles that culminated in the transfer of at least one blastocyst and implantation and pregnancy rate related to the day of transfer.
       
    Conclusions: Transfer of fair and poor quality embryos at the blastocyst stage is feasible and is associated with higher implantation rates as compared to transfer of similar quality embryos on day 3.
       

  • Phillippe Terriou, Christophe Sapin, et al
    Embryo score is a better predictor of pregnancy than the number of transferred embryos or female age.
    Fert.&Ster. Vol.75(3), March 2001, pg.525
      
    Objective: To compare the value of 17 IVF variables, including a new mean score of transferred embryos (MSTE), in predicting pregnancy rate.
      
    Design: Retrospective study
      
    Patients: Women who underwent 10,000 embryo transfers.
    Main Outcome Measures : Duration of infertility, type of infertility , female age, rank of IVF attempt, type of ovarian treatment, progesterone level, sperm count, sperm motility, sperm morphology, number of retrieved oocytes, number of mature oocytes, maturation rate, number of embryos obtained, fertilization rate, number of transferred embryos, cumulative embryo score (CES), mean score of transferred embryos (MSTE), and pregnancy rate.
      
    Results: Outcome of IVF-ET was significantly correlated with female age, type of infertility, number of retrieved oocytes, number of mature oocytes, maturation rate, embryos obtained, fertilization rate, transferred embryos, CES, and MSTE. Multivariate analysis demonstrated that MSTE was a better predictor of pregnancy than the number of transferred embryos and female age.
       
    Conclusion: Embryo quality is the best predictor of pregnancy. The embryo score described herein should be used in IVF-ET programs to choose the best embryos for transfer.
       

  • Hongxia Li, Steven T Nakjima, et al
    Differences in hormonal characteristics of conceptive versus nonceptive menstrual cycels.
    Fert.&Ster. Vol.7r5(3), March 2001, pg. 549
      
    Objective: To determine the hormonal characteristics of a fecund menstrual cycle.

    Design: Prospective observational study.
       
    Setting: Clinical research center.
      
    Results: The mean peak value of periovulatory urinary FSH was significantly higher in conceptive cycles than in nonconceptive cycles. The mean serum E2 concentration was significantly higher on day 0 (day of peak urinary FSH concentration) in conceptive cycles than in nonconceptive cycles; but mean peak values of serum E2 did not differ significantly. No other significant differences were observed in serum and urinary hormone profiles between conceptive and nonconceptive cycles.
      
    Conclusions: A lower,broader peak of FSH in urine was observed in nonconceptive cycles compared with conceptive cycles. Urinary FSH measurements may be useful in predicting less fecund ovulatory cycles and may identify some types of reduced female fertility.
         

  • Anne Ego, Damien Subtil, et al
    Survival analysis of fertility after ectopic pregnancy
    Fert. & Ster. Vol.75(3), March 2001, pg.560-6
      
    Objective: To evaluate the reproductive outcome after ectopic pregnancy and to assess the contribution of risk factors to future fertility.
      
    Setting: Register of ectopic pregnancies established in an urban area around Lille, France.
     
    Patients: Three hundred and twenty eight women treated between April 1994 and March 1997 who had not been using an IUCD at the time of the ectopic pregnancy and were trying to become pregnant.
     
    Conclusion: More than half of the women treated for ectopic pregnancy spontaneously conceived and had a normally progressive pregnancy at 1 year. Fertility depends more on established patient characteristics than characteristics of ectopic pregnancy itself or treatment thereof.
      

  • Ben W J Mol, John A Collins, et al
    Cost-effectiveness of hysterosalpingography, laparoscopy and Chlamydia antibody testing in subfertile couples.
    Fert.& Ster. Vol.75(3), March 2001, pg.571-80
      
    Objective: To evaluate the cost-effectiveness analysis of hysterosalpingography (HSG), laparoscopy, and Chlamydia antibody testing (CAT) in subfertile couples
       
    Design: Cost-effectiveness analysis
      
    Setting: Decision analytic framework
      
    Patients: Data of >2000 subfertile couples in the Canadian Infertility Treatment Evaluation Study. Results of CA-125 measurements and CAT were simulated from baseline characteristics.

    Interventions: Expectant management was considered to be the reference strategy (strategy 1). In strategy 2 and 3, IVF was offered either immediately or after 2.5 years. In strategy 4, the decision to offer or delay treatment was based on the couple’s chance of spontaneous conception. Nine strategies incorporated combination of CAT, CA-125 measurement, HSG and laparoscopy.

    Results: The strategy starting with CAT was the most cost-effectiveness in couples whose 3 year chance of conception was > 14%, whereas the strategy starting with HSG was the most cost-effective in couples with worse fertility prospects.

    Conclusions: The diagnostic work-up to detect tubal pathology in subfertile couples should start with CAT in couples with relatively good fertility prospects and immediate HSG in couples with relatively poor fertility prospects.
       

  • Rebecca C Taylor, Jonathan Berkowitz and Peter F McComb
    Role of laparoscopic salpingostomy in the treatment of hydrosalpinx
    Fert.& Ster. Vol.75(3), March 2001, pg. 594-600
       
    Results: The overall IUP and EP rates were 24.5% and 16.5% respectively. Analysis of historical variables, assigned independently, demonstrated a significantly higher IUP rate with a positive history of gonorrhea and a significantly higher EP rate with a positive history of pelvic inflammatory disease, lack of history of intrauterine device (IUD) usage, or the performance of a bilateral procedure. The logistic regression model to predict intrauterine pregnancy had an overall predictive value of 77.5% and included the following significant variables: secondary infertility, positive history of gonorrhea, and the operative finding of moderate periadnexal adhesions. The logistic regression model to predict ectopic pregnancy had an overall predictive value of 89.0% and included the following significant variables: previous ectopic pregnancy, negative history of IUD use, positive history of PID, a bilateral procedure, and perihepatic adhesions.
         

  • M Ludwig, H Riethmuller-Winzen et al
    Health of 227 children born after controlled ovarian stimulation for in vitro fertilization using the luteinizing hormone-releasing hormone antagonist cetrorelix.
    Fert.& Ster. Vol.75(1), Jan. 2001, pg.18-22
      
    Objective: To summarize data from completed phase II and III clinical trials on children born after controlled ovarian stimulation using the luteinizing hormone-releasing hormone antagonist cetrorelix.
      
    Design: All children born after ovarian stimulation in patients treated for infertility who were in prospective studies until March 23, 1999
      
    Patients: Children born after IVF or IVF plus ICSI.
      
    Interventions: Controlled ovarian stimulation with cetrorelix in a multiple-dose or single/dual-dose protocol.
      
    Main Outcome Measures: Outcome of pregnancy and, in deliveries, the date of birth, number and sex of children born, birth weight, body length, and abnormalities were recorded. At approximately 1 year of age and 2 years of age, body weight and length and abnormalities in physical and mental development were recorded.
     
    Results: Two hundred nine and 18 children were born after fresh and frozen embryo transfers, respectively. Of the pregnancies, 76.25 resulted in live birth and ectopic pregnancy occurred in 3.4% (8 of 21); one heterotopic pregnancy and four induced abortions were recorded. The malformation rate among all live births, stillbirths and aborted fetuses was 3.1%.
      
    Conclusions: Use of cetrorelix in controlled ovarian stimulation does not harm the subsequently born children.
       

  • R.F. Harrison, S Jacob, et al
    A prospective randomized clinical trial of differing starter doses of recombinant follicle-stimulating hormone (follitropin -b) for first time in vitro fertilization and intracytoplasmic sperm injection treatment cycles.
    Fert.&Ster. Vol.75(1), jan.2001, pg.23
      
    Objective: Comparison of the efficacy of differing starter doses of recombinant follicle stimulating hormone (rFSH) for IVF and intracytoplasmic sperm injection cycles when the treatment is administered both subcutaneously and intramuscularly.
     
    Design: Single center 1-year prospective randomized study.
     
    Patients: 345 couples in first cycle
     
    Interventions: Treatment with subcutaneous or intramuscular rFSH, followed by E2 and ultrasound follicle tracking, with later oocyte collection and zygote transfer.
     
    Main Outcome Measure: Ovarian response and other clinically dependent variables.
     
    Results: Intramuscular administration was significantly more likely to result in a need for increased dosage than was subcutaneous administration.
     
    Conclusion: In the main study total dosage used, the ICSI metaphase II oocyte numbers were significantly lower and there was a trend toward a need for a dosage increase on day 5 when 150 IU rFSH was the starter dosage, as compared to a starting dosage of 200 IU. Otherwise, there is little advantage to using the higher dosage.
       

  • The North American Ganirelix Study Group: Margo Fluker, James Grifo, et al
    Efficacy and safety of ganirelix acetate versus leuprolide acetate in women undergoing controlled ovarian hyperstimulation.
    Fert.&Ster. Vol.75(1), Jan.2001, pg.38-45
     
    Objective: To assess the efficacy, safety, and local tolerance of ganirelix acetate for the inhibition of premature luteinizing hormone (LH) surges in women undergoing controlled ovarian hyperstimulation (COH).
     
    Design: Phase III, multicenter, open-label randomized trial
     
    Setting: In vitro fertilization (IVF) centers in North America
     
    Patient(s): Healthy female partners (n=313) in subfertile couples for whom COH and IVF or intracycloplasmic sperm injection were indicated.
     
    Interventions: Patients were randomized to receive one COH cycle with ganirelix or the reference treatment, a long protocol of leuprolide acetate in conjunction with follitropin-B for injection.
     
    Outcome measures: Number of oocytes retrieved, pregnancy rates, endocrine variables, and safety variables.
     
    Results: The mean number of oocytes retrieved per attempt was 11.6 in the ganirelix group and 14.1 in the leuprolide group. Fertilization rates were 62.4% and 61.9% in the ganirelix and leuprolide groups, respectively, and implantation rates were 21.1% and 26.1%. Clinical and ongoing pregnancy rates per attempt were 35.4% and 30.8% in the ganirelix group and 38.4% and 36.4% in the leuprolide acetate group. Fewer moderate and severe injection site reactions were reported with ganirelix.(11.9% and 0.6%) than with leuprolide (24.4% and 1.1%).
     
    Conclusions: Ganirelix is effective, safe and well tolerated. Compared with leuprolide acetate, ganirelix therapy has a shorter duration and fewer injections but produces a similar pregnancy rate.
       

  • Melissa D, Kahsar-Miller, et al
    Prevalence of polycystic ovary syndrome (PCOS) in first-degree relatives of patients with PCOS.
    Fert. & Ster. Vol.75(1), Jan.2001, pg.53-8
      
    Objective: To determine the rate of clinically evident polycystic ovary syndrome (PCOS) among first-degree female relatives within families with a proband affected by PCOS.
      
    Design: Clinical and biochemical evaluation of the mothers and sisters of 93 patients with PCOS. The diagnosis of PCOS was established by: (1) a history of oligomenorrhea, (2) clinical evidence (i.e. hirsutism) or biochemical evidence (i.e. elevated total for free T) of hyperandrogenism, and (3) the exclusion of related disroders.
     
    Setting: Tertiary care university
     
    Patients: Patients with PCOS and their mothers and sisters.

    Interventions: Interview, physical examination, and hormonal testing on blood samples were performed for all subjects.
       
    Main Outcome Measures: The presence of hirsutism and hyperandrogenemia was determined in the mothers and sisters of the patients with PCOS.
     
    Results: Of the 78 mothers and 50 sisters evaluated clinically, 19(24%) and 16(32%) were affected with PCOS, respectively. A higher rate of PCOS was observed when only premenopausal women not taking hormones (i.e. Untreated) were considered (i.e. 35% of mothers and 40% of sisters), consistent with amelioration of symptoms with hormonal therapy or aging. These rates of PCOS are significantly higher than that observed in general population (approximately 4%) and suggest the involvement of a major genetic component in the disorder.
      
    Conclusion: The rates of PCOS in mothers and sisters of patients with PCOS were 24% and 32%, respectively, although the risk was higher when considering untreated premenopausal women only.
       

  • Thomas G Matkov, Michael Zenni, et al
    Preoperative semen analysis as a predictor of seminal improvement following varicocelectomy.
    Fert. & Ster. Vol.75(1), Jan.2001, pg.63
      
    Objective: To determine the predictive role of preoperative semen analysis on both seminal improvement and pregnancy rates following varicocelectomy
     
    Design: Retrospective data analysis.
     
    Patients: One hundred ten consecutive patients who underwent varicocelectomies. Seminal improvement data were available for 84 patients, and pregnancy data were available for 58 patients.
     
    Interventions: Stratification of patients based on preoperative total motile sperm count (TM). Varicocelectomy was performed on all patients.
     
    Main Outcome Measures: TMs, pregnancy rates, and conception techniques following varicocelectomy of each preoperative group.
     
    Results: Men with mild to moderate oligoasthenospermia (TM > 5 million) had significantly better seminal improvement following varicocelectomy. While preoperative stratification showed no difference in pregnancy rates (when assisted reproductive techniques were included), men who achieved a postoperative TM > 20 million were more likely to achieve conception by less invasive techniques (natural and intrauterine insemination vs. in vitro fertilization [IVF])
     
    Conclusions: Varicocelectomy may be the most cost-effective initial intervention in males with TM>5 million. Patients with TM <5 million and concomitant female factor infertility may be better initial candidates for IVF.
      

  • R.P. Dickey, S.N. Taylor, et al (The Fertility Institute of New Orleans, Louisiana)
    Relationship of follicle numbers and estradiol levels to mulitple implantation in 3,608 intrauterine insemination cycles.
    Fert.& Ster. Vol.75(1), Jan.2001, pg. 69-78
     
    Objective: To determine the relationship of follicle numbers and estradiol (E2) levels to multiple implantations in human menopausal gonadotropin (hMG) and clomiphene citrate (CC) cycles.
     
    Design: Fifteen-year prospective study.
     
    Patients: Women who underwent 3608 cycels of husband or donor intrauterine insemination (IUI).
     
    Results: Triplet and higher-order implantations – but not twin implantations – were related to age, E2 levels and number of follicles ³ 12mm and ³ 15mm, but not number of follicles ³ 18mm, in hMG and CC+hMG cycles. For patients less than 35 years old, three or more implantations tripled when six or more follicles were ³12mm, in CC, hMG, and CC+hMG cycles, and when E2 was ³ 1000 pg mL in hMG and CC+hMG cycles. For patients 35 or older pregnancy rates in hMG and CC+hMG cycles doubled when six or more follicles were ³ 12mm, or E2 levels were >1000pg mL, whereas 3 or more implantations were not significantly increased.
     
    Conclusions: Withholding hCG or IUI in CC, hMG, and CC+hMG cycles when six or more follicles are ³ 12mm may reduce triplet and higher-order implantations by 67% without significantly reducing pregnancy rates for patients under 35 years of age.
      

  • M Aboulghar, R Mansour, G.Serour et al (The Egyptian IVF-ET Center, Maadi, Cairo, Egypt).
    Controlled ovarian hyperstimulation and intrauterine insemination for treatment of unexplained infertility should be limited to a maximum of three trials.
    Fert.& Ster. Vol.75(1), Jan.2001, pg.88
     
    Objective: To investigate the opitmum number of cycles of controlled ovarina hypertstimulation and intrauterine insemination in the treatment of unexplained infertility.
     
    Design: Observational prospective study.
     
    Setting: In vitro fertilization embryo transfer center
     
    Patients: Five hundred ninety-four couples with unexplained infertility
     
    Interventions: Controlled ovarian hyperstimulation (COH), intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI).
     
    Conclusions: In unexplained infertiity, the cycle fecundity in the first three trials of COH and IUI was higher than in cycles 4-6, with a statisically significant difference. Patients should be offered IVF or ICSI if they fail to conceive after three trials of COH and IUI.
       

  • Bolumar F, and the European Study Group on Infertility and Subfecundity (Univ Miguel Hernandez, Alicante, Spain; et al)
    Body Mass Index and Delayed Conception: A European Multicenter Study on Infertility and Subfecundity
    Am J Epidemiol 151: 1072-1079, 2000
       
    Introduction: Subfertility, which is defined as the inability to conceive after 9.5 months of unprotected intercourse.
       
    Results: An increased risk of delayed conception was also observed among women whose BMI was less than 20 kg/m2. The adjusted fecundability ratio was 0.52 for female smokers whose BMI was 30 kg/m2 or greater. After adjustment for risk factors, 47% of women who were obese and 19% of lean women needed over 12 months to conceive, compared with 12% of normal-weight women.
        

  • Behre HM, Kuhlage J, et al (Inst of Reproductive Medicine of the Univ, Munster, Germany)
    Prediction of Ovulation by Urinary Hormone Measurements With the Home Use ClearPlanâ Fertility Monitor: Comparison With Transvaginal Ultrasound Scans and Serum Hormone Measurements
    Hum Reprod 15: 2478-2482, 2000
      
    Methods: Data on a total of 149 cycles were analyzed.
      
    Findings: During the 2 days of CPFM peak fertility, ovulation was detected in 91.1% of the cycles. In none of the cycles did ovulation occur before CPFM peak fertility or the serum LH surge day.
      
    Editor’s Comments: The home urinary test to predict ovulation described in this report measures both estrone glucuronide and LH.
        

  • Jeanty P, Besnard S, et al (Women’s Health Alliance, Nashville, Tenn)
    Air-Contrast Sonohysterography as a First Step Assessment of Tubal Patency
    J Ultrasound Med 19: 519-527, 2000
      
    Methods: Air-contrast sonohysterography was performed to assess tubal patency in 114 women with infertility.
      
    Results: Cervical stenosis prevented introduction of the balloon catheter in 5 patients. Air-contrast sonohysterographic and laparoscopic assessments of tubal patency agreed in 17 patent tubes and in 6 closed or nonvisualized tubes.
       
    Conclusion: Air-contrast sonohysterography is a comfortable, safe, rapid, and accurate first-line procedure for assessing tubal patency in women with infertility. The procedure was comfortable even for patients with closed tubes, as the air simply refluxed around the balloon catheter. (With hysterosalpingography, the resistance to pushing the piston of the syringe is greatly increased when tubes are closed, and this increased pressure is painful.) Additionally, air-contrast sonohysterography can identify other uterine abnormalities, such as synechiae, polyps, and endoluminal fibroids.
         

      

 

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