Faculty Bibliography

OBJECTIVE: To characterize incidence, chorionicity, amnionicity, and pregnancy outcome for monozygotic twin pregnancy (MZT) after IVF. DESIGN: Retrospective review. SETTING: University-based fertility center. PATIENT(S): Autologous and oocyte donation IVF cycles eventuating in 4,976 clinical gestations from 2000 to 2007. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): MZT incidence, chorionicity, zygosity, pregnancy outcome. RESULT(S): Ninety-eight MZTs were diagnosed after first-trimester ultrasound evaluation (2% incidence). The incidence in cycles transfering autologous oocytes was 1.7% but was 3.3% with donor oocytes; however, women <35 years old using their own oocytes displayed a similar rate (3.1%) to women using donor oocytes. Eighty MZTs occurred after fresh day-5 transfer; only 14 followed fresh day-3 transfer (2.6% vs. 1.2%). The MZT incidence in day-3 transfers without hatching was not different from those with hatching (1.3% vs. 1.1%). In addition, MZT incidence did not differ significantly whether or not ICSI was performed (2.4% vs. 2.0%). Four MZTs occurred after frozen-thawed embryo transfer (0.8% incidence). Ninety-five percent of all placental arrangements were confirmed as monochorionic-diamniotic on obstetric ultrasounds. CONCLUSION(S): These findings confirm a higher incidence of MZT after IVF. Monochorionic-diamniotic implantations were increased, whereas monochorionic-monoamniotic were not. The MZT risk factors included young age and extended culture, but not zona penetration or cryopreservation

OBJECTIVE: To determine whether there is a difference in pregnancy outcomes, stratified by age, between women undergoing elective single blastocyst transfer (eSBT) versus those undergoing double blastocyst transfer (2BT). DESIGN: Retrospective analysis. SETTING: University IVF center. PATIENT(S): A total of 1,141 nondonor IVF cycles in women aged <40 years from January 2004-March 2007. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Eggs retrieved, embryos cryopreserved, implantation rates, clinical pregnancy rates (PR), live birth rates (LBR), spontaneous abortion rates (SAB). RESULT(S): Pregnancy outcomes in 52 cycles of women <40 years of age who underwent eSBT were compared with 1,086 cycles of women who underwent 2BT in fresh IVF cycles from January 2004-March 2007. Overall, the eSBT was associated with a statistically significant 92% reduction in the twinning rate (from 25%-2%) while maintaining a high clinical PR (63% in the eSBT group vs. 61% in the 2BT group). CONCLUSION(S): Women who are <40 years of age undergoing nondonor fresh IVF cycles can electively choose to transfer a single blastocyst for the purpose of significantly reducing their risk of multiples without compromising their PR

OBJECTIVE: To compare rates of implantation, pregnancy, miscarriage, multiple gestation, and selective reduction between patients undergoing day 5 (d5) and day 3 (d3) ETs. DESIGN: Retrospective cohort study. SETTING: University-based IVF center. PATIENT(S): The first d5 ET cycle of patients 42 years of age from 2003 to 2006 was compared with a historical control of first cycle d3 ET patients 42 years of age from 1996 to 1999 who would have met current d5 ET criteria. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Rates of implantation, clinical pregnancy, miscarriage, live birth, high order multiple pregnancy (HOMP), and selective reduction. RESULT(S): D5 ET patients had higher implantation rates (39% vs. 30%), with no difference in the no-transfer rate. D5 ET patients had lower rates of HOMP (2.5% vs. 11%) and HOMP delivery (0.7% vs. 3.5%), multiple pregnancy (27% vs. 33%), multiple delivery (19% vs. 26%), and twin delivery (18% vs. 23%). There were fewer selective reductions of HOMP with d5 ET (1.7% vs. 3.8%). CONCLUSION(S): Extended culture improves embryo selection through increased implantation, facilitating fewer embryos per transfer, which lowers multiple gestation rates and the need for HOMP reduction

OBJECTIVE: To explore the long- and short-term trends in LH-suppression protocol use and patient profile characteristics. DESIGN: Descriptive study, retrospective cohort. SETTING: Large, university-based IVF center. PATIENT(S): Four thousand five hundred one fresh IVF cycles categorized by use of GnRH antagonist, luteal GnRH agonist, and follicular microdose GnRH agonist. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Frequency of use of LH-suppression protocol, patient and cycle characteristics, and outcomes at 10-year (1996-2005), 5-year (2001-5), and 3-year intervals (2004-6). RESULT(S): In both the <40 and >/=40 age groups, GnRH antagonist use increased from 2001 to 2005, while luteal GnRH agonist and microdose use decreased. The most recent luteal agonist patients were better responders and had higher implantation, clinical pregnancy, and delivery rates. Antagonist patients in the <40 and >/=40 age groups had a better response in 2005 than in 2001 with higher clinical pregnancy rates. Microdose patients responded worse in 2005 than in 2001, although pregnancy rates did not change significantly. Such trends were echoed from 2004 to 2006. CONCLUSION(S): The target population for GnRH antagonist has broadened to include younger, normal responders in addition to the traditional poor responder. Luteal agonist and microdose protocols are chosen less frequently and remain targeted toward good and poor responders, respectively

In an 8-year review of ectopic pregnancy (EP) rates in donor egg recipients and standard patients undergoing in vitro fertilization-embryo transfer (IVF-ET) at a large university-based program, we report an EP rate of 0.6% in donor egg recipients and 0.9% in standard IVF patients, a difference that is not statistically significant. Donor egg recipients were found to have a significantly lower incidence of tubal disease compared with standard IVF patients; however, tubal disease was not found to be an independent risk factor for EP in our practice, perhaps owing to aggressive management of tubal disease

Cancer patients produce similar numbers of oocytes after ovarian hyperstimulation compared with age-matched infertile controls, suggesting that malignancy does not adversely affect ovarian response

Although several early IVF successes were achieved after transferring fully formed blastocysts, the majority of embryos replaced worldwide over the past 30 years have been at the cleavage stage. The programme at this study centre has previously found that delaying an embryo transfer to day 5 can reduce the chance for a high-order multiple gestation without compromising the pregnancy rate because fewer embryos can be replaced. To evaluate the impact of transfer day and embryonic stage at cryopreservation on cycle outcome, 6069 fresh and 706 frozen transfers from 2000-2006 performed at this study centre were retrospectively analysed. Approximately half of the fresh transfers were performed on day 3, with a shift to day-5 transfer over the study period with no change in cryopreservation incidence. Implantation, clinical pregnancy and live birth rates were significantly higher following day-5 transfer. When frozen-thawed embryos (2-cell to day-6 blastocysts) were transferred, acceptable pregnancy and live birth rates were achieved at all stages but thawed embryos transferred as day-5 blastocysts generated consistently higher clinical pregnancy and live birth rates. Transfer of embryos frozen on day 6 had the highest miscarriage and lowest live birth rates. Barring government regulation, an IVF programme's day for cryopreservation generally depends on its management of and success with fresh embryo transfer

OBJECTIVE: To determine if there is a difference between clinical outcomes with respect to inter-cycle time period. DESIGN: Retrospective analysis MATERIALS AND METHODS: We analyzed the clinical outcomes of 168 patients who underwent 2 consecutive fresh IVF cycles with various intercycle time duration from 1/2001-3/2009. Inclusion criteria were 2 consecutive IVF cycles in which the first cycle did not result in a pregnancy. All poor prognostic patients, whose medical history was characterized by high FSH levels on day 2 (D2) or a prior poor response to gonadotropins, were excluded. Patients were grouped according to time interval between cycles (grp 0: back to back cycles, grp 1: 35-59 days, grp 2: 60-89 days). Analysis included age, D2 FSH, D2 estradiol (E2), total gonadotropin dose (IU), # of eggs retrieved (ER), # embryos transferred (ET), cancellation rate (CR), no start cycle rate, clinical pregnancy rate (PR) and twin pregnancy rate. CR reflected those patients who did not undergo egg retrieval. No Starts patients did not start a cycle secondary to elevated D2 bloodwork or ovarian cysts. PR included patients with a fetal heartbeat(s) activity on ultrasound. Outcomes of the second IVF cycle were analyzed by chi square and ANOVA. RESULTS: Comparisons of Clinical Outcomes. (Table presented). CONCLUSIONS: Patients opting for back-to-back cycles (grp 0) had a significantly higher likelihood of not starting the second cycle when compared to patients who took a 1 month reprieve. This may be due to a high prevalence of residual ovarian cysts. However, if patients were eligible to start a subsequent cycle and completed the cycle, then there was no statistical difference in PR