Faculty Bibliography

OBJECTIVE: To determine the relationship between blastocyst growth parameters and birth weight. DESIGN: Cohort study. SETTING: University-affiliated fertility center. PATIENT(S): In vitro patients who delivered a singleton after a single-blastocyst transfer. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Birth weight adjusted for gestational age at delivery and gender, with adjusted birth weight examined for association with blastocyst scores and grades. RESULT(S): After standard in vitro fertilization (IVF) and thawed embryo transfers, greater birth weight was associated with a higher inner cell mass grade. The grade of the trophectoderm and stage of the blastocyst did not relate to weight. CONCLUSION(S): Embryonic growth as early as day 5 can predict the progress of fetal development as measured by birth weight.

This is the first report of viable pregnancies established with ICSI after 24-hour incubation of washed ejaculated sperm from men with poor sperm parameters. Because both pregnancy rates and viable pregnancy rates were significantly increased compared with 2- to 4-hour-incubated historical controls, 24-hour incubation before ICSI may be beneficial in selecting the most favorable ejaculated sperm

OBJECTIVE: To evaluate the prognostic value of transvaginal ultrasound (TVUS) detection of fetal heart motion (FHM) in view of maternal age and chromosomal analysis of spontaneously aborted fetal tissue. DESIGN: A 3-year retrospective, descriptive study. SETTING: Two medical center-based infertility-care facilities. PATIENT(S): 336 pregnancies were initiated by intrauterine insemination or embryo transfer for women of reproductive age who were seeking infertility treatment. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): beta hCG levels measured > 40 mIU/mL at 4-5 weeks' gestation and were followed by an initial TVUS at 5-8 weeks. Of these pregnancies, 52 ended in a first trimester loss. Twenty were defined by failure to detect FHM by 7 weeks' gestation (Group I), and 32 were marked by the loss of prior FHM at a mean of 2.6 weeks later (Group II). Fetal tissue was removed by dilatation and suction curettage. Cytogenetic studies were performed from short-term cultures of dissected chorionic villi and/or sac. RESULT(S): Chromosomal aberrations were found in 75.0% of abortuses in Group I and 65.6% in Group II. Different types of chromosomal abnormalities were present in each these groups. The maternal age-related trisomies which can progress to term (i.e., 13, 18, 21) were associated with early TVUS detection of FHM. The frequency of chromosomal abnormalities varied significantly with maternal age, with normal fetal karyotypes in 7 of 11 (63.6%) women < 35 years, but only in 9 of 41 (22.0%) women > or = 35 years despite the detection of FHM in 24 of 41 (58.5%) of these older women. Detection of FHM was associated with pregnancies continuing beyond the first trimester in 284 of 316 (90.0%) overall, but differed significantly with age (166 of 174 [95.4%] women < 35 years vs. 118 of 142 [83.1%] women > or = 35 years). CONCLUSION(S): Although the occurrence of chromosomal abnormalities in spontaneous demises did not differ according to TVUS detection of FHM, the types of aberrations were distributed differently. Since maternal age remains a significant factor in early fetal loss, TVUS detection of FHM should not be as reassuring for women > or = 35 years as for younger women

To evaluate embryonic and endometrial factors for their value in predicting pregnancy outcome in in-vitro fertilization (IVF) and embryo transfer, a retrospective data collection and prospective uterine artery colour Doppler imaging study was performed in a university-based IVF-embryo transfer programme setting. A total of 210 patients were included and grouped as follows: (I) IVF with controlled ovarian stimulation (214 cycles); (II) frozen-thaw cycle of autologous embryos (30 cycles); (III) oocyte donation, no cryopreservation (12 cycles); (IV) frozen-thaw cycle with embryos from donated oocytes (10 cycles). Embryo quality was significantly better in pregnant than non-pregnant cycles (group I, P = 0.0104; groups II-IV, P = 0.0418). The endometrial echo was significantly thicker in pregnant versus non-pregnant patients in group I (P = 0.0059), but not in groups II-IV (P = 0.741). Past uterine surgery or abnormalities had no effect on pregnancy outcome. There were no significant differences in mean uterine artery resistance index or peak systolic velocity in pregnant versus non-pregnant patients in groups II-IV. Thus, embryo quality is the most reliable predictor of pregnancy outcome. Endometrial measurements were significantly thicker in subsequently pregnant patients only in group I, where the endometrium reflects the hormonal environment. Doppler parameters were not useful in predicting pregnancy outcome

OBJECTIVE: To determine whether ovulation induction regimens, particularly the short protocol, has an effect on the corpus luteum (CL) from the previous cycle. DESIGN: Infertility patients were followed in an academic research environment. Patients were treated with either the short protocol (GnRH agonist [GnRH-a] and hMG) or hMG alone in a controlled ovarian hyperstimulation cycle. SETTING: Infertility center in academic setting. PATIENTS: Patients requiring ovulation induction. INTERVENTIONS: The blood samples were drawn on day 2 or 3 as a baseline before initiation of any treatments, generally on day 5 and usually every other day thereafter until ovulation. Serum P, E2, and relaxin were determined. MAIN OUTCOME MEASURES: Serum P, E2 and relaxin. RESULTS: Patients receiving hMG alone showed no change in serum P levels in the first few days of treatment whereas most short-protocol patients (18/30; 60%) showed an increase of P within 3 days of the initiation of treatment. The increase in P almost always was associated with an increase in relaxin as a marker of the luteal production of this P. CONCLUSION: The short protocol with its flare of gonadotropins is able to stimulate the CL from the previous cycle, resulting in an early increase in P that comes from the CL as indicated by its association with an increased relaxin in the same subjects

PURPOSE: To compare the use of human chorionic gonadotropin (hCG) to a gonadotropin releasing hormone (GnRH) agonist, nafarelin, in initiating ovulation and supporting the luteal phase after priming with clomiphene. METHODS: In 26 infertile women 50 mg clomiphene citrate produced a preovulatory-size follicle. Then, 11 women were randomized to receive two 400-micrograms doses of nafarelin intranasally 16 h apart, and 15 women were injected intramuscularly with 5000 IU of hCG (luteal day 0 = LD0). Starting on LD6, 7 more 400-micrograms doses of nafarelin were repeated on an every 16-h schedule or a single 2500 IU dose of hCG was given, respectively. Serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), progesterone (P), and hCG were measured. On LD13, endometrium was evaluated with ultrasonography and biopsy in 19 nonpregnant women. RESULTS: As judged by a threefold rise in serum LH, an LH surge was detected on LD1 in all 11 nafarelin patients, but in only 8 hCG patients (P = 0.01). LH and FSH levels were significantly higher on LD1, 7, and 8 and were significantly suppressed on LD13 in the nafarelin group. All patients had mid-luteal P levels greater than 10 ng/ml and luteal phases longer than 13 days. Significantly different luteal E2 or P levels were noted only on LD13, with lower values in the nafarelin group. Pregnancies were achieved in 3 of 11 nafarelin cycles and 2 of 15 hCG cycles. Luteal phase defects were also similar: 4 of 8 nafarelin patients and 7 of 11 hCG patients. CONCLUSION: Nafarelin or hCG in conjunction with clomiphene can result in viable pregnancies, but is associated with low pregnancy rates and a high incidence of luteal phase defects

OBJECTIVE: To evaluate the use of a cervical tenaculum to improve ovarian access during oocyte retrieval. DESIGN: Description of a new technique. SETTING: Normal human volunteer in an academic research environment. PATIENT: An infertile woman undergoing controlled ovarian hyperstimulation and ultrasound-guided oocyte retrieval. Access to her right ovary was obstructed by her uterus. INTERVENTIONS: During the retrieval procedure, a tenaculum was applied to the patient's cervix and downward traction was applied. RESULTS: The ovary became closer to the vaginal wall. CONCLUSION: Applying downward cervical traction with a tenaculum can bring an ovary closer to the vaginal wall, avoiding possible uterine injury and facilitating oocyte collection

OBJECTIVE--To compare the use of two gonadotropin-releasing hormone agonists, nafarelin acetate (NA) and leuprolide acetate (LA), in conjunction with human menopausal gonadotropins (hMG)/human chorionic gonadotropin (hCG) and intrauterine insemination (I

The need to prevent complications in the woman and fetus mandates that pregnancies in diabetic women always be planned and that safe and effective contraceptives be used at all times until it is determined that pregnancy is a safe and desired option. Pregnancy may aggravate complications of diabetes such as retinopathy and coronary artery disease. A pregnant diabetic woman is also more likely to experience such complications as hypertension, urinary tract infection, polyhydramnios, and cesarean section. Her fetus is at increased risk for congenital malformations, prematurity, stillbirth, neonatal morbidity, and diabetes later in life. Good diabetic control must be maintained before and throughout the pregnancy to minimize the risk of these and other complications. Until such time as good control is achieved and the woman desires pregnancy, a reliable method of contraception should be used. Most recent research supports the use of barrier methods, low-dose monophasic or triphasic oral contraceptives, or progestin-only methods, at least for the short-term. Under some circumstances the intrauterine device may be an appropriate option. Long-term data regarding the use of these methods is lacking. The decision regarding which method of contraception is used should be made by the woman in consultation with her physician