Faculty Bibliography

OBJECTIVE: To report a case of a heterotopic primary abdominal pregnancy after two-blastocyst IVF-ET. DESIGN: Case report. SETTING: University-based IVF program. PATIENT(S): A woman with a heterotopic abdominal pregnancy after IVF-ET. INTERVENTION(S): Pituitary down-regulation with luteal antagon, ovulation induction with menotropins, IVF-ET, progesterone in oil for luteal support, dilation and curettage for missed abortion, laparoscopy, and resection of abdominal gestation. MAIN OUTCOME MEASURE(S): Human chorionic gonadotropin levels, pelvic ultrasound examinations, and laparoscopic and pathologic findings. RESULT(S): A heterotopic abdominal pregnancy occurred after a two-blastocyst IVF-ET. The concurrent intrauterine gestation resulted in a miscarriage. CONCLUSION(S): The number of embryos transferred has been identified as a powerful risk factor for heterotopic pregnancy; however, heterotopic pregnancy can occur following a two-embryo, blastocyst stage transfer

OBJECTIVE: To reevaluate clinical management of isolated teratozoospermia, in couples initiating IVF. DESIGN: Retrospective analysis of fertility indices in 535 cycles. SETTING: A large, university-based fertility center. PATIENT(S): Consecutive couples (n = 495) who had a semen analysis using Kruger/Tyberberg strict criteria at our center within 12 months before undergoing their first and/or second IVF cycle in 2002-2004 with >2 million postwash, motile sperm on the day of egg retrieval. INTERVENTION(S): Eggs were fertilized either by conventional IVF or ICSI. Semen analysis and gamete/embryo manipulation was standardized in all cases. MAIN OUTCOME MEASURE(S): Fertilization, fertilization failure, pregnancy, and live birth rates. RESULT(S): There was no statistical difference in fertilization, fertilization failure, pregnancy, and live birth rates in the first or second IVF cycle when comparing couples with isolated teratozoospermia (<5% normal morphology) to those with a normal semen analysis. Furthermore, no improvement in these outcomes was noted when ICSI was used to treat these teratozoospermic couples. CONCLUSION(S): Because isolated teratozoospermia generally does not impact on the major indices of IVF, these patients need not be subjected to the unnecessary cost and potential risks of ICSI. Future studies, however, should focus on different sperm morphologic and biochemical parameters to determine if they are important for clinical management in IVF

A randomized clinical trial of 406 patients with advanced maternal age by Mastenbroek and co-workers recently published in the New England Journal of Medicine showed a significant decrease in pregnancy outcome after preimplantation genetic screening (PGS). It is our opinion that this study suffers from a number of insurmountable inaccuracies and that these are either a direct consequence of the inexperience of the team or of a general disregard of vital guidelines reported in the literature. Most importantly, the authors show that in their hands embryo biopsy may affect as many as half the embryos. The error rate was not presented, shedding doubt on the authors' abilities to reliably diagnose the biopsied cells. An evaluation of the study indicates that poor biopsy technique, sub standard fixation and FISH methods, poor IVF outcomes and inappropriate patient selection are the cause of the discouraging results obtained by these authors rather than problems inherent to PGS

OBJECTIVE: To assess the clinical value of transabdominal ultrasound (TAS)--assisted embryo transfer on outcomes of in vitro fertilization--embryo transfer (IVF-ET) in comparison to the 'clinical touch' method of transcervical embryo transfer by one physician and to determine if transabdominal ultrasound should be applied to all cases of embryo transfer in this practice. DESIGN: A retrospective comparison study. SETTING: A university-based IVF practice. PATIENT(S): Two hundred forty-nine patients who underwent transcervical transfer of fresh embryos created using autologous oocytes performed by the same physician from July 1, 2003, to June 30, 2004. INTERVENTION(S): On selected days, at time of embryo transfer, transabdominal ultrasound was performed to guide catheter placement depth approximately 1 cm from the uterine fundus. MAIN OUTCOME MEASURE(S): The presence of at least one gestational sac on ultrasound was compared in the two study groups; additionally, the clinical pregnancy rate (presence of fetal cardiac activity observed on ultrasound), the ectopic pregnancy rate, the biochemical pregnancy rate, and the implantation rate (number of gestational sacs identified on ultrasound per number of embryos transferred) between groups was evaluated. Characteristics of the two cohorts were analyzed to verify similarities between the treatment and control groups, including age of recipient, prior IVF history, day of transfer (day 3 or day 5 after retrieval), difficulty of transfer, the use of a tenaculum, and the quality and number of embryos transferred. RESULT(S): No statistical difference was seen in the presence or number of gestational sacs following embryo transfer with or without transabdominal ultrasound guidance. CONCLUSION(S): No additional advantage is conferred when using transabdominal ultrasound to perform embryo transfer. In experienced hands, the 'clinical touch' method of embryo transfer yields equivalent results to transabdominal ultrasound-guided embryo placement. However, in patients with a prior history of difficult uterine sounding or embryo transfer, transabdominal ultrasound guidance may still play a role