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ABSTRACT
Year : 2014  |  Volume : 1  |  Issue : 1  |  Page : 48-68

Complications of ART Radisson Blu Beach Resort, Goa, India 6th to 9th October 2013


Date of Web Publication14-Feb-2014

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How to cite this article:
. Complications of ART Radisson Blu Beach Resort, Goa, India 6th to 9th October 2013. IVF Lite 2014;1:48-68

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. Complications of ART Radisson Blu Beach Resort, Goa, India 6th to 9th October 2013. IVF Lite [serial online] 2014 [cited 2022 Jan 18];1:48-68. Available from: http://www.ivflite.org/text.asp?2014/1/1/48/127103

Sunday 6 th October 2013


  ACCU-vit: a New Strategy for Managing Poor Responders Top


Sakina Kagalwala

Department of Embryology, Rotunda CHR, Assisted Reproduction Laboratory, Mumbai, Maharashtra, India, E-mail: ivflab@rotundaivf.com

Background and Aim: Previous trials have shown that neither conventional in vitro fertilization (IVF) nor natural cycle IVF is an effective treatment option for poor ovarian responders. However, none of the trials have examined the efficacy of accumulating embryos with serial minimal stimulation cycles and vitrifying the resulting embryos. Women with poor ovarian reserves, who commonly do not respond to conventional stimulation protocols, are left with few options when planning a family. The current study was undertaken to evaluate the efficacy of serial minimal stimulation IVF cycles with vitrification of embryos (ACCU-VIT) for treatment of poor responders when compared with conventional IVF protocols. Materials and Methods: This is a retrospective data analysis of poor responders from February 2011 to March 2012. A total of 140 patients were included in the study. A total of 55 patients were offered minimal stimulation cycles with vitrification and embryo banking (ACCU-VIT Group) and 85 patients underwent conventional controlled ovarian stimulation for IVF. The inclusion criteria for ACCU-VIT group were patients with at least one previous conventional IVF cycle with poor response (defined as ≤4 MII oocytes). Embryos were vitrified using Cryotec Vitrfication protocol on day 3. Once six embryos were banked with us, a frozen embryo transfer (ET) was planned. A maximum of three embryos were transferred. Main outcome measure was the clinical pregnancy rate defined as positive fetal heartbeat at 12 weeks of pregnancy. Results: The mean age was 38.5 years in the ACCU-VIT group and 35.7 years in the conventional IVF group. In the ACC-VIT group, each patient underwent an average of 2.7 cycles of embryo accumulation before planning a frozen ET. An average of 6.2 embryos was vitrified for each patient. The cycle cancellation rate was 16.6% in the ACCU-VIT group and was significantly higher in the conventional IVF group (22.2%). The clinical pregnancy rate was higher in the ACCU-VIT group (28.5%) than the conventional IVF group (18.7%). The cumulative pregnancy rate was statistically higher in the ACCU-VIT group (41.5%) than the conventional IVF group (22.3%). Conclusion: Accumulating vitrified embryos in serial minimal stimulation cycles (ACCU-VIT) followed by a frozen ET is a better treatment option for poor ovarian responders when compared with conventional IVF. This approach allows the poor responder women to have consecutive cycles of embryo accumulation before the follicular reserve is depleted. It will maximize the ovaries' already limited life span, allowing patients the opportunity to store embryos while oocyte production is still active.


  A Comparison of Two Different Vitrification Methods for Cryopreservation of Mature Human Oocyte Top


S Kagalwala, G Gandhi, G Allahbadia 1 , M Kuwayama 2 , A Allahbadia 1 , A Khatoon, R Ramani, M Madne, S Alsule

Department of Embryology, Rotunda CHR, Assisted Reproduction Laboratory, 1 Rotunda CHR, Assisted Reproduction, Mumbai, Maharashtra, India, 2 Repro-Support Medical Research Center, Assisted Reproduction, Tokyo, Japan, E-mail: ivflab@rotundaivf.com

Background and Aim: Vitrification is a highly effective method for successful cryopreservation of oocytes. Various media, methods and carrier devices are being used for optimizing the vitrification technique. Cryotop vitrification method is known to give excellent results. The Cryotech method is different from the Cryotop method in terms of the constituents of its solutions as well as the design of the plates and the carrier device. The current study was carried out to compare the efficacy of two different methods of vitrification for cryopreservation of human oocytes: The Cryotop method and the Cryotech method. Materials and Methods: This is a retrospective data analysis of donor egg in vitro fertilization cycles using vitrified oocytes from October 2010 to August 2012. The oocytes were vitrified using either the cryotop or cryotech vitrification method. A total of 611 mature oocytes were vitrified and 131 embryo transfer (ET) cycles were performed using the embryos created after fertilizing the warmed oocytes with intracytoplasmic sperm injection (ICSI). Donor oocytes were vitrified using either cryotech or cryotop vitrification method. The frozen oocytes were then warmed using the respective warming media. The surviving oocytes were fertilized by ICSI. ET was performed in the recipients using these embryos. The survival, fertilization, cleavage and the clinical pregnancy rates were compared in the two groups. Results: A total of 275 mature oocytes were vitrified using cryotech method and 336 mature oocytes using cryotop method. The mean age of the egg donors was 25.3 ΁ 2.8 years and 24.8 ΁ 2.4 years for Cryotech and Cryotop methods respectively. The survival rate of warmed oocytes with Cryotech media was 97.1% (n = 267/275) while for Cryotop media it was 95.1% (n = 319/336). The fertilization rate of Cryotech group was 90.7% (n = 240/267) and Cryotop group was 86.1% (n = 274/319; P < 0.05). The cleavage rate for Cryotech group was 96.8% (n = 232/240) and Cryotop group was 91.9% (n = 251/274; P < 0.01). The clinical pregnancy rate for Cryotech group was 54.8% (n = 34/62) and Cryotop group was 40.6% (n = 28/69). Conclusion: Cryotech vitrification method for oocyte cryopreservation gives slightly higher survival and fertilization rates and significantly higher cleavage rate compared with the Cryotop method. Even though, the survival rate of oocytes in both groups did not show a statistically significant difference, the embryo development was better in the Cryotech group, as reflected by higher cleavage rate. This may be attributed to less trauma to the oocytes vitrified and warmed using Cryotech method. The Cryotech method would be very useful in building donor oocyte banks and fertility preservation of cancer patients.

Monday 7 th October 2013


  Cabergoline in Ovarian Hyperstimulation Syndrom Top


Rajat K Ray, S Samal

Ray Hospital and Test Tube Baby Centre, Rourkela, Odisha, India, E-mail: rajatkuray@rediffmail.com

Aims: The aim of the following study is to examine the effectiveness of cabergoline in preventing ovarian hyperstimulation syndrome (OHSS) and its complications. Settings and Design: Non-randomized clinical trial. Materials and Methods: A total of 18 patients, which were at risk of OHSS and underwent assisted reproductive techniques during July 2012 to June 2013 were studied. Patients were divided equally into an intervention and a control group. The intervention group was treated with cabergoline (1 mg every other day for 8 days) commencing from the day of ovum pick up. The control group did not receive cabergoline and their OHSS, if occurred, were managed conservatively after hospital admission. The rates of OHSS occurrence were compared. Statistical Analysis Used: Student's t-test, Chi-square and Fisher's exact test. Results: The incidence of OHSS in the cabergoline-treated group, was significantly (P = 0.01) lower than that in the control group (11% vs. 33%). Conclusions: The findings of the study indicate that the incidence of OHSS is reduced after use of cabergoline.


  Low Dose Human Chorionic Gonadotropin for Luteal Phase Rescue In Gonadotrophin-Releasing Hormone Antagonist Cycles with Agonist Trigger for Polycystic Ovary Syndrome Cases for Intracytoplasmic Sperm Injectio Top


Kunjimoideen Kinattingal, Sreeja Sajith, Premu Johnson

ARMC IVF, Kozhikode, Kerala, India,

E-mail: drkmoideen@gmail.com

Objective: The reproductive outcomes following the administration of low dose human chorionic gonadotropin (hCG) on the day of oocyte retrieval, on the day of embryo transfer (ET) and 3 days later were evaluated in cases of polycystic ovary syndrome (PCOS). Design: Prospective study. Materials and Methods: A total of 100 infertile women with PCOS who are at high risk of ovarian hyperstimulation syndrome (OHSS), having total of dominant follicles (more than 16 mm) in 14 nos on the last day of stimulation was included. They underwent intracytoplasmic sperm injection treatment with a gonadotrophin-releasing hormone (GnRH) antagonist protocol. Final oocyte maturation was achieved with a single bolus of 2 mg of Luprolide acetate and patients received IM bolus of HP hCG 1500 IU s/c right after oocyte retrieval, on ET day, 3 days after ET. Results: The incidence of clinically significant OHSS was 12% (6/50), admission treatment was required only in three cases (6%). Implantation rate was 36% and clinical pregnancy rate was 44% (22/50). Conclusion: Low dose hCG successfully rescues the luteal phase in GnRH agonist trigger cycle, provides excellent reproductive outcomes. The incidence of OHSS was much decreased; hospitalization treatment was required in rare cases.


  Empty Follicle Syndrome: Successful Managemen Top


Sam P Abraham

Abraham's Infertility, 4D Ultra Sound, Colposcopy, Laparoscopy and Test Tube Baby Centre, Changacherry, Kerala, India, E-mail: drsampabraham@hotmail.com

Empty follicle syndrome (EFS) is a frustrating situation for the entire assisted reproduction techniques (ART) team. We report a method of rescuing oocytes in three patients who had empty follicular syndrome due to a drug related problems rather than clinical dysfunction. When oocytes were not retrieved from one ovary, even after repeated aspiration and flushing of mature follicles in two cases, the procedure was abandoned leaving all follicles in the second ovary intact. The human chorionic gonadotropin (hCG) level on the day of oocyte retrieval was estimated and EFS was confirmed. A second dose of hCG from a different batch was given to all three patients and after 36 h follicles were aspirated from the intact ovary successfully. In the first 5 oocytes were obtained, 3 oocytes fertilized after intra cytoplasmic sperm injection and 2 grade A embryos transferred. In the second case 4 oocytes were obtained, three fertilized after intracytoplasmic sperm injection (ICSI), all three embryos transferred. In the third case 5 out of 10 oocytes were fertilized after ICSI, three embryos were selected for transfer.


  Role of Low-Molecular-Weight Heparin in Recurrent In Vitro Fertilization Failure Top


Richa Katiyar

Department of Gynaecology, Fortis Hospital, New Delhi, India, E-mail: dr.richa.katiyar@gmail.com

Low-molecular-weight heparin (LMWH) is a class of medication used as an anticoagulant in diseases that feature thrombosis, as well as for prophylaxis in situations that lead to a high risk of thrombosis. LMWH are derived from heparin, which is a naturally occurring polysaccharide, by fractionation or depolymerization and have average molecular weight of <6000 Da. LMWH help in recurrent in vitro fertilization failures (RIF) by reducing the thrombosis of blood in vessels as well as by their other non-coagulant functions. Neelam Potdar et al. in Hum. Reprod. Update (2013) found after systematic review and meta-analysis that in women with ≥3 RIF, the use of adjunct LMWH significantly improves live birth rates by 79% compared with the control group; however, this is to be considered with caution, since the overall number of participants in the studies was small. They summed up that to get one extra live birth; eight women would have to be treated. Lodigiani et al., in a total of 265 patients and 569 cycles found significantly higher pregnancy rates in patients with previous ART implantation failures after giving LMWH. Cochrane (2013) summarizes that heparin may increase live births and clinical pregnancies but the findings need to be viewed with caution and need better-designed clinical research trials to justify their use. Furthermore important is to remember that though various LMWH are available (dalteparin, enoxaparin, bemiparin, etc.) World Health Organization regards LMWH as individual products that should not be considered as clinically equivalent, as they differ in their structural and biological properties.


  Can We Make In Vitro Fertilization Safer with A Good Vitrification Program? Top


Goral N Gandhi, Gautam N Allahbadia, Sakina Kagalwala

Rotunda Center for Human Reproduction, Bandra West, Mumbai, Maharashtra, India, E-mail: wecare@rotundaivf.com

Is in vitro fertilization (IVF) a safe process? It is basically a safe process. More than 5 million babies over the globe have been conceived through IVF. However, there are certain risks associated with IVF and some of the commonest risks of IVF are multiple pregnancies and ovarian hyperstimulation syndrome (OHSS).

There are three areas where vitrification can play a key role in making IVF a safer procedure.

1. Vitrification - An ideal way to prevent multiple pregnancies

2. Vitrification - An ideal approach to prevent OHSS

3. Vitrification and Minimal stimulation.

Vitrification - an Ideal Way to Prevent Multiple Pregnancies: To prevent the multiple pregnancies, we must reduce the number of embryos that we transfer. Consequently, we must have a very efficient cryopreservation program available to cryopreserve the supernumerary embryos. We at Rotunda - Center for Human Reproduction (CHR) are using Cryotec vitrification to freeze all our embryos. We have an embryo survival rate of 98.6%. In the data presented here, we have a clinical pregnancy rate (CPR) of 63.5% and an implantation rate of 29.3% for O-(2-18F-fluoroethyl)-L-tyrosine (FETs). Vitrification - an Ideal Approach to Prevent OHSS: OHSS is a potentially life-threatening, iatrogenic complication of IVF resulting from the extensive use of gonadotropins. A new approach to reduce the OHSS risk has been introduced, consisting of elective cryopreservation of all the available embryos and postponing the embryo transfer. At Rotunda - CHR, we have used this approach to prevent OHSS and have a CPR of 66.7% in the subsequent FETs for this group of patients.

Vitrification and Minimal Stimulation: Women with a poor ovarian reserve, who commonly do not respond to heavy stimulation, are left with few options when planning a family. One such option is embryo banking with a minimal stimulation IVF protocol. (IVF Lite protocol). For poor responders, we have a CPR/patient of 48.5%. Conclusion: We have a very efficient method and right protocol for vitrification now available and we must ensure that we use this tool to its fullest potential and offer a safer and more efficient IVF program to our patients.


  How to Avoid Complications in Assisted Reproduction Techniques Through Preimplantation Genetic Diagnosis Top


Esther Velilla 1],[2

Department of Embryology, 1 Institute of Marques, 2 Center for Embryo Medicine, Barcelona, Spain, E-mail: esther.velilla@pgdcem.com

Preimplantation genetic diagnosis (PGD) allows couples who are at risk of transmitting genetic diseases to have a healthy offspring. In addition to that, PGD has been widely used in assisted reproduction techniques (ART) for aneuploidy screening (PGS) to avoid chromosomal risk and to increase the evolving pregnancy rate. A high percentage of in vitro fertilization embryos are chromosomally abnormal. Most of the chromosomal errors are incompatible with embryo implantation and the development of a term pregnancy. PGS permits to select chromosomal normal embryos in order to achieve an evolving pregnancy. However, until now PGS had two main limitations: (i) Embryo mosaicism and (ii) the limited number of chromosomes studied. Embryo mosaicism is one of the main sources of error when performing PGD in cleavage stage embryos and although it appears to decrease from day +3 to day +6 of embryo development it is a randomized phenomenon that can't be solved. On the other hand, different techniques have been developed for the study of all the chromosomes: Fluorescent in situ hybridization-24, microarrays techniques, quantitative polymerase chain reaction and new generation sequencing. The aim of this session is to analyze the application of PGD 24 chromosomes in couples at risk of aneuploid embryos: Advance maternal age (>37 years), genetic male factor and recurrent miscarriages.


  Complications in Assisted Reproduction Techniques: Fertilization Failure In In Vitro Fertilization and Intracytoplasmic Sperm Injection Top


Akanksha Mishra

Department of Embryology, Sabine Hospital and Research Centre, Pezhakkappilly, Kerala, India, E-mail: embryologist_am@yahoo.com

The majority of couples experiencing infertility receive an explanation to the cause after routine investigations such as semen analysis, ovulation and  Fallopian tube More Detailss work-ups. However, in about one-third of infertile couples world-wide, the cause of infertility cannot be detected by routine investigations alone and theirs is categorized as "unexplained infertility." Many-a-times, the cause of infertility is failed fertilization of the oocyte. Unfortunately, this cannot be detected unless an in vitro fertilization (IVF) is performed. There are some factors at the molecular level with the sperm or the oocytes or both, that can lead to major or complete failed fertilization in IVF. Intracytoplasmic sperm injection (ICSI) can circumvent some, but not all, of these factors and failed fertilizations in ICSI have also been observed. Calcium signaling and calcium store mobilization is very important for fertilization. Phospholipase C zeta (PLCζ) is widely considered as the sperm factor that initiates oocyte activation and the absence or reduced expression of PLCζ has been associated with oocyte activation failure. A number of pharmacological agents have been used successfully to attain artificial oocyte activation, albeit with concerns regarding their mechanism of action and long-term epigenetic effects. Injection of PLCζ complimentary ribonucleic acid into oocytes causes oocyte activation in a manner more similar to that which occurs naturally following fertilization by the sperm. However, although PLCζ was discovered more than a decade ago, the protein in its pure form still remains elusive.

A study being conducted at the Oxford Fertility Unit and Research Center, NDOG, Oxford, aims to address this issue by way of incorporation of wild type PLCζ reading frame into mammalian cells followed by PLCζ expression and immunobead isolation. The injection of purified PLCζ along with the sperm into the oocyte at the time of ICSI could, at least theoretically, pave the way forward to providing a therapeutic tool to those couples with previous history of fertilization failures. Although at research stage at present, this could be a possibility in near future. In turn, the positive outcomes using PLC in preventing and/or treating fertilization failure can unravel further molecular mysteries of fertilization.


  Have We Written the Obituary For Conventional In Vitro Fertilization With In Vitro Fertilization Lite? Top


Gautam Allahbadia

Rotunda Center for Human Reproduction, Mumbai, Maharashtra, India, E-mail: gautam@rotundaivf.com

The psychological, physical, emotional, and financial burden on a couple undergoing in vitro fertilization (IVF) treatment is very high. Mild stimulation represents an increasingly valid alternative to conventional IVF. Patient experience lesser side-effects from the conventional aggressive regimen. The biggest advantage of milder stimulation is that the risk of ovarian hyper stimulation can be brought down significantly - 1.4% versus 3.7% in mild and standard groups, respectively, as reported by Ledger in 2007. The second main advantage is a significantly lower risk of multiple pregnancies - 0.5% versus 13.1% in mild and standard groups, respectively.

The natural cycle IVF method has long been abandoned in favor of gonadotropin-stimulated protocols to improve pregnancy rates. Such lengthy expensive regimens are not free from short- and long-term risks and complications. Mild stimulation protocols reduce the mean number of days of stimulation, the total amount of gonadotropins used and the mean number of oocytes retrieved and have the possibility of repetition each month at a much lower cost.

Due to the high costs of assisted reproductive technology procedures, there is widespread concern about equity in access to reproductive health care. In 2008, we established India's first budget IVF center, Rotunda Blue where, with minimal stimulation IVF, we could bring down the cost by over 40% per cycle by using lesser amount of urinary gonadotropins per cycle without compromising on quality or results. Fewer oocytes translated to reduction in the use of laboratory disposables and expensive culture media. Next, we started a combination of clomiphene citrate, human menopausal gonadotropins and cetrorelix cycles to decrease costs further while achieving similar pregnancy rates. Reducing costs in developing countries can be mainly dictated by reducing the usage of gonadotropin in assisted reproduction techniques cycles. These milder stimulation cycles with a flexible antagonist protocol helps us achieve comparable pregnancy rates with a very substantial cut in cost. The reduction in cost enables patients to attempt more cycles, thus increasing cumulative rates of success. If the cost is reduced by 40%, then even the lower economic groups will have almost equal access to infertility treatments and IVF pregnancy would be more widely available.


  Ovarian Hyperstimulation Syndrome: Is it Preventable? Top


Z Kilani, L Haj Hassan, T Shaban

The Farah Hospital, Amman, Jordan, E-mail: farah1@go.com.jo

Superovulation to treat infertile women remains in spite the vast experience over the past 40 years a medical method not without devastating and serious consequences in otherwise healthy young women seeking pregnancy. Ovarian hyperstimulation syndrome (OHSS) is considered the gravest complication of superovulation, which can be life threatening. It is characterized by formation of multiple cysts in both ovaries and fluid displacement from intravascular to the third space. It can vary from mild to severe forms. While in mild cases the syndrome includes ovarian enlargement, abdominal distention and weight gain. In severe cases, a critical condition can emerge with ascites, pleural effusion, liver and kidney dysfunction and thromboembolic sequalae requiring admission to the intensive care unit. The condition might end with residual physical complications, psychological manifestations and even death.

The incidence of OHSS has been reported to be as high as 33% with the severe form occurring in 0.5-4% of patients. Prevention of this serious syndrome relies principally on identifying patients at risk and individualization of stimulation protocols. Although the condition of OHSS is poorly understood and its pathogenesis remains a controversial subject, several measures have been adopted to limit the occurrence of this complication and improve the management of patients at risk without cycle cancellation, including: (a) Withholding or reducing human chorionic gonadotropin (hCG) dose, (b) withholding gonadotropins and delaying hCG administration until Estradiol level decreases (coasting), (c) inducing final oocyte maturation using gonadotrophin-releasing hormone agonist or (d) recombinant human luteinizing hormone, (e) in vitro maturation, (f) cryopreservation of embryos. Other strategies include follicular aspiration and intravenous albumin administration. It will be emphasized that the main factor behind the shift of fluid in the third space is the vascular endothelial growth factor (VEGF). Its intense existence is demonstrated in highly vascularized CL and acts directly on endothelial cell to induce proliferation and angiogenesis. Messenger ribonucleic acid to VEGF is enhanced by hCG in a time and dose dependent way. In OHSS tyrosine hydroxylase gene, which is essential for Dopamine synthesis is down regulated. High VEGF expression is associated with decrease in dopamine production. DA administration interferes with VEGF effect observed in OHSS. The pathophysiology and management of spontaneous OHSS with and without pregnancy will be discussed.


  An Unusual Complication During a Fertility Enhancing Laparoscopic Surgery - The Lost Surgical Instrument, A Surgeon`s Nightmare and A Novice Method to Resolve The Complication Top


Meenu Agarwal

Morpheus Bliss Fertility Centre, Pune, Maharashtra, India, E-mail: drmjainagarwal@hotmail.com

Summary: The aim is to discuss a case when while doing laparoscopic myomectomy one blade of the needle holder broke and got lost inside the patients body. It was retrieved laparoscopically with the help of a magnetic piece . Introduction: A 42-year-old female was undergoing laparoscopic myomectomy in a nursing home setup. All the complications associated with the myomectomy were taken care of until it was noticed that while repairing the uterine defect one blade of the needle holder broke and got lost in patients body. After futile efforts to trace are under direct vision the lost piece was finally recovered with the help of a magnetic piece laparoscopically. Materials and Methods: A small magnetic piece was bought. It was sterilized by keeping it in Cidex solution. The piece was tested on the needle holder outside the patients body to see whether it was effective. It was held with a grasper and introduced inside patients body through the port used for morcellator. Result: As soon as the magnetic piece held in a grasper was put inside the patients body the lost piece of the instrument came out of nowhere and got stuck to the magnetic piece. It was the removed under direct vision. Discussion: This was an unexpected complication. It is difficult to manage such complications in a small nursing home set up where there are no facilities for C-arm, portable X-ray machine or the magnetic forceps. Quick thinking by the operating team helped in managing the situation laparoscopically.


  Fertility Enhancing Surgery Inendometriosis Top


Nagendra Sardeshpande

Worli Hospital for Women, Worli, Mumbai, Maharashtra, India, E-mail: drnagendras@hotmail.com

Introduction: Endometriosis is a benign, estrogen dependent gynecological disease affecting 5-10% of women of reproductive age (20-40% of women undergoing assisted reproduction techniques [ART]) with symptoms including chronic pain, dysmenorrhea, dyspareunia and infertility. Infertility in almost 60% of women with endometriosis. Endometriosis and Infertility: Mechanical interference i.e. the most accepted theory. There is an increasing role of immunological, genetic and hormonal factors. ART in endometriosis remain unsatisfactory, revealing impaired pregnancy and implantation rates in comparison with infertility due to tubal and male factors. Pre-operative Evaluation: (1) Laparoscopy is the gold standard. (2) Transvaginal sonography - Endometriomas appear as homogenous internal echoes with thick walls, peripheral blood flow and ground glass echogenicity of cyst fluid. (3) Magnetic resonance imaging (MRI). Transvaginal ultrasound can suggest rectovaginal endometriosis through visualization of a hypoecogenic lesion between rectum and vagina. MRI, in association with rectum ecoendoscopy, best to identify deep endometriosis. Surgery for Endometriosis: (1) Adhesiolysis, (2) identification and separation of ureter and bowel, (3) ablation of superficial peritoneal disease, (4) excision of deep infiltrating endometriosis, (5) management of endometriomas, (6) surgery for relief of symptoms. Ablation of endometriotic lesions with adhesiolysis in order to improve fertility in minimal and mild endometriosis is more effective when compared with diagnostic laparoscopy itself. Surgical treatment is the best option for deep endometriosis, due to high incidences of recurrence with medical treatment. Careful palpation of lesion to check for infiltration and introduction of rectal and vaginal probes aids surgery. Pregnancy rates after laparoscopic procedure for rectovaginal endometriosis treatment varies from 44.4% to 72% respectively. Bowel endometriosis is the most frequent extragenital site of endometriosis (5.4-12%). Radical excision induces improvement in 91-100% of the bowel symptoms with pregnancy rates of 43-45%. Presacral neurectomy was found to reduce pain symptoms in endometriosis without significant side effects. Surgery for Endometriomas: Dilemmas (1) reduced ovarian reserve prior to treatment, (2) increased risk of poor response and POF, (3) expectant management optimal with low Anti-Mullerian Hormone (<0.5 zng/ml)? Risks of non-intervention (1) puncture during oocyte retreival (2.8%), (2) spontaneous rupture, (3) increase size during treatment, (4) early stage malignancy (0.7%). Guidelines for surgery (1) ESHRE recommends non-intervention in endometriomas <4 cm, (2) conservative approach for bilateral endometriomas due to increased risk of reduced ovarian reserve and ovarian failure, (3) multiple surgeries avoided since recurrence after repeat surgery is high and there is associated risk of progressive ovarian damage. Technique of ovarian cystectomy (1) vasopressin for hemostasis and hydrodissection, (2) reduce use of cautery, (3) close bed with 2-0/3-0 polyglactin 910, (4) ovarian suspension, (5) adhesion barriers, (6) thrombin gel? (7) perioperative gonadotrophin-releasing hormone analogue therapy questionable value. Alternative therapies (1) three stage technique, (2) combined excision with ablation, (3) laser ablation, (4) aspiration with or without sclerotherapy/methotrexate.


  Ocyte Vitrification Top


Goral N Gandhi, Gautam N Allahbadia, Sakina Kagalwala

Rotunda Center for Human Reproduction, Mumbai, Maharashtra, India, E-mail: wecare@rotundaivf.com

The potential advantages of oocyte cryopreservation have been apparent for many decades. Oocyte cryopreservation has become a mainstream fertility technique with excellent results, especially in fertility preservation and oocyte donation programs. Vitrification is an efficient method to preserve oocytes. Indeed, the number of publications concerning the efficiency and reliability of oocyte vitrification has increased exponentially over the past decade. Vitrification provides high survival rates and comparable fertilization, embryo development and implantation to fresh oocytes. Several studies have reported that fertilization and pregnancy rates are similar to in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) with fresh oocytes when vitrified/warmed oocytes are used as part of IVF/ICSI.

The results obtained with oocytes vitrification using cryotech method at Rotunda Center for Human Reproduction, Mumbai, India are reassuring. In a comparison of the laboratory parameters of fresh and vitrified donor oocytes, no statistical difference was found in the fertilization rate, cleavage rate and % of good grade embryos between the two groups. The in vitro performance of vitrified oocytes was similar to fresh oocytes. Furthermore the live birth rate with vitrified donor oocytes was 45.3% and it was comparable to live birth rate with fresh donor oocytes. Thus the application of this technique to assisted reproduction techniques not only gives better survival rate but also good clinical outcomes from the resultant embryos.

The Cryotec vitrification method (Cryotech, Japan) chosen by the study center has many advantages over the previous methods of vitrification of Dr. Kuwayama. Now, with major improvement in the solutions and the newly designed vitrification plates, a new method called Cryotec has been developed (Cryotech, Japan). This video presentation shows the detailed method of oocyte cryopreservation using Cryotec Vitrification method.

In conclusion, the success of oocyte cryopreservation has improved dramatically over the past decade and preliminary data for safety are reassuring. Egg banking holds promise for women who want to preserve their fertility and delay motherhood for various social reasons such as education and career development and for medical reasons usually ahead of cancer treatment.


  Laparoscopic Utero-Vaginal Anastomoses for Cervical Agenesis Top


Ameya Padmawar, Rizwana Syed

Rotunda Fertility Clinic and Keyhole Surgery Center, Mumbai, Maharashtra, India, E-mail: abpadmawar@yahoo.com

Congenital cervical agenesis is a Mullerian developmental anomaly resulting in cyclical dysmenorrhea and cryptomenorrhea. Literature review reveals most of the subjects undergo hysterectomy for symptom resolution. We are presenting a case report illustrating the role of laparoscopy in achieving symptomatic relief, conservation of the uterus - restoration of uterine function and keeping the option of future fertility open. The subject was a young girl of 13 years of age with symptoms of cyclical dysmenorrhea and cryptomenorrhea. Clinical examination did not reveal much information. Magnetic resonance imaging of the pelvis revealed a uterus enlarged due to hematometra and cervical agenesis, blind vaginal pouch. Since the parents and the subject were keen on conserving the uterine function laparoscopy was offered as a surgical option. The video illustrates the surgical technique for achieving uterovaginal anastomoses using laparoscopy using all principles of minimally invasive surgery. A silastic foleys catheter was placed in the uterine cavity for keeping the passage patent and allowing epithelization of the surgically prepared conduit pathway. The catheter was expelled out after 9 weeks of the surgery. A hysteroscopy at 10 weeks revealed a normal uterine cavity and a healed, well epithelized uterovaginal passage. At 4-month follow-up of the patient, revealed normal menstruation and relief of her symptoms. Laparoscopic uterovaginal anastomoses should be considered as a first line treatment for cervical agenesis based on the following: minimally invasive surgical technique, achieving complete resolution of symptoms, uterus conservation for future fertility.


  Can Contraceptive Products Have an Impact On Future Fertility? Top


Amos Ber

Company Maccabi Health Centers, Israel,

E-mail: dr.amosber@gmail.com

The impact of using combined birth control pill (COC) on future fertility has been debated for years. Some studies have shown women have difficulty getting pregnant once they stop COC, whereas others found no impact and even an easier time. In many articles, a delay in return of ovulation was seen. This effect was usually more prominent in women using COC with higher doses of 50 mcg EE and above. Similarly, previous use of injectables was associated with a significant reduction in subsequent fecundity. The delay in the return of fertility was more than a year. As with previous COC use, the effect on subsequent fertility could at least partly be due to residual ovarian suppression after stopping usage. Studies investigating impact of intrauterine contraceptive devices (IUD) on subsequent fertility are consistent and showing no impact on future fertility. Some studies showed an impaired fertility after a short IUD usage that was not seen in longer use. This might be a result of an early removal due to complications mainly PID seen in the first 3 weeks after insertion. Though the number of articles is still small, the effect of the medicated IUD seems to be similar to the copper IUD, with no impact on future fertility. We can conclude that hormonal contraceptives have small or no impact on future fertility except as to delaying return to regular ovulation seen mainly in high dose COC and Injectables.


  Complications of Assisted Reproduction Techniques Top


Nadia L Suarez

New Hope Fertility Clinic, Punto Sao Paulo, Mexico, E-mail: dranadia-suarez@nhfc.mx

Impaired fertility has increasingly become a health service issue because of the availability of new treatments like intracytoplasmic sperm injection, but older treatments, including ovulation induction with or without insemination, are still in wide use. The novelty of in vitro fertilization (IVF) has attracted a large number of studies on the health of both the newborns and the women subjected to these procedures, but less is known about the long-term health effects of IVF on the women. Complications can occur during the ovulation induction, the oocyte collection procedure and post-operatively. The pregnancy achieved can be ectopic and it can end in a miscarriage. Ovarian hyperstimulation syndrome is considered the most serious complication of ovulation induction. For oocyte collection, bleeding has been reported in 0.03-0.5% and infections in 0.02-0.3% of embryo transfers. About 2-5% of IVF pregnancies have been reported to be ectopic and 0.1-0.3% heterotopic and estimates of IVF pregnancies ending in miscarriage have varied from 15% to 23% respectively. It would be important to establish a routine follow-up system for IVF and OI treatments and their complications. This should also provide information on the duration and causes of infertility, the exact nature and duration of maternal drug exposure and maternity background data.


  A Study Comparing Cabergoline Versus Coasting as A Method of Preventing Ovarian Hyperstimulation Syndrome In Long Protocol Cycles Top


Rutvij Dalal

Sabine Hospital and Research Centre, Pezhakkappilly, Kerala, India, E-mail: rutvij.dalal@gmail.com

Background: One of the major and life-threatening side-effects of assisted reproductive technique is ovarian hyperstimulation syndrome (OHSS). The available data however, have been showed that both Cabergoline (anti vascular endothelial growth factor) and coasting reduce the severity of OHSS. Objective: We aimed to compare coasting and Cabergoline administration in prevention of severe OHSS. Materials and Methods: A total of 60 in vitro fertilization/intracytoplasmic sperm injection cycles were selected. Patients at risk of developing OHSS were randomly divided into two groups. For 30 patients in coasting group, exogenous gonadotropins were withheld to allow E2 to decrease while gonadotrophin-releasing hormone-a was maintained. Then 10,000 unit human chorionic gonadotropin (hCG) was administrated and oocyte retrieval was performed 36 h later. In cabergoline group, 30 patients were administered with 0.5 mg cabergoline tablet on day of hCG injection, continued for 8 days. Results: The mean number of retrieved, good quality, mature oocytes and the mean number of embryos were significantly different in two groups (P < 0.05). The clinical pregnancy rate was 13.3% in coasting and 26.7% in Cabergoline group that was not significantly different (P > 0.05). The incidence of severe OHSS was similar in two groups. Conclusion: The Cabergoline was as effective as coasting in the prevention of early severe OHSS in high risk patients, but yielded more retrieved oocytes.


  Oocyte Vitrification for Fertility Preservation: Principles, Practice and Pitfalls Top


Goral N Gandhi, Gautam N Allahbadia

Rotunda Center for Human Reproduction, Bandra West, Mumbai, Maharashtra, India, E-mail: wecare@rotundaivf.com

Fertility preservation (FP) is a very fast emerging branch of reproductive medicine, involving the preservation of reproductive gametes and tissues. Cancer patients who are to start chemotherapy or undergo surgery, patients undergoing in vitro fertilization (IVF), women with other medical conditions leading to premature menopause and healthy women who wish to delay their fertility for social, educational or professional reasons are the main beneficiaries of FP strategies. The aim of this presentation is to provide the current status of oocyte vitrification as a means of FP. Historically, embryo cryopreservation was the only option offered to female patients. This option, whereas successful, has a major disadvantage about the requirement of a sperm source to create the embryos. This option is obviously closed for single women.

Last few years have seen tremendous advancements in the field of cryobiology, with special emphasis on oocyte vitrification. These advancements have greatly changed the way IVF centers operate. Until recently, egg freezing was offered to young, oncological female patients, who are facing chemotherapy or surgery. However, the American Society for Reproductive Medicine at the end of 2012 endorsed oocyte cryopreservation as a standard practice for FP. Some research has suggested that elective egg freezing is a cost-effective method for achieving a future live birth for women under age 39, compared with the possibility of undergoing IVF at a later time in life.

Some of the fascinating applications of oocyte vitrification have emerged:

1. FP for social or oncological or other medical reasons

2. Possibility to create donor banks for egg donation programs

3. Opportunity to avoid ovarian hyperstimulation syndrome

4. Opportunity to accumulate oocyte for poor responders.

The concept of FP offers hope to all women who are concerned about their future fertility. It greatly increases a woman's potential to have children later in life.

In this talk, I present the general experience of oocyte vitrification from our group and others, confirming that oocyte vitrification is now a very efficient, reliable and reproducible option for FP.


  The Advantages and Disadvantages of Gonadotrophin-Releasing Hormone Antagonist Top


Peter Kovacs

Kaali Instuitute, IVF Center, Budapest, Hungary, E-mail: peterkovacs1970@hotmail.com

Background and Aim: Ovarian stimulation is an integral part of in vitro fertilization. The stimulation protocol and the amount and type of gonadotropins used during it are individually determined based on age, ovarian function markers, antral follicle count, weight and previous response to treatment. In general, most protocols utilize two types of medications; one to induce multi-follicular development and one to prevent premature luteinization. Premature luteinization can be effectively prevented with both gonadotropin releasing hormone agonist (GnRHa) and antagonist. Since their mechanism of action differs there are differences in the way they need to be applied as well. Methods: Review of the literature. Discussion and Conclusions: When administered continuously GnRHa down-regulates its pituitary receptors after an initial flare effect. Therefore, it typically has to be administered over a longer period of time before the desired effect is achieved. The antagonist induces an immediate competitive inhibitory effect upon binding to the receptors therefore it can be started during the follicular phase once the risk of ovulation becomes evident. Its use is associated with shorter stimulation, the need for less gonadotropin and significantly fewer injections. The hormonal changes it induces also differ from the endocrine changes with the agonist and this could impact on the stimulation outcome, egg yield, oocyte quality, embryology parameters and ultimately the treatment outcome. Due to the fewer injections and reduced gonadotropin need this is the preferred stimulation method by the patients. Compared with the agonist with the GnRH antagonist similar stimulation outcome can be achieved with fewer injections and an overall shorter duration of stimulation. Recent trials have reported similar clinical outcome with the two approaches. Ovarian hyperstimulation risk is lower with the antagonist especially that it gives us the flexibility to induce ovulation with an agonist in hyper-responders. The profound deep decline in luteinizing hormone level may adversely affect the response to stimulation.


  Intrauterine Insemination Conversion to In Vitro Fertilization: Indications and Rationale Top


Neelam Ohri

New Life Rotunda, Advanced Fertility Center, Varanasi, Uttar Pradesh, India, E-mail: drneelamohri@gmail.com

Controlled ovarian hyperstimulation (COH) in intrauterine insemination (IUI) cycles might improve pregnancy rate by increasing the number of oocytes available for fertilization and implantation. However in high responders, COH may expose women to the risk of multiple pregnancy and ovarian hyperstimulation syndrome. Accordingly, monitoring the cycle and adjustments of the dose of gonadotropins and cancellation of the cycle when necessary are important treatment modality. Multiple pregnancy rates can also be reduced by aspiration of supplementary follicles followed by IUI. Indications for Cancellation of the Cycle: High estradiol (E2) levels and the number of follicles have generally been used as indications for canceling a cycle. It is reported that when there are more than 4 follicles larger than 14 mm on the day human chorionic gonadotropin, multiple follicles can develop. Rationale for Converting in In vitro Fertilization (IVF): With the advent of gonadotropin releasing hormone agonist antagonists, it became practical and possibly safer to convert stimulated IUI cycles to IVF instead of canceling cycles. Interestingly, to date, few studies have investigated the efficacy of the conversion from IUI to IVF and reported that conversion of gonadotropin IUI cycles in patients with excessive follicles to IVF is a safe and effective strategy. Most studies, which compared the pregnancy rate between the IVF group and the conversion from IUI to IVF group reported that the clinical pregnancy rate was similar between the two groups; however, implantation rates were higher in the conversion group. These cycles seem to be a mild stimulation protocol that uses lower doses of Gonadotropins. For this reason, patients can have better endometrial receptivity, the implantation rate can be increased and the cost can be lowered. With single or double embryo transfer policies in place, the prevalence of multiple pregnancy rates could be prevented. It was found that the E2 level in the conversion from IUI to IVF group was significantly lower than that in the regular IVF group. High levels of E2 may increase uterine contraction and thus adversely affect the IVF implantation rate.


  Role of albumin in ovarian hyperstimulation syndrome Top


Ila Gupta

Artemis Health Institute, Gurgaon, Haryana, India, E-mail: Ila_gupta007@yahoo.co.in

Aims: Role of Albumin in ovarian hyperstimulation syndrome (OHSS). Settings and Design : Retrospective Study at Artemis Health Institute, Gurgaon from February 2011 to 2013. Materials and Methods: Both albumin and hydroxyethyl starch have been used extensively in the treatment of OHSS, but very few studies have compared their efficacy. This is the study to compare the efficacy of 50 ml 20% human albumin (n = 43) and 500 ml 6% HAES (n = 43) in polycystic ovary patients of age group of 25-32 years and body mass index 20-22% undergoing in vitro fertilization/intracytoplasmic sperm injection with high-risk of developing OHSS (E2 >3000 pg/ml or >15 follicles, presence of free fluid, OV. size >7 cm). Prophylactically albumin and HAES administered on day of ovum pick up and embryo transfer. Patients were followed until day 7 of embryo transfer to check for severity of OHSS. Results: No severe OHSS case was observed in the albumin and HAES groups, while 2 patients from Albumin group and 1 patient from HAES group went into Moderate OHSS. Pregnancy rate same in both groups. Conclusions: Recommended preventing OHSS by using HAES, since it is as efficient but safer and cheaper than human albumin. The use of IV albumin in severe OHSS, but only when there is a drop in the level of albumin or following aspiration of a large volume of albumin-rich ascitic fluid is recommended. Albumin may be a feasible means of secondary prevention, ameliorating but not eliminating the physiological oppression of the disease.


  Surgical management of endometriotic cyst and its impact on ovarian reserve Top


Meenu Agarwal

Morpheus Bliss Fertility Centre, Pune, Maharashtra, India, E-mail: drmjainagarwal@hotmail.com

Introduction: Endometriosis is the presence endometrial tissue and glands at places outside uterus. It is associated with dysmenorrhea, dyspareunia and is a known cause of infertility. Diagnosis is confirmed on laparoscopy surgical treatment for endometriosis can be useful when the symptoms of endometriosis are severe or when there has been an inadequate response to medical treatment. Surgery is the p treatment of choice in cases of pelvic pain and infertility. Surgical therapies for endometriosis may be either classified as conservative, in which the uterus and ovarian tissue is preserved, or definitive, which involves hysterectomy (removal of the uterus), with or without removal of the ovaries. Laparoscopic excision of ovarian endometriomas gives immense pain relief. It is recommended that patients undergoing laparoscopic endometriotic cyst excision for infertility treatment should plan pregnancy soon after the surgery. The effect of endometriotic cyst excision on the ovarian reserve is still unsolved issue. In various studies post-operative AMH values, ovarian response to ovulation Induction (no of follicles), no of oocytes retrieved at Ovum pick have been studied as a measure to evaluate the affect of cyst excision on ovarian response. Discussion: Endometriomas occupy a large part of ovarian volume and decrease healthy ovarian tissue. Laparoscopic excision of endometriomas may adversely affect the ovarian reserve if not done carefully. In an already diseased ovary even a little loss of healthy ovarian tissue will make a large difference in residual ovarian reserve. In our study at MBFC, we have found reduced ovarian reserve in patients of endometriosis who underwent laparoscopic cyst excision as against women with endometriosis who were stimulated without cyst excision after medical suppression in patients with endometriosis undergoing in vitro fertilization (IVF) with endometriotic cyst suppression with medical management followed by IVF seem to give better oocyte yield in our study; however, large trials need to be conducted to study the effect of laparoscopic cyst excision on ovarian reserve.


  Role of bed rest after intrauterine insemination and embryo transfer Top


Pratik Tambe

Nirmiti Fertility and IVF, Thane, Maharashtra, India, E-mail: drpratiktambe@gmail.com

Embryo implantation after in vitro fertilization is a very complex event influenced by embryo quality and endometrial receptivity. Several methodologies and interventions have been described to increase the implantation rate, but bed rest is probably the most commonly prescribed. Since the etiology of implantation failure in most cases is not related to an excess of activity, it is questionable whether bed rest could be an effective strategy to improve pregnancy outcome. We performed a systematic review to evaluate the effect of prescription of bed rest to increase pregnancy rate. A systematic literature search was performed in MEDLINE to identify articles reporting randomized controlled trials (RCTs), which compared different time length of bed rest in infertile women undergoing embryo transfer (ET). We also revisit the Cochrane meta-analysis of 2009 on post ET interventions for in vitro fertilization/intracytoplasmic sperm injection patients. The conclusion is that there is insufficient evidence to support the routine use of a certain amount of time for women to have bed rest to improve pregnancy outcome after undergoing ET. In stark contrast, most of the current evidence recommends a 10-15 min interval of supine positioning following IUI as a method of improving success rates.


  A paternal influence on the embryonic capacity for implantation observed in a surrogate motherhood program Top


I Giakoumakis, D Daphnis, M Solanou, E Vlachopoulou, K Zotos, G Daligkaros, N Sofikitis

Mediterranean Fertility Institute, Crete, Greece, E-mail: ddaphnis@ivfgreece.com

We evaluated the influence of semen quality on the outcome of a surrogate motherhood program (SMP). Thirty two couples (group A) with normal semen parameters (i.e. sperm concentration, % motile sperms and % morphologically normal sperms) of semen analysis participated in our SMP. Another group of 28 couples (group B) with an abnormal value in at least one semen parameter was also included in this SMP-study. All female partners underwent ovarian stimulation and semen samples were collected from the male partners. These women asked to participate in our SMP because of a history of hysterectomy or the presence of malignant hypertension, sickle cell anemia, chronic renal failure, or liver insufficiency (among others). Intracytoplasmic sperm injection (ICSI) techniques were performed in all mature oocytes of each couple of groups A and B. One surrogate woman underwent transfer of two embryos generated from each couple of groups A and B. Thus, 32 surrogate women received embryos from the group A and 28 surrogate women received embryos from the group B. In addition, 31 couples (group C) with normal semen parameters participated in our SMP asking additionally for donor oocytes. Another group of 26 couples (group D) with an abnormal value in at least one parameter of semen analysis was also included in this SMP-study asking additionally for donor oocytes. The % fertilized oocytes (at 18 h post-ICSI), the % cleaved oocytes (at 36 h post-ICSI) and the % 8-12-cell stage embryos (at 72 h post-ICSI) were significantly lower (P < 0.05; Chi-square test) in group B than in group A and in group D than in group C. The proportion of (the pregnant surrogate women) to (the total number of the surrogate women who underwent embryo transfer) was significantly lower in group B (8/28) than in group A (14/32) (P < 0.05; Chi-square test) and in group D (8/26) than in group C (14/31). Couples requesting to participate in an SMP with at least one abnormal semen parameter have worse prognosis to achieve pregnancy suggesting that paternal factors affect detrimentally the outcome of SMP. Paternal factors affecting the last events of the fertilization process (such as oocyte activating factor, reproducing element of the centrosome, among others) and early embryonic development or embryonic capacity for implantation (i.e. paternal Deoxyribonucleic acid fragmentation, sperm nuclear proteins, paternal chromosomal aberrations, among others) may be the connective links between decreased semen quality and less optimal outcome in an SMP.


  A new strategy to reduce complications and improve results in assisted reproduction techniques for hashimoto's thyroiditis patients using a distinct dietary supplementation Top


Herbert Zech

IVF Centers Prof. Zech, 6900 Bregenz, Austria,

E-mail: h.zech@ivf.at

Introduction: In assisted reproduction techniques (ART), autoimmune thyroid disease (AITD) presents as common concomitant disease. Causing hypothyroidism and influencing cell-metabolism, AITD can impair fertility and pregnancy. Hashimoto thyroiditis (HT) patients undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) are thought to benefit from a broad therapeutic concept. We compared the outcomes of two different therapeutic schemes for HT patients and compared them to ART patients without thyroiditis. Materials and Methods: Female AITD patients were stimulated using the long protocol. TSH level was adjusted to under 2 ΅IU/mL using L-thyroxine as required. Concurrent medication from the time of oocyte puncture included daily administration of fragmin (dalteparin) and acetylsalicylic acid (ASA), as well as 5-10 mg prednisolone. Group 1 (n = 56) took additionally high-dose folic acid and group 2 (n = 50) was orally supplemented with a micronutrient preparation containing selenium, high-dose folic acid, B-vitamins, antioxidants and iron (Fertilovit; F THY). We compared the number of oocytes, fertilization rate, blastocyst formation rate, pregnancy-and ongoing pregnancy rate between the two groups and the average ART outcome of healthy patients within the same age group. Results: We observed a significant increase in blastocyst rate and ongoing pregnancy rate of AITD patients with micronutrient supplementation. These patients also needed less L-thyroxine to achieve optimal TSH levels. The outcome corresponded to the average of healthy IVF patients without AITD. Conclusions: AITD patients undergoing IVF/ICSI benefit substantially from a broader therapeutic approach including micronutrient supplementation. This therapeutic regimen results in a marked increase of pregnancy rate while requiring less L-thyroxine.


  Gonadotrophin free in vitro fertilization vs classical in vitro fertilization Top


Nadia L Suarez

New Hope Fertility Clinic, Punto Sao Paulo, Mexico, E-mail: dranadia-suarez@nhfc.mx

The first child born after in vitro fertilization (IVF) was conceived in a spontaneous cycle, however, natural cycle IVF and has since been largely ignored, mostly due to the advances in ovarian stimulation. In the last few years, the definition of success has changed toward achieving one healthy pregnancy that comes from one good embryo, aiming toward a more physiological approach, with less medication and higher quality in the laboratories. For 25 years, ovarian stimulation has been applied aiming to increase the number of oocytes to compensate for inefficiencies of the IVF. Currently used medication regimens for ovarian stimulation are complex, expensive, may require weeks of daily injections and intense monitoring is usually needed. Such regimens are associated complications such as ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. Other negative effects associated with ovarian stimulation include emotional stress, high drop-out rates and physical discomfort. Moreover, uncertainties remain regarding long-term health risks and an increased incidence of low birth weight and birth defects in the offspring conceived following IVF treatment. A potential concern regarding the application of milder stimulation protocols is that a decreased ovarian response following mild stimulation will reduce pregnancy rates. However, increased efficacy of IVF laboratory procedures and the current tendency to limit the number of embryos transferred, has reduced the need for large quantities of oocytes. Furthermore, supportive evidence regarding a potentially negative effect of supraphysiological steroid levels on endometrial receptivity, corpus luteum function, oocyte and embryo quality, indicate that limited ovarian stimulation and response might have a beneficial effect upon implantation potential.


  In vitro maturation of oocytes results are comparable and may have advantages over standard in vitro fertilization Top


Adrian Ellenbogen, Tal Shavit, Einat Shalom-Paz

Department of Obstetrics and Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel,

E-mail: ellenbogen55@yahoo.com

Introduction: In vitro maturation (IVM) has advanced significantly from its initial description to its current widespread clinical applications. Despite these advances, however, there are still many controversial issues surrounding this treatment. Given that IVM is an emerging protocol (at least in humans), there are many controversial areas of debate and especially regarding the subject of the best candidates for IVM; how should we select our patients? Aims: The aim is to evaluate the outcome of IVM procedure in perspective with known routine in vitro fertilization (IVF) results. Settings and Design: University IVF Unit. Materials and Methods: The PubMed database was searched from 1999 to 2012 for publications concerning the indications and results of IVM and to examine the possibility that IVM results may be comparable to standard IVF. Results: IVM of the oocyte procedure obtained a 35% clinical pregnancy rate in young women, comparable with IVF in many programs. The IVM obstetrics and perinatal outcome are comparable with IVF/intracytoplasmic sperm injection. The improvement in treatment and protocol has produced good results. Conclusions: In vitro maturation of oocytes is a simple procedure. It is economical and less stressful for women. Puncture is simple and safe. It can avoid short-term complications, such as ovarian hyperstimulation syndrome and long-term complications, such as hormone dependent neoplasms including breast and ovarian cancers. Studies to date have not identified an alarming rate of congenital anomalies in IVM children. IVM holds great promise as an alternative to assisted reproduction techniques


  Is there an increased risk of chromosomal abnormalities after assisted reproduction techniques? Top


Amos Ber

Company Maccabi Health Centers, Israel,

E-mail: dr.amosber@gmail.com

The articles dealing with the risk of malformations following assisted reproduction techniques (ART) are inconsistent and contradictory. A retrospective cohort study using data from three population-based registers in Australia found a 53% increased risk of major birth defects in singleton embryos: 8.7% of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) singletons compared with 5.4% of non IVF/ICSI singletons a similar result was found in another large study in Australia. Other articles found the risk of a birth defect to be increased among women with a history of infertility, but no accompanying history of treatment with ART. Some articles even found a lower malformation rates following ART. In this review lecture I will try to explain the mechanisms behind the possible association between ART and birth defects. Given the fact that there is no increased risk after cryopreservation and that sub fertile couples not undergoing ART tend to show more birth defects we will try and see if it is the ART treatment or the sub fertile patient that is responsible for this increased birth defects rate. A large meta-analysis found an increased birth defects rate in IVF and ICSI versus spontaneously conceived children. In the case of ICSI, but not IVF, the increased risk of birth defects persisted after adjustment for maternal age and several other risk factors. Another meta-analysis tried to separate the risk of major malformation in ART offspring attributable to sub fertility from the risk attributable to ART. After adjusting for sub fertility, they found no increased risk. The available data is confusing. A history of infertility, either with or without assisted conception, has been found to be significantly associated with birth defects. Increased risk of fetal malformations with ICSI, not confirmed in all studies. It remains to be determined whether IVF, with or without ICSI, is associated with an increased risk of fetal abnormalities or is it to a large extent a reflection of the unique parental characteristics of couples requiring these infertility treatments.

Tuesday 8 th October 2013


  Delayed Ovarian Hyperstimulation Syndrome Top


Soumyaroop Dash

Srishti Assisted Fertility and Advanced Laparoscopy Center, Puducherry, India, E-mail: sdash2k1@yahoo.co.in

This lecture will look into the aspect of late ovarian hyperstimulation syndrome, which presents as a special challenge to the management of ovarian hyperstimulation, as all the cases are associated with pregnancies. Ovarian hyperstimulation stimulation syndrome is one of the most dreaded complications of Gonadotropin therapy. The early variant, is invariably, associated with the HCG given as the ovulation trigger, whereas, the late variant, is almost always associated with endogenous hCG production as a result of a pregnancy. The special challenges posed in the management of ovarian hyperstimulation syndrome along with the safe continuation of pregnancy will be discussed, with an overview on prediction and probable prevention of the condition.


  Adnexal torsion in assisted reproduction techniques Top


Shai E Elizur

IVF Unit, Assuta Medical Center, Tel Aviv, Israel, E-mail: shai.elizur@gmail.com

Adnexal torsion is defined as the twisting by at least one complete turn of the adnexa, ovary, or more rarely the tube alone, around a center-line consisting of the infundibulopelvic ligament and tubo-ovarian ligament. Ischemia is the direct consequence of the twists in the adnexa. It is caused by the drop in adnexal circulation. In the absence of treatment, the ischemia will result in necrosis of the ovary, fallopian tube or whole adnexal structure followed by loss of the ovary or the adnexa. Ovarian stimulation is recognized as an etiology for adnexal torsion due to the increase in volume and weight of the adnexa and exceptionally leads to bilateral adnexal torsion. The risk of adnexal torsion following in vitro fertilization is 0.08%, increasing to 0.6% in pregnancies obtained by ovarian stimulation and up to 7.5% in patients presenting with ovarian hyperstimulation syndrome. Patients with adnexal torsion usually experience the sudden onset of intense unilateral pain that usually develops over a short period of time. Associated signs such as nausea and vomiting are present in about 70% of cases of adnexal torsion. A latero-uterine tender mass may be found during clinical examination. US examination reveals a pathological adnexal image in most cases. The only certain way to diagnose adnexal torsion is surgery, whether by laparoscopy or laparotomy. When adnexal torsion is suspected, surgical treatment should take place as an emergency. Conservative treatment consists of untwisting the adnexa. Radical treatment with adnexectomy of the twisted adnexa is rarely performed today and should be avoided if possible.


  Pelvic abscesses after oocyte retrievals for assisted reproduction techniques Top


Ofer Fainaru

Department of Obstetrics and Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel,

E-mail: ofainaru@techunix.technion.ac.il

Pelvic abscess formation is a rare but well-recognized complication of oocyte retrieval after in vitro fertilization. The risk of infection and abscess formation has been shown to be higher in patients with endometriomas or previous pelvic inflammatory disease (PID). Infections occurring after oocyte retrieval up are attributed to: (1) Direct inoculation of bacteria from the vagina during the intervention. (2) Accidental puncturing of latent infection pockets of the uterus or ovary. (3) Intestinal perforation. The symptoms are often poor and not specific; therefore the diagnosis is sometimes difficult to establish. Nevertheless, an ovarian abscess after oocyte retrieval may be a severe complication that requires accurate diagnosis and prompt intervention. Initial treatment is with intravenous antibiotics. When no response to antibiotics is demonstrated within 72 h, if the abscess ruptures, or if surrounding organs are affected by the inflamed mass, immediate laparoscopy or laparotomy for drainage is the main treatment. The use of ultrasonographically-guided aspiration is controversial and has yet to be further evaluated. Prevention of infection and abscess formation is possible by compliance with the strict rules of asepsis at the time of the intervention: i.e. Sterile operative fields, sterilized or single use material. The use of antiseptics to prepare the vagina may be of value, but studies have failed to show significant benefit over saline in terms of reduced infection risk. The administration of prophylactic broad-spectrum antibiotic therapy is controversial however its use in cases of punctured endrometriomas and previous PID or other intra-abdominal infection is most probably justified.


  In Vitro0 Fertilization In Developing Economies Top


Gautam Allahbadia

Rotunda CHR, Assisted Reproduction Laboratory, Mumbai, Maharashtra, India, E-mail: gautam@rotundaivf.com

World-wide more than 80 million couples suffer from infertility, the majority being citizens of developing economies. In developing societies, childlessness is often highly stigmatized and leads to profound social suffering for infertile women in particular, yet most infertile people in the developing world have virtually no access to effective treatment. Bilateral tubal blocks due to sexually transmitted diseases and pregnancy-related infections is the most common cause of infertility in developing countries, a condition that is potentially treatable with assisted reproductive technologies (ART). New reproductive technologies are either unavailable or very costly in developing countries due to private monopoly. Guidelines in the successful implementation of infertility care in low-resource areas include simplification of ART procedures like adopting IVF Lite, minimizing the complication rate of procedures like elimination of ovarian hyperstimulation syndrome, providing training-courses for health-care workers and incorporating infertility treatment into sexual and reproductive health-care programs. One of the United Nation's Millennium Development Goals was for universal access to reproductive health-care by 2015, and World Health Organization has recommended that infertility be considered a global health problem and stated the need for adaptation of assisted reproduction technology in low-resource countries. In India, we have been trying to make IVF more affordable to ensure a wider reach across the socio-economic strata with introduction of cheaper and more patient-friendly Assisted Conception procedures without compromising on results. Routine IVF, is slowly being challenged by simpler and more cost-effective methodologies. These include natural cycle IVF, minimal stimulation IVF (msIVF) and IVF Lite (msIVF + vitrification + accumulation of embryos + remote embryo transfer) (msIVF + ACCUVIT + rET).


  What are we learning from time lapse technology? Top


Esther Velilla

Department of Embryology, Institute Marques, Barcelona, Spain, E-mail: esther.velilla@pgdcem.com

Both the culture of gametes and embryos as well as the selection of optimal embryos for transfer suppose a critical step in the laboratory of in vitro fertilization (IVF). Until now, classical morphological assessment evaluates certain embryonic parameters in specific moments of their development and these are the ones that will be used to select which embryos have a better prognosis of implantation and ongoing pregnancy. Although multiple observations provides a better understanding of the embryonic development, using standard incubators obliges to find a balance between the number of observations and the need of not exposing embryos to suboptimal conditions.

The development of the Time-Lapse technology: (i) Makes possible to perform periodic observations of the embryos without needing to modify the growing conditions and (ii) it has been possible to detect certain events and alterations that would otherwise go unnoticed. As a result, several studies have established some morphkinetic markers predictive of good quality embryos and implantatory potential embryo at day +3 and day + 5, as well as to relate some morphkinetic parameters with the embryo's chromosome dotation.Morphkinetic parameters provide us additional important information to improve the classical embryonic selection criteria and achieve a better prognosis in the IVF treatments.


  Myomectomy: laparoscopic versus laparotomy-farah hospital experience Top


Z Kilani, L Haj Hassan, S Kilani, T Shaban

The Farah Hospital, Amman, Jordan,

E-mail: farah1@go.com.jo

Uterine leiomyomas are clinically appeared in 25-50% of women. Leiomyomas called also fibroids, are benign neoplasms usually require treatment only when they cause symptoms. The most common symptoms for which women seek treatment are abnormal uterine bleeding and pelvic pressure or pain.

The current practical methods for treatment of fibroids are:

Surgical:

Laparotomy, myomectomy

Laparoscopic myomectomy

Robotic - Assisted laparoscopic myomectomy

Embolization to the uterine artery.

Non-Surgical:

High intensity focused ultrasound (HIFU)

Gonadotropin-releasing hormone

Progesterone antagonist mifepristone (RU 486).

The main discussion will focus on laparoscopic surgery to be or not to be? Advantages and hazards. Farah surgical method will be elaborated to prevent bleeding, hematoma and adhesions. HIFU will be discussed which might replace in some cases all previous available methods.


  Fetal challenges in assisted reproduction techniques pregnancies Top


Chitra Andrew, S Suresh

Mediscan Systems, Chennai, Tamil Nadu, India,

E-mail: chitraandrew@gmail.com

Ectopic pregnancy and multiple gestations are the main fetal complications of assisted reproduction techniques (ART) pregnancies. The perinatal complications include preterm birth, growth restriction and increased mortality. Ectopic pregnancy is increased 3-5 in ART pregnancies times due to previous tubal disease and pelvic infection. Technical factors include volume and technique of transfer of embryos. Ectopic pregnancy especially pregnancy of unknown location (PUL) where serum HcG is positive and at the but ultrasound does not reveal pregnancy requires a protocol based approach to avoid missing diagnosis. Aneuploidy screening in ART pregnancies is altered in multifetal pregnancies depending on chorionicity and intracytoplasmic sperm injection pregnancy. When there is discordance for anomalies on targeted scan or screen positivity, decision for invasive procedure and need for selective fetal reduction has to be decided taking into account the couple's preferences. Fetal reduction for pregnancies with higher orders multiples and those with anomalies in twin pregnancies are to prevent preterm labor. The protocol includes decision to perform reduction, evaluation, counseling, timing and technique and post reduction follow-up. Decision to reduce is based on the number of fetuses and chorionicity. Fetal reduction has been performed in our center from 1991. Over 2500 procedures have been performed. The procedures performed in the last year were over 400 and these have been followed to delivery. The take home baby rates are >80% and comparable to several published studies. A successful ART cycle requires careful, protocol based but individualized fetal care to increase take home baby rates.


  Outcome of twin pregnancy in hysteroscopically corrected patients of incomplete septum Top


Kemal Ozgur, Hasan Bulut, Murat Berkkanoglu,

Kevin Coetzee, Serdar Ay 1

Antalya IVF, Antalya, 2 Sinanpaşa Family Health Center, Beşiktaş, Istanbul, Turkey, E-mail: kemalozg@yahoo.com

Aims: The aim is to compare the gestational timing of obstetric events in patients who had hysteroscopic surgery for incomplete uterine septa with patients who had normal uteruses, following the confirmation of clinical twin intrauterine pregnancies (TIUPs) from intracytoplasmic sperm injection - embryo transfer treatment. Settings and Design: Retrospective dual cohort study. Materials and Methods: An incomplete septum was diagnosed if (1) the fundal myometrium (Fm) was at least 11 mm and (2) the difference between the Fm and corneal myometrium at least 5 mm. A clinical TIUP was defined as the visual confirmation of two fetal hearts by ultrasound. Live birth was defined as a delivery of a live fetus after 20 weeks, miscarriage as the spontaneous loss of a clinical pregnancy before 20 weeks and preterm delivery as a delivery of a live fetus prior to 38 weeks. 704 clinical TIUPs were extracted from our in vitro fertilization database and divided into two groups for analysis, those in normal uteruses (n = 616) and those in hysteroscopically corrected uteruses (n = 88). Results: In the septum group the miscarriage rate (7.95% vs. 3.1%) was significantly higher and the live delivery rate was significantly lower (81.8% vs. 92.7%). The septum group had more preterm deliveries (87.7% vs. 83.6%) and a higher proportion of these were extreme (14.1% vs. 6.4%) and very preterm (19.7% vs. 12.0%) deliveries. Conclusions: The surgical correction of incomplete uterine septa unquestionable leads to an improvement in uterine reproductive performance, but patients with TIUP pregnancies remain at risk for higher than normal miscarriage and lower live delivery rates.


  Assisted reproduction techniques: the aftermath Top


Swati Allahbadia

Rotunda Blue Fertility Clinic and Keyhole Surgery Center, Mumbai, Maharashtra, India,

E-mail: doctor@rotundafertilityclinic.com

Pregnancies following an assisted reproductive procedure may be complicated by the pre-existing medical derangements in the patient such as diabetes, hypothyroidism, hyperprolactinemia, obesity, hypertension or chronic diseases like tuberculosis. Multiple Surgeries done on these patients such as curettages, metroplasties, myomectomies or synechiotomy predispose them to the rare and life-threatening Placenta accreta or even percretas and uterine rupture. These women have a higher risk of Ectopic pregnancies compared to those who conceive spontaneously. Abortions and preterm deliveries are also known to be associated with this unique group of patients. Advanced age with increased risk of chromosomal anomalies and passing on chromosomal abnormalities like the microdeletion of the Y chromosome to the offspring need investigation and management. Multiple pregnancies and their attendant problems also need special attention. Further there are the social and psychological issues of advanced parental age, financial strain and anxiety about outcomes of these precious pregnancies that need attention well into the postpartum period. This presentation aims to present these problems with case studies and review of literature to help obstetricians better manages this new "high risk" group of women who conceived after assisted reproduction techniques.


  In vitro maturation: its growing role in preventing assisted reproduction techniques complications Top


Shai E Elizur

IVF Unit, Assuta Medical Center, Tel Aviv, Israel,

E-mail: shai.elizur@gmail.com

In vitro maturation (IVM) is a specialized in vitro fertilization (IVF) treatment in which no or minimal hormonal stimulation is used. Follicular aspiration is done when the follicles are small in size (5-12 mm) and the aspirated oocytes are still immature (in the germinal vesicle or metaphase 1 (MI) stage]. The immature oocytes are matured in the laboratory using designated IVM medium supplemented with the hormones follicle stimulating hormone (FSH) and luteinizing hormone (LH). Oocyte maturation is assessed 24-48 h after their retrieval and oocytes that matured in-vivo (MII stage) are fertilized by intracytoplasmic sperm injection. The research into maturation of oocytes goes back to 1935 but it was only in 1991 when IVM of oocytes was incorporated as a treatment for human infertility and the first human pregnancy was reported. Conventional IVF treatment requires that the ovaries be stimulated with FSH and LH in order to increase the number of mature oocytes retrieved and consequently to improve pregnancy rate. However, ovarian stimulation protocols carry a risk (of up to 6% in high risk patients) of developing ovarian hyperstimulation syndrome (OHSS) which may be associated with significant morbidity. Several methods have been proposed in order to minimize the risk of OHSS in those high-risk patients among them is IVM. Today IVM is mainly considered as treatment for patients with polycystic ovarian syndrome or polycystic ovaries and for fertility preservation.


  Complications and management of monochorionic twins Top


Chitra Andrew, S Suresh

Mediscan Systems, Chennai, Tamil Nadu, India, E-mail: chitraandrew@gmail.com

Chorionicity assessment is very important in twin pregnancy. This is because monochorionic twin pregnancies are more associated with complications owing to unbalanced vascular anastomoses within the placenta. The associated complications include twin reversed arterial perfusion sequence, severe malformations in one twin, selective fetal growth restriction and Twin twin transfusion syndrome (TTTS). TTTS occurs in 15% of MCDA twins which is overall 1 in 2000 pregnancies. If untreated the condition results in 80% mortality. The condition is due to arterio-venous anastomoses (AVA) which could be unbalanced. Selective fetal growth restriction especially when early in onset may predispose to single twin demise and vascular consequence to the co-twin. These can lead to neurological complications and hence laser ablation of the moribund twin will improve chances for the co twin. In 2004, the EURO fetus trial showed that fetoscopic laser ablation results in higher survival for at least one survivor and improved neurological outcome for TTTS compared with amnioreduction. Introduction of fetoscopic procedures and use of laser has improved outcomes. Laser procedure is used to ablate the anastomotic vessels and" dichorionize" the placenta. In twin reversed arterial perfusion sequence, interstitial laser is used for cord occlusion at the hilum. In selective fetal growth restriction with impending fetal demise cord occlusion permits survival of the co-twin to a more mature gestational age without the fear of neurological damage. The procedures used with careful choice of the cases can improve the take home rates in pregnancies complicated by these rare complications.


  Should we injure the endometrium? Top


Ofer Fainaru

Department of Obstetrics and Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel,

E-mail: ofainaru@techunix.technion.ac.il

Aims: Endometrial injury in the cycle preceding ovarian stimulation has been proposed to improve implantation in women undergoing in vitro fertilization (IVF). We sought to examine the association between endometrial injury and implantation, to describe possible mechanisms for this effect and to try and establish clinical guidelines for infertile couples in light of the current evidence. Materials and Methods: Review of current literature. Results: We reviewed observational data, randomized controlled trials and meta-analyses of studies comparing the efficacy of endometrial injury versus no intervention in women undergoing IVF. Finally, we reviewed evidence from basic science studies that suggest potential mechanisms for improved implantation after injury. Conclusions: Current evidence suggests that endometrial injury performed prior to the embryo transfer cycle improves clinical pregnancy and live birth rates in women undergoing IVF. Elevated pro-inflammatory cytokine expression and an increased abundance of inflammatory cells (such as macrophages and dendritic cells) in the endometrium following injury are proposed mechanisms for improved uterine receptivity.


  Ovarian hyperstimulation syndrome prevention with gonadotropin releasing hormone agonist agonist trigger Top


Kemal Ozgur, Hasan Bulut, Murat Berkkanoglu, Kevin Coetzee

Antalya IVF, Antalya, Turkey, E-mail: kemalozg@yahoo.com

Aims: The aim is to analyze the incidence of ovarian hyperstimulation syndrome (OHSS) in high response patients following antagonist COS with ovulation induction using either gonadotropin releasing hormone agonist (GnRHa) or the traditional human chorionic gonadotropin (hCG) trigger, as well as, the embryology and pregnancy outcomes following intracytoplasmic sperm injection - embryo transfer. Settings and Design: A retrospective dual cohort study. Materials and Methods: COS was performed using a GnRH antagonist protocol with rFSH and hMG. Ovulation was induced with a GnRHa or a hCG trigger. 160 high response patient cycles (>15 oocytes) were extracted from our in vitro fertilization database, 97 received hCG and 63 GnRHa. Results: Significantly more oocytes (30.7 ΁ 8.34 vs. 26.9 ΁ 9.0) were retrieved from GnRHa cycles than hCG cycles, more were mature (75.1% vs. 66.1%) and more fertilized (77.7% vs. 72.7%). Embryo quality as defined by the number of good quality 8 cell embryos (5.5 ΁ 3.21 vs. 4.8 ΁ 2.84) on day 3 and the number of usable blastocysts (11.0 ΁ 5.16 vs. 9.55 ΁ 4.31) was also greater in the GnRHa group. The average number of embryos replaced per cycle was similar (1.81 ΁ 0.39 vs. 1.88 ΁ 0.32), however the early pregnancy loss rate was higher in the hCG group (11.6% vs. 20.9%) and the clinical pregnancy rate (50.5% vs. 60.3%) lower in the hCG group. 3 cycles from the hCG group developed OHSS. Conclusions: Ovulation induction with GnRHa in high responders not only limits the risk of developing OHSS, but overall also produces better reproductive outcomes, as more mature oocytes, more good quality embryos, a lower pregnancy loss rate and a higher clinical pregnancy rate was obtained.


  Difficult embryo transfer Top


Ritu Jain

Vardhman Medicare Centre, Institute of IVF/ICSI, Laparoscopy and Child Care, Gurgaon, Haryana, India, E-mail: vmcgurgaon@gmail.com

Aim: Embryo transfer (ET) is the most important, independent factor that influences the success of the treatment cycle. We analyze all the variables of ET and present the best practice to improve success rates. Review of Literature: Difficult ET lowers success rate significantly, 10.5% versus 33.3% if the ET is atraumatic. Certain factors decrease pregnancy rate like

  • Blind ET
  • Touching the fundus
  • Mucus in catheter
  • Uterine contractions
  • Infection at tip of catheter
  • Increased interval between loading discharging
  • Transmyometrial transfer.


On the other hand better pregnancy rates are achieved with

  • Ultrasound guided transfer
  • Midcavity placement of embryos
  • Aspiration of cervical mucous prior to transfer
  • Minimizing uterine contractions by minimal handling
  • Aseptic technique
  • Minimizing the time between loading and uterine placement of embryos
  • Avoiding transmyometrial transfer
  • Performing a dummy transfer in difficult cases and dilating the cervix prior to the in vitro fertilization cycle in difficult cases is of benefit.
  • Administration of progesterone post ovum pick up will minimize uterine contractions. Soft catheters are less traumatic. Slow release of embryos and withdrawing of the catheter maintain the pressure on the plunger to prevent recoil is recommended. Correct loading of the embryos in the catheter to prevent their accidental spillage is also important. Checking the catheter post ET will ensure completeness of transfer. Newer techniques of hysteroscopic endometrial embryo delivery will be discussed.



  Factors affecting success rate of assisted reproduction techniques Top


Sandeep Talwar

Department of IVF, Bourne Hall Clinic, Gurgaon, India, E-mail: sonutalwar2001@yahoo.co.in

Age of female partner, ovarian reserve, type of pathology, peak estradiol levels, type of gonadotrophin used, agonist versus antagonist, no. of embryos transferred, endometrial quality, effect of uterine malformations. Age: Woman's age is the most important affecting live birth after assisted reproductive technique (ART). From Centers for Disease Control 2002 data - live birth rate per cycle range from 40% in women aged 27-6% at age 43 years. Miscarriage rate (reaching 45% at 43 years) contributes to low live birth rate. Ovarian Reserve: Based on CDC data, compared with average live birth rate of 28.3%, live birth rate of 13.9% is seen with reduced ovarian reserve. Type of Pathology: Couples with male and female infertility have live birth rate of 26.4%. Uterine factor infertility-Live birth rate of 22.9%. Very little difference with diagnosis of tubal factor, ovulatory dysfunction, male factor or unexplained infertility. Similar live birth rate of 30-35%. Patients with endometriosis - A meta-analysis of studies concluded that these patients have lower pregnancy rates and that too those with severe endometriosis. Hydrosalpinx and ART-50% reduction in clinical pregnancy rate (Strandell A. Hum Reprod Update 2000). Peak Estradiol Levels: Increasing peak estradiol levels are associated with improved pregnancy rates after embryo transfer (ET) (Chen CH, et al., Fertil Steril. 2003, July). Type of Gonadotrophin Used: hMG versus Recombinant follicle stimulating hormone in a long protocol resulted in higher clinical pregnancy rates (van Wely M, et al., Fertil Steril 2003 Nov; 80 (5):1086-93). Agonist versus Antagonist: Agonists are superior to antagonists in no. of oocytes produced although percentage of mature oocytes produced and levels of fertility are comparable in both protocols. For poor responders antagonists are better (Frydman R, Ann Urol (Paris). 2005 Oct; 39). In vitro fertilization (IVF) versus intracytoplasmic sperm injection (ISCI) : Should be used for male infertility and failed fertilization. Pregnancy rates with ICSI are similar to those with IVF (CDC website). In non-male factor infertility there is no advantage of using ICSI over IVF in fact fertilization rates with IVF are higher. No. of Embryos Transferred: Endometrial quality - Endometrial dynamics do not correlate with pregnancy outcomes. Trilaminar pattern on day of ET was positively related to pregnancy out comes (Detti L, J Ultrasound Med. 2008 Nov).


  Effect of uterine malformations; does clean air have a role to play in assisted reproduction techniques results? Top


Richard Ajayi

The Bridge Clinic, Lagos, Nigeria,

E-mail:gloriae@thebridgeclinic.com

Introduction: The seminar and publication by Cohen et al. where they showed a significant reduction in their pregnancy rate when they moved from one clinic to the other has brought this topic to attention and indeed there are many publications and literature to support this position. Furthermore, the elaboration and volatile organic compounds by new equipment have been shown. On the order hand, there are publications that also suggest that volatile organic compounds are really much ado about nothing. Conclusion: My presentation will examine the evidence with the intention of defining if there is a need for the required investment in providing and eliminating volatile organic compounds from in vitro fertilization laboratories.


  Ultraviolet air purification system for healthcare industry Top


Sudeep Sethi

SPC Heat Pipes FZC, Dubai, UAE,

E-mail: sudeep.sethi@spcoils.ae

Health care buildings are built tight and insulated to combat energy loss and as a result of that biological and chemical concentrations continually rise within the building's envelope. HealthCare facilities face a myriad of indoor air quality (IAQ) issues from not bringing in enough outside air, not sterilizing the air and that leads to bacteria thriving in such environment and multiply exponentially. Ultraviolet air purification systems improve IAQ significantly and especially in the healthcare industry. Ultraviolet air purifiers will neutralize biological contaminants such as mold, bacteria, viruses, spores, allergens, all kind of odors and thousands of other airborne contaminants. Ultra violet (UV) energy disrupts the deoxyribonucleic acid of a wide range of microorganisms, rendering them harmless and eventually eradicating them from air. UV germicidal lamps are low pressure mercury lamps that emit UV energy at 254 nm and when applied in ducts for some time it purifies the air and keeps the system germ free and at the same time keeps the equipment more energy efficient and reduces replacement costs.


  Is a gonadotropin releasing hormone agonist trigger and remote embryo transfer the optimal approach for women with polycystic ovary syndrome undergoing in vitro fertilization? Top


Peter Kovacs

Kaali Institute, IVF Center, Budapest, Hungary, E-mail: peterkovacs1970@hotmail.com

Background and Aim: Polycystic ovary syndrome (PCOS) affects 5-7% of the reproductive age women. Since cycle irregularity and anovulation are typical features of the syndrome those wishing to become pregnant usually require some form of ovarian stimulation. When anovulation is the sole infertility problem women are usually prescribed medications to restore regular preferably mono-follicular development. Those with a more complex infertility problem and those who fail controlled ovarian hyperstimulation cycles generally proceed with human chorionic gonadotropin in vitro fertilization (IVF). During IVF the stimulation of women with PCOS to induce multi-follicular development however can turn out to be challenging. Some women with PCOS respond very slowly while others are very sensitive to stimulation and tend to hyper-respond. Ovarian hyperstimulation syndrome (OHSS) is the most serious, potentially life-threatening complication of IVF. Women with PCOS are at a high risk for this complication and therefore need to be managed carefully. Methods: Review of literature. Discussion and Conclusions: There are several management tools to choose from to minimize the risk of OHSS. For those at risk a proper, individually selected drug regimen is required and careful monitoring is mandatory. In general antagonist based protocols are safer as they are associated with a lower OHSS risk. The use of the antagonist allows flexibility with the final trigger injection leading up to the retrieval as well. Typically human chorionic gonadotropin (hCG) is administered to trigger ovulation. hCG however is also responsible for the initiation of those vasoactive changes that could result in OHSS and therefore when the response to stimulation is excessive its use should be avoided. Alternatively gonadotropin releasing hormone agonist (GnRHa) can be used to initiate the preovulatory changes. GnRHa results in retrieval and embryology outcome (fertilization rate, embryo development) that is comparable to that achieved with hCG. The induction of ovulation with GnRHa however is associated with a compromised luteal phase. The luteinizing hormone surge it induces is shorter and the luteal phase estradiol and progesterone levels are lower resulting in a decline in implantation and pregnancy rates. There are two options to choose from when GnRHa is used as the final trigger injection. Elective cryopreservation with the currently available vitrification technology is highly effective and essentially comparable pregnancy rates can be achieved to that achieved in a fresh cycle. This should be offered in those cases when high number of eggs are retrieved (>15-20 oocytes). When the number of eggs retrieved is lower a modified luteal support with low dose hCG administered on the day of retrieval can be considered. In this latter case the transfer in the fresh cycle is still possible with good clinical outcome and only a minimal risk of OHSS.


  Advances in the management of thromboembolic complications of assisted reproduction techniques Top


Srinivas Samavedam

Department of Critical Care, CARE Hospital, Hyderabad, India, E-mail: srinivas3271@gmail.com

The use of assisted reproduction techniques (ART) is rising all over the world. The developing world is not far behind. The science of ART is developing rapidly and is becoming increasingly available to a bigger proportion of population. As experience with the various modalities of ART increases, the prevalence of certain complications is also rising. The most significant of these complications is the group of disorders resulting from thrombosis. These thrombo embolic complications (TEC) could be arterial or venous or rarely both.

Thrombotic manifestations involving venous system are most often reported in the deep veins of the leg and consequent pulmonary embolism. Other territories where clinically significant venous thromboses have been reported are the portal venous system, hepatic veins, cerebral venous sinuses and renal veins. Upper extremity venous thrombosis is reportedly more common in the population undergoing ART than in the general population. The high oestradiol concentrations in the lymph returning to the thoracic duct are implicated in the pathogenesis of this increases prevalence. Similarly, arterial thromboses are most often reported in cerebral, myocardial and mesenteric beds. Ischemic strokes and myocardial infarctions are the most commonly published consequences. The timing of occurrence of these TECs is also temporally different. Arterial thromboses seem to occur earlier than venous events. Venous thromboses have been reported as late as 45 days after embryo transfer (ET). Successful ETs are associated with venous thromboses more often than arterial occlusions. Imaging modalities remain the mainstay for the diagnosis of TECs. Doppler sonography and magnetic resonance angiography are relatively safe and non-controversial for establishing the diagnosis of a vascular occlusion. Ventilation perfusion scan and computed tomography pulmonary angiography still have a role to play in situations where other modalities have yielded negative results or prognostic information is needed. The role of biomarkers is limited in this subset of patients. Heparin and low-molecular-weight heparin remain the mainstays for the treatment of non-life-threatening TECs. However, thrombolysis with tissue plasminogen activator is unavoidable in ischemic strokes and major pulmonary Embolii. Proper risk assessment, early diagnosis and appropriate treatment are the cornerstones of management.

Wednesday 9 th October 2013


  The ovarian hyperstimulation syndrome -free in vitro fertilization clinics: the blue print Top


Richard Ajayi FRCOG, FWACS

The Bridge Clinic, Lagos, Nigeria,

E-mail: gloriae@thebridgeclinic.com

Introduction: The morbidity and mortality associated with the ovarian hyperstimulation syndrome (OHSS) is such that most in vitro fertilization (IVF) practitioners go to great length to prevent the development of this syndrome and indeed there are clear strategies that can be employed that can minimize or eliminate the risk of OHSS. On the order hand, women at risk of having OHSS tend to produce many oocytes which increase their chances of pregnancy. The balance is getting an adequate yield of oocytes and therefore, the benefits without developing the OHSS. Our knowledge of OHSS has improved recently through the identification of vascular endothelia growth factor (VEGF) as the main causative factor. VEGF is expressed on the granulosa cells, causes hyper-permeability of the vascular endothelium and fluid shift from the intravascular compartment into the third space. Accumulation of fluid in these spaces is responsible for most of the symptoms experience by patient who has OHSS. To achieve the balance of getting good oocyte yield without OHSS requires the following: Identification of patient as risk of having OHSS, patient who have high Anti-Mullerian Hormone ≥5 ng/ml, large number of antra follicles and patients who have polycystic ovarian syndrome are at significant risk of having OHSS. Use of antagonist protocol with agonist trigger this has been shown to prevent early OHSS and when combined with "freeze all" i.e. oocytes and embryo vitrification and patient can have interval transfer using either their natural cycle of hormone replacement cycle. Use of low dose follicle stimulating hormone (FSH) for patient at risk or tailing off FSH when follicles are >14 mm has been shown to reduce risk of OHSS. Reducing the dose of human chorionic gonadotropin (hCG) to 5,000 IU reduces the risk. However, in overweight women reducing the dose of hCG may be associated with low oocytes yield at retrieval and poor implantation rate. Coasting has been used many years to prevent or at least reduce the risk of OHSS. The use of pharmacological agents such as dopamine agonist, which antagonizes VEGF at the receptor level, has been shown to reduce the risk of OHSS and metformin in patients who have polycystic ovary syndrome. Paracentesis either vaginal or abdominal has been shown to reduce the morbidity of OHSS and hospitalization in event OHSS develops. Conclusion: My presentation will focus on strategies that can be employed to achieve safe and effective IVF treatment thereby providing our patients with the higher chance of pregnancy with the attendant risk of OHSS.


  Intensive care management of ovarian hyper stimulation syndrome Top


Srinivas Samavedam

Department of Critical Care, CARE Hospital, Hyderabad, India, E-mail: srinivas3271@gmail.com

The application of assisted reproduction techniques (ART) is on the rise. It is a global phenomenon and the developing world is not an exception. With increased use of ART, certain complications are increasingly being reported. One such complication, which has received lot of attention and publicity, is the ovarian hyperstimulation syndrome (OHSS). The syndrome is essentially a consequence of exaggerated response to ovulation induction. The syndrome is more often associated with gonadotrophin induced stimulation. The severity of this self-limiting syndrome varies from the mildest form to its most serious fatal form. The pathophysiological hallmark of the syndrome is increased capillary permeability. This forms the basis of the accumulation of protein rich fluid in third space compartments leading to mechanical and functional derangement of several organ systems. Vascular endothelial growth factor seems to play a key role in the pathogenesis of the syndrome. The endothelial integrity, viscosity of blood and flow are all compromised as a result of the action of this factor. Several risk factors have been identified which can determine the severity of the syndrome. Interestingly, pregnancy seems to predispose to a persistent and occasionally severe form of the syndrome. Milder forms of the disease can be managed on out-patient basis. However, patients with more severe grades of the disease need to be hospitalized. Some of them would require intensive monitoring of volume status and targeted fluid therapy. Attention to the hypercoagulable state of OHSS is crucial. Critical electrolyte abnormalities have to be aggressively sought and treated. Invasive hemodynamic monitoring is needed in a very small proportion of these patients. The need for albumin, diuretics and ultrafiltration needs to be carefully assessed. Thrombolytic therapy may be needed for those who have pulmonary, cerebro vascular or coronary thrombosis.


  Complications of ovarian hyperstimulation syndrome and how to get the patient home Top


Bharesh Dedhia

Department of Surgical Critical Care, Fortis Hospital, Mumbai, Maharashtra, India,

E-mail: bharesh.dedhia@fortishealthcare.com

Ovarian hyperstimulation syndrome (OHSS) results from supraphysiological stimulation of ovaries, usually during ovulation induction by gonadotropins. It was shown that human chorionic gonadotropin (hCG) along with vascular endothelial growth factor (GF), Angiotensin II, Epithelial GF, Insulin like GF I, Transforming GF (TGF), Platelet-derived GF, etc., may play a role. OHSS is classified as (1) mild (2) moderate (3) severe. Mild: Cystic ovarian enlargement ~5 cm. Moderate: Ovarian enlargement between 5 and 12 cm accompanied by: Gastrointestinal (GI) symptoms-bloating, abdominal distension with tenderness, N/V etc., ultrasonography (USG) pelvis shows moderate amounts of fluid. Severe: Massive ovarian enlargement >12 cm, ΁S/S of moderate OHSS which are more pronounced with clinical evidence of intravascular fluid loss. Clinical signs may include: Ascites, pleural effusion, pericardial effusion, anasarca, abdominal pain, electrolyte imbalance, hypovolemia, oliguria, acute respiratory distress syndrome (ARDS), thromboembolic phenomena and hypovolemic shock. Management: As pathogenesis of OHSS remains enigmatic, the treatment remains empiric. Mild OHSS: Mild OHSS requires reassurance that in absence of pregnancy, symptoms should resolve within 2 weeks after administration of hCG. This does not require hospitalization. However, if pregnant, symptoms may progress. Moderate OHSS: In this case patients with moderate ascites and mild hemoconcentration, hospitalization and in vitro fertilization are required. Any deterioration such as abdominal pain and/or severe GI symptoms should be managed under hospitalization according to guidelines for severe OHSS. Severe OHSS: Severe OHSS requires hospitalization and prompt treatment. Basic disturbance include acute shift of fluids from intravascular compartment to peritoneal, pleural and sometimes pericardial cavity. Hemoconcentration: The dramatic and rapid shift of intravascular fluid into the third spaces is responsible for morbidity and occasional mortality of OHSS. This is indicated by hemoconcentration. Additional measure of hemoconcentration is leukocytosis; as high as 35,000/mm 3 may be seen. Fluid Therapy: Crystalloids remain mainstay of fluid therapy. Because of the tendency for hyponatremia NS is preferred. Intra vascular volume replacement should result in improved renal perfusion before it escapes into third space. However, this transient hemodilution is achieved at expense of increasing ascites. Whenever adequate fluid balance cannot be restored by crystalloids alone, colloids should be utilized. At present, many agree that as albumin is the protein that is lost in OHSS, it is the preferred volume expander. 20-40 g of Albumin repeated every 2-12 h, is an extremely effective plasma expander in OHSS. Tense Ascites: At a relatively advanced stage, tightening abdominal wall with rapid accumulation of ascitic fluid can be seen. At this stage of relatively restored intravascular volume and improved renal perfusion, there is sudden paradoxic onset of oliguria, increasing creatinine, This results from significant rise in intraabdominal pressure (abdominal compartment syndrome) produced by tense ascites, which may impede renal venous outflow, causing congestion, renal edema and possibly thrombosis. Treatment includes paracentesis and diuresis in some patients. Paracentesis: The indications for paracentesis include the need for symptomatic relief, tense ascites, oligoanuria, rising creatinine and hemoconcentration unresponsive to medical therapy. Paracentesis should only be performed with USG guidance. The critical form of OHSS is complicated by multiple system failure. The most severe consequences of OHSS are renal failure, heart failure, thromboembolic phenomena and ARDS. Patients in such a critical condition should be in intensive care unit. The therapy remains largely empiric. Oliguria and rising creatinine is seen. Dopamine drip may be helpful. Intensive monitoring, including central venous pressure and pulmonary capillary wedge pressure may be required. Once renal failure has occurred, hemodialysis may be necessary. At this stage, if the patient is pregnant, the painful alternative of pregnancy termination should be strongly considered. Heart Failure: Increased capillary permeability may result in cardio-respiratory problems. Diaphragmatic movement may be restricted compromising respiratory function. Cardiac output may be impaired. Pleural effusions only require drainage if symptomatic and pericardial effusions are best managed conservatively. Thrombosis: Although abnormalities of the coagulation system have been identified, there is no coagulation abnormality in most. Increased risk of thromboembolism probably relates to frequent occurrence of hemoconcentration. To reduce risk, patients should be encouraged to move their legs; use deep vein thrombosis stockings and SC heparin or low-molecular-weight heparin (LMWH) may be helpful. Treatment of Thrombus in OHSS: Prophylactic heparinization may be effective for high risk patients, especially for those with associated OHSS, but when thromboembolism is diagnosed treatment with heparin or LMWH is recommended and should be maintained throughout pregnancy. Surgical Management: Surgical management is reserved only for acute cyst complications such as hemorrhage or torsion and for ruptured ectopic pregnancy or abortion. In case of unruptured ectopic gestation, expectant management (in face of falling hCG levels) or chemotherapy should be preferred. Because of ascites and ovarian enlargement, laparoscopy is contraindicated and surgery should be avoided.


  Relevance and importance of contemporary imaging in thrombo-embolic complications of assisted reproduction techniques Top


Bhavin Jankharia

Department of Radiology, Jankharia Imaging, Mumbai, Maharashtra, India, E-mail: bhavin@jankharia.com

Aims: To discuss the role of contemporary imaging in thrombo embolic (TE) complications of assisted reproduction techniques (ART). Settings and Design: This is a review of the current status of imaging in TE complications. Materials

and Methods:
Not relevant. Statistical Analysis Used: Not relevant Results: Patients with ART, especially those with ovarian stimulation, are prone to venous and arterial thrombosis, venous more than arterial. The overall incidence however is low. Computed tomography angiography (CTA), color Doppler (CD) and magnetic resonance imaging angiography (MRA) are the three main modalities that help evaluate arterial and venous thrombosis, in situation where the clinical examination needs further bolstering. CD is a quick and effective way of examining the superficial arteries and veins throughout the body from the head and neck to the lower limbs. It is however time-consuming for the operator and operator dependent. CTA is a quick and highly accurate modality for the evaluation of arterial and venous thromboses throughout the body. For pulmonary thromboembolism, it is the gold standard. Its disadvantages include the need to inject iodinated contrast and the associated radiation. MRA is also an accurate modality for TE complications. Its main use is for intracranial lesions, where it also shows the associated parenchymal manifestations of acute venous thrombosis. MRA can be performed with and without gadolinium contrast. Conclusions: Contemporary imaging allows accurate evaluation of TE complications in ART.




 

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