Non-invasive prenatal testing via free fetal DNA has revolutionized the way physicians manage their pregnant patients in the first trimester. Currently, the only way to assess embryonic genetic competency prior to implantation is to perform embryo biopsy, an invasive procedure. If free fetal DNA exists, does free embryonic DNA? Assess if non-invasive pre-implantation genetic screening (PGS) may be possible by assessing for presence of free DNA in spent IVF media from embryos undergoing PGS via blastocyst trophectoderm biopsy. Prospective cohort analysis. IRB approved. Patients underwent IVF with trophectoderm biopsy for PGS at an academic center. On day 3 of embryo development, each embryo was placed in a separate single 15 ul droplet of media, then underwent assisted hatching. On day 5/6 of development, for each blastocyst undergoing trophectoderm biopsy, each corresponding droplet was collected. All biopsied embryos received a PGS result via array CGH and embryo transfer was performed as planned. A separate laboratory blinded to patient characteristics and biopsy results assessed all media for presence of DNA where an egg, sperm, or embryo would have contact to at any point in the IVF laboratory. Next, each spent media droplet was amplified for DNA. PGS was performed on the media with the highest DNA copies via array CGH and the result was compared with the PGS result obtained for the corresponding embryo biopsy. Seven patients participated, resulting in 57 embryos evaluated. Prior to testing the spent media, all types of media used in the lab were amplified for DNA as a contaminant, and none was found. Next, spent media droplets were assessed for the presence of DNA. Fifty five of the 57 samples had detectable DNA ranging from 2 to 642 ng/ul. Six samples ranging in DNA levels from 52 to 642 ng/ul underwent PGS, rendering two results with DLRSD < 0.85, a measure of test accuracy. The fluid sample diagnosis and trophectoderm diagnosis were identical in both samples, demonstrating a 45XY monosomy 13 embryo, and a normal male embryo. Remaining samples had an unreliable DLRSD > 0.85. Re-amplification overnight yielded much higher DNA levels, but no improvement in DLRSD. We demonstrate the presence of free embryonic DNA in spent media, and a PGS result can be rendered consistent with biopsy, albeit at a low rate. Improvements in DNA collection and amplification may someday allow for non-invasive PGS.

To evaluate if day of blastocyst biopsy is associated with embryo chromosomal status as determined by high density oligonucleotide microarray comparative genomic hybridization (aCGH). Retrospective cohort analysis at a private fertility center. In-vitro fertilization (IVF) cycles from January 2014 - December 2014 with blastocysts that underwent trophectoderm biopsy for comprehensive chromosomal screening (CCS) with aCGH were included. Both donor and autologous cycles were included. Repeat cycles from the same patient were excluded. Cycles were evaluated for oocyte age, blastocyst number, day of blastocyst biopsy (day 5, day 6 or day 7), and euploidy rate. Cycles were stratified by SART age group (donor, <35, 35-37, 38-40, 41-42, >42) and analyzed to determine whether day of trophectoderm biopsy is associated with euploidy rate. Statistical analysis was performed with a mixed model test of fixed effects. A total of 388 IVF cycles and 2,132 biopsied blastocysts were evaluated (Table 1). Average patient age was 35. The percent of blastocysts biopsied on day 5, day 6, and day 7 were 62.5%, 35.8% and 1.7%, respectively. Average blastocyst euploidy rate on day 5, day 6, and day 7 were 49.5%, 36.5% and 32.9%, respectively. Earlier day of blastocyst biopsy was significantly associated with increased euploidy rate (p<0.0001). Younger maternal age (p<0.0001) and higher number of blastocysts biopsied per patient (p=0.0063) were both independently associated with greater euploidy. Donor status, infertility diagnosis, partner age and stimulation protocol were not significantly associated with euploidy after controlling for covariates. Faster progression to the blastocyst stage, allowing for earlier trophectoderm biopsy, is independently associated with a higher percentage of euploid embryos. This relationship was shown for both autologous and donor embryos. For patients who choose not to biopsy, these data support selection of a day 5 blastocyst for transfer over a later-developing embryo. Additionally, these results can assist in counseling of patients undergoing IVF with CCS regarding expectations by utilizing not only maternal age and number of total blastocysts, but also day of biopsy to best predict likelihood of a euploid embryo for transfer. To our knowledge, this is the first study to examine day of blastocyst biopsy and euploidy rate presented by SART category.Tabled 1Embryo characteristics by SART age groupdonor<3535-3738-4041-42>43Avg # oocytes retrieved33.2718.5615.3113.697.558.03Ave # matureoocytes21.813.239.959.355.646.23Fertilization rate (%)66.466.862.965.171.476.9Blast rate (%)62.864.263.260.352.645.0Ave # D5 blasts8.324.573.122.971.281.13Ave # D6 blasts5.262.942.411.961.151.42Ave # D7 blasts0.230.130.030.090.060.03Ave D5 euploid rate (%)78.371.757.946.234.28.8Ave D6 euploid rate (%)63.858.141.533.021.11.4Ave D7 euploid rate (%)63.950.050.033.300Total Euploid rate (%)76.165.749.742.828.210.0 Open table in a new tab

Selecting embryos with the highest implantation potential is the most important challenges in the field of Assisted Reproduction. Previously, morphologic criteria were the most commonly used standards for embryo selection. The introduction of preimplantation genetic screen (PGS-24) provides a novel method to determinate embryo competence. Our goal was to evaluate the clinical outcomes in patients with and without PGS-24 testing. Retrospective study. 532 patients who underwent FET using vitrified-thawed blastocysts at our fertility center from Jan 2013 to Dec 2013 were included. 253 received PGS-24 testing and 279 patient did not. Patients were divided into 5 age groups (<35, 35-37, 38-40, >40 and donor). Clinical pregnancy rate and implantation rate were compared. Clinical pregnancy rate and implantation rate for each age group were generally higher in the PGS compared to the non-PGS group (Table 1). The mean number of embryos transferred was significantly lower in PGS group vs non-PGS. These data demonstrate significant improvements in clinical outcomes in patients with PGS-24 testing, suggesting that PGS-24 is an effective method to determine blastocyst competence. Furthermore, PGS-24 screening facilitates elective single embryo transfer while reducing the probability of ovarian hyperstimulation syndrome and avoiding multiple gestation.Tabled 1COMPARISONS OF CLINICAL OUTCOMES BETWEEN PATIENTS WITH AND WITHOUT PGS-24 SCREENINGTable 1 (A) Sample SizeAge GroupsSample SizePGS-24NO PGS-24DONORN=82N=103<35N=67N=8835-37N=42N=4238-40N=39N=25>40N=23N=21Table 1 (B) Comparisons of Clinical Pregnancy Rate and On Going Clinical Pregnancy RateAge GroupClinical Pregnancy Rate (%)On Going Pregnancy Rate (%)PGS-24NO PGS-24p valuePGS-24No PGS-24p valuedonor66440.00*54380.04*<3569630.4260510.2935-3771520.0767450.04*38-4067600.5956480.51>4052190.04*43100.02*Table 1 (C) Comparisons of Implantation Rate and Implantation Leading to Ongoing PregnancyAge GroupsImplantation Rate (%)Implantation Leading to Ongoing PregnancyPGS-24No PGS-24P valuePGS-24No PGS-24p valuedonor55280.00*47230.00*<3558460.1150380.1135-3761270.00*58210.00*38-4052380.2046350.29>405340.00*4440.00*Table 1 D. Number of Transferred EmbryosAge GroupsNumber of Transferred EmbryosPGS-24No PGS-24p valuedonor1.7±0.542.1±0.900.00*<351.4±0.521.8±0.530.00*35-371.4±0.671.9±0.660.00*38-401.5±0.552.0±1.070.01*>401.5±0.592.0±0.760.02** P<0.05 Significant difference Open table in a new tab

To evaluate the correlation between blastocyst grade, time of blastocyst formation, maternal age and chromosomal aneuploidy. Retrospective analysis. 377 patients who underwent IVF at our center from Jan 2013 to Dec 2013 were included. A total of 1403 blastocysts underwent trophectoderm biopsy and comparative genomic hybridization (CGH). The association of morphologic score, time of blastocyst formation, maternal age and the rate of aneuploidy were analyzed. Embryos that progressed to blastocysts on day5 were less likely to be aneuploid than day6 blastocysts (Table1 A). A surprisingly high percentage of grade AA blastocysts were aneuploid. More than half of the grade AB and BB blastocysts were aneuploid (Table 1B). The aneuploidy rate increased significantly with maternal age (Table 1C). Our data suggest a correlation between aneuploidy and the time of blastocyst formation, blastocyst quality and maternal age. A significant proportion of grade AA blastocysts were aneuploid suggesting morphologic analysis alone is insufficient to ensure transfer of normal embryos. Younger age groups had a high percentage of aneuploidy suggesting that PGS testing may be considered even in younger patients. Very few D6 blastocysts from patients >40 years were euploid. PGS-testing should be strongly considered in D6 embryos in this age group.Tabled 1THE ASSOCIATION BETWEEN TIME OF BLASTOCYST FORMATION, EMBRYO GRADE, MATERNAL AGE AND RATE OF ANEUPLOIDYTable1 (A) Association between time of blastocyst formation and aneuploidyAneuploidy Rate (%)Age GroupsD5 BlastocystD6 Blastocystp valuedonor29 (n=217)38 (n=88)0.17<3524 (n=229)46 (n=128)0.00*35-3737 (n=139)53 (n=100)0.02*38-4055 (n=160)68 (n=124)0.04*41-4276 (n=80)84 (n=45)0.36>4276 (n=42)93 (n=51)0.04*Table1 (B) Association between embryo grade and aneuploidyAneuploidy Rate (%)p valueAAAB/BABBAA vs AB/BAAA vs BBAB/BA vs BBD5 Blastocyst31 (n=527)55 (n=197)58 (n=118)0.00*0.00*0.64D6 Blatocyst42 (n=177)58 (n=118)69 (n=224)0.120.00*0.04*Table1 (C) Association between maternal age and aneuploidyAge Groupsdonor<3535-3738-4041-42>42Aneuploidy Rate (%)323344617985p valuedonor vs <35 p=0.87; donor vs 35-37 p=0.00*; donor vs 38-40 p=0.00*; donor vs 41-42 p=0.00*; donor vs >42 p=0.00*; <35 vs 35-37 p=0.00*, <35 vs 38-40 p=0.00*; <35 vs 41-42 p=0.00*; <35 vs >42 p=0.00*; 35-37 vs 38-40 p=0.00*; 35-37 vs 41-42 p=0.00*; 35-37 vs >42 p=0.00*; 38-40 vs 41-42 p=0.00*; 38-40 vs >42 p=0.00*; 41-42 vs >42 p=0.29* p<0.05 statistical significant difference Open table in a new tab

OBJECTIVE: Our goal is to determine the effects of elevated serum progesterone (P4) at the day of human chorionic gonadotropin (hCG) trigger on the clinical outcomes following in vitro fertilization-embryo transfer (IVFET). DESIGN: Retrospective case control study. MATERIALS AND METHODS: We reviewed 655 IVF-ET cycles in which ovulation were performed using antagonist protocol. The thresholds of serum P4 were set at 1.4, 2.0 and 2.5 ng/ml. Patients with a level of P4 less than the threshold were subjected to control group, and those with a level higher than threshold were subjected to elevated p4 group. The clinical outcomes between two groups were compared. RESULTS: The total number of retrieved oocytes was significantly higher in elevated P4 group (18.8 10.8, 22.2 10.8 and 25.2 10.8) than in control(12.2 7.7, 14.0 9.1 and 14.8 9.5) at all three P4 thresholds(p1⁄40.000). The number of blastocysts was also significantly higher in elevated P4 group (4.5 4.5, 5.6+5.5 and 6.2 5.9) than in control (2.7 3.1, 3.2 3.5 and 3.2 3.6) at all thresholds (p1⁄40.000). However, when the thresholds were set to 2.0 and 2.5ng/ml, the clinical pregnancy rate was lower in the elevated P4 group (41.6% and 37.3%) than in control (46.3% and 46.0%), but the difference were not statistically significant (p1⁄40.197, p1⁄40.144 respectively). The fertilization rate was not different.

Our goal is to determine the effects of elevated serum progesterone (P4) at the day of human chorionic gonadotropin (hCG) trigger on the clinical outcomes following in vitro fertilization-embryo transfer (IVF-ET). Retrospective case control study. We reviewed 655 IVF-ET cycles in which ovulation were performed using antagonist protocol. The thresholds of serum P4 were set at 1.4, 2.0 and 2.5 ng/ml. Patients with a level of P4 less than the threshold were subjected to control group, and those with a level higher than threshold were subjected to elevated p4 group. The clinical outcomes between two groups were compared. The total number of retrieved oocytes was significantly higher in elevated P4 group (18.8±10.8, 22.2±10.8 and 25.2±10.8) than in control(12.2±7.7, 14.0±9.1 and 14.8±9.5) at all three P4 thresholds(p=0.000). The number of blastocysts was also significantly higher in elevated P4 group (4.5±4.5, 5.6+5.5 and 6.2±5.9) than in control (2.7±3.1, 3.2±3.5 and 3.2±3.6) at all thresholds (p=0.000). However, when the thresholds were set to 2.0 and 2.5ng/ml, the clinical pregnancy rate was lower in the elevated P4 group (41.6% and 37.3%) than in control (46.3% and 46.0%), but the difference were not statistically significant (p=0.197, p=0.144 respectively). The fertilization rate was not different.Tabled 1HSVHomemadeCryotoptotal% Survived81.484.671.482.6Fertilization Rate88.678.26081.1Transferred2222Blastocyst Rate19.434.910031.2% Positive HCG10062.510077Implantation Rate62.554.557.9 Open table in a new tab Our data demonstrated that higher serum progesterone reflects good follicular recruitment and better chance of obtaining blastocysts for transfer or cryopreservation.Our data suggested that elevated P4 levels may adversely affect clinical pregnancy rate in IVF-ET patients. However, the difference was not sufficient to warrant a clinical intervention such as deferring fresh embryo transfer and freezing all embryos for future transfer.To elucidate the mechanisms underlying the increased probability of pregnancy in FET than ET, additionalfactors should be analyzed.

ObjectiveIt has long been thought that fresh embryo transfer (ET) is a better way to achieve higher pregnancy rates when compared to frozen embryo transfer (FET). With the advance of embryo cryopreservation technique, especially the development of vitrification, several reports demonstrated higher pregnancy rates in FET cycles than in ET cycles. Our goal is to discern the potential effects of ovarian stimulation on implantation potential by comparing the clinical outcomes between ET and FET.DesignRetrospective case control study.Materials and Methods1263 patients 40 years of age or less who underwent ET or FET in our center from Jan 2010 to March 30, 2013 were included. Of the 1263 patients, 682 received ET and 581 received FET. Embryos were slow frozen or vitrified using the Cryotop method (Cryotop, HSV, homemade straws etc). Patients were divided into three age groups (35, 35-37 and 38-40 years of age). Clinical pregnancy rates were compared between the ET and FET groups that were matched for age.ResultsTabled 1Comparisons of clinical outcomes between ET and FET patientsAge (year)TansferNo. of cyclesNo. of transferred embryosClinical pregnancy rate (%)<35ET2872.0±0.653.3FET3042.1±0.963.2P valueP=0.099P=0.01735-37ET1822.3±0.848.4FET1482.0±0.850.7p valueP=0.001P=0.37938-40ET2132.9±1.238.0FET1292.5±1.248.8p valueP=0.001P=0.032 Open table in a new tab ConclusionOur data demonstrated a significantly greater chance of clinical pregnancy in patients who underwent a FET than with ET. This suggests that endometrial receptivity may be impaired in ET patients after ovarian stimulation. To maximize the probability of pregnancy, postponing fresh transfer and freezing all embryos for future transfer should be considered. ObjectiveIt has long been thought that fresh embryo transfer (ET) is a better way to achieve higher pregnancy rates when compared to frozen embryo transfer (FET). With the advance of embryo cryopreservation technique, especially the development of vitrification, several reports demonstrated higher pregnancy rates in FET cycles than in ET cycles. Our goal is to discern the potential effects of ovarian stimulation on implantation potential by comparing the clinical outcomes between ET and FET. It has long been thought that fresh embryo transfer (ET) is a better way to achieve higher pregnancy rates when compared to frozen embryo transfer (FET). With the advance of embryo cryopreservation technique, especially the development of vitrification, several reports demonstrated higher pregnancy rates in FET cycles than in ET cycles. Our goal is to discern the potential effects of ovarian stimulation on implantation potential by comparing the clinical outcomes between ET and FET. DesignRetrospective case control study. Retrospective case control study. Materials and Methods1263 patients 40 years of age or less who underwent ET or FET in our center from Jan 2010 to March 30, 2013 were included. Of the 1263 patients, 682 received ET and 581 received FET. Embryos were slow frozen or vitrified using the Cryotop method (Cryotop, HSV, homemade straws etc). Patients were divided into three age groups (35, 35-37 and 38-40 years of age). Clinical pregnancy rates were compared between the ET and FET groups that were matched for age. 1263 patients 40 years of age or less who underwent ET or FET in our center from Jan 2010 to March 30, 2013 were included. Of the 1263 patients, 682 received ET and 581 received FET. Embryos were slow frozen or vitrified using the Cryotop method (Cryotop, HSV, homemade straws etc). Patients were divided into three age groups (35, 35-37 and 38-40 years of age). Clinical pregnancy rates were compared between the ET and FET groups that were matched for age. ResultsTabled 1Comparisons of clinical outcomes between ET and FET patientsAge (year)TansferNo. of cyclesNo. of transferred embryosClinical pregnancy rate (%)<35ET2872.0±0.653.3FET3042.1±0.963.2P valueP=0.099P=0.01735-37ET1822.3±0.848.4FET1482.0±0.850.7p valueP=0.001P=0.37938-40ET2132.9±1.238.0FET1292.5±1.248.8p valueP=0.001P=0.032 Open table in a new tab ConclusionOur data demonstrated a significantly greater chance of clinical pregnancy in patients who underwent a FET than with ET. This suggests that endometrial receptivity may be impaired in ET patients after ovarian stimulation. To maximize the probability of pregnancy, postponing fresh transfer and freezing all embryos for future transfer should be considered. Our data demonstrated a significantly greater chance of clinical pregnancy in patients who underwent a FET than with ET. This suggests that endometrial receptivity may be impaired in ET patients after ovarian stimulation. To maximize the probability of pregnancy, postponing fresh transfer and freezing all embryos for future transfer should be considered.

To determine the effects of elevated serum progesterone (P4) at the day of hCG trigger on the clinical outcomes following IVF-ET. Retrospective case control study. We reviewed 655 IVF-ET cycles. The thresholds of serum P4 were set at 1.4, 2.0 and 2.5 ng/ml. Patients with a level of P4 less than the threshold were subjected to control group, and those higher than threshold were subjected to elevated p4 group. The clinical outcomes between two groups were compared. The total number of retrieved oocytes was significantly higher in elevated P4 group (18.8±10.8, 22.2±10.8 and 25.2±10.8) than in control(12.2±7.7, 14.0±9.1 and 14.8±9.5) (p=0.000). The number of blastocysts was significantly higher in elevated P4 group (4.5±4.5, 5.6+5.5 and 6.2±5.9) than in control (2.7±3.1, 3.2±3.5 and 3.2±3.6) (p=0.000). However, when the thresholds were set to 2.0 and 2.5ng/ml, the clinical pregnancy rate was lower in the elevated P4 group (41.6% and 37.3%) than in control (46.3% and 46.0%), but the difference were not statistically significant (p=0.197and p=0.144).Tabled 1Outcome of ET cycles in women with different P4 levels on the hCG dayNumber of cyclesClinical pregnancy rate (%)Total blastocyst numberNumber of retrieved oocytesFertilization rate (%)P4≤1.4321 (49%)44.52.7±3.112.2±7.777.8±22P4>1.4334 (51%)46.14.5±4.518.8±10.878.8±20P valueP=0.374P=0.000P=0.000P=0.054P4≤2.0523 (79.8%)46.33.2±3.514.0±9.179.4±21.2P4>2.0132 (20.2%)41.75.6±5.522.2±10.874.2±19.5P valueP=0.197P=0.000P=0.000P=0.195P4≤2.5604 (92.2%)46.03.2±3.614.8±9.578.6±21.1P4>2.551 (7.8%)37.36.2±5.925.2±10.876.1±19.6P valueP=0.144P=0.000P=0.000P=0.491 Open table in a new tab Our data demonstrated that higher serum P4 reflects good follicular recruitment and better chance of obtaining blastocysts. It also suggested that elevated P4 may adversely affect pregnancy rate. However, the difference was not sufficient to warrant a intervention such as deferring fresh embryo transfer and freezing embryos for future transfer.

BACKGROUND: For each new IVF patient, the treating clinician must decide on an initial starting dose of gonadotropin before the actual stimulation cycle. A number of factors predicting the ovarian reserve may be used for this purpose; however, the cycle-to-cycle variation factors are unknown. OBJECTIVE(S): To assess the intercycle variation of these potential predictive factors of ovarian response. MATERIALS AND METHOD(S): Basal (day 1, 2, or 3) serum levels of anti-Müllerian hormone (AMH), FSH, E2, inhibin-B, T, LH, P, and ultrasound parameters (antral follicle count [AFC] and ovarian volume) were measured in successive cycles. Spearman's rank correlation coefficients (ρ) were calculated for the correlation between values measured in consecutive cycles. RESULT(S): Several potential predictive factors demonstrated considerable intercycle variation. The median values in consecutive cycles and the correlation between potential predictive factors are summarized in the table. CONCLUSION(S): Correlation between the 2 assessment days was relatively high for serum AMH and T, indicating that the levels of these hormones were less affected by intercycle variation than other parameters. Among the potentially predictive factors for ovarian reserve, AMH was the least subject to intercycle variation, indicating that it may be useful in predicting ovarian response even when levels are determined before the cycle in which treatment is initiated.TableEndocrine and ultrasonographic parameters assessed in cycles 1 and 2.Cycle 1, median (range)Cycle 2, median (range)Correlation ρ (95% CI)Serum AMH, ng/mL1.84 (0.1, 6.9),n = 1361.91 (0.1, 10.9),n = 1370.88(0.83; 0.91)AFC12.0 (1, 38),n = 19611.0 (2, 33),n = 1980.67(0.58; 0.74)Serum FSH, IU/L6.16 (0.1, 13.1),n = 1896.67 (3.1, 15.6),n = 1730.63(0.53; 0.71)Serum E2, pmol/L110.5 (25, 407),n = 189100.6 (25, 760),n = 1730.54(0.42; 0.64)Serum inhibin B, pg/mL49.8 (5, 205),n = 18947.9 (5, 139),n = 1730.53(0.42; 0.63)Serum T, nmol/L1.04 (0.2, 3.3),n = 1891.11 (0.2, 3.5),n = 1730.84(0.79; 0.88)Serum LH, IU/L4.58 (0.3, 15.5),n = 1894.97 (1.9, 17.4),n = 1730.56(0.45; 0.66)Total ovarian volume, mL11.98 (3.4, 46.6),n = 19010.92 (1.9, 35.7),n = 1940.48(0.36; 0.58)Serum P, nmol/L1.47 (0.6, 21.0),n = 1891.61 (0.6, 14.5),n = 1730.29(0.13; 0.43) Open table in a new tab

OBJECTIVE: To compare the pregnancy rates of 990 fresh IVF/ICSI with 212 FET blastocyst transfers as a function of patient age. DESIGN: Ongoing longitudinal review. MATERIALS AND METHODS: From Jan. 2007 to Dec. 2008, an extended culture with triple gas system was used for 990 fresh IVF/ICSI cycles. After transfer the left blastocysts were cryopreserved by slow rate method. At the same time, 212 blastocyst FET cycles were completed. Main outcome measures: clinical pregnancy rate (CPR) (defined as viable delivery and/or ongoing pregnancy). RESULTS: The pregnancy rates of different patient age groups are shown in table 1 for donor and non-donor cycles. Table 1: Pregnancy results by age group in 990 fresh IVF/ICSI cycles and 212 blastocyst FET cycles.Table 1Pregnancy results by age group in 990 fresh IVF/ICSI cycles and 212 blastocyst FET cycles.Donor<35 yrs35-37 yrs38-40yrs≥41 yrsTotalFresh Cycle #187273164162204990Fresh Cycle Pregnancy rate142 (76%)178 (65.2%)89 (54.3%)76 (46.9%)58 (28.4%)543 (54.8%)Fresh Cycle CPR129 (69%)148 (54.2%)66 (40.2%)58 (35.8%)40 (19.6%)441 (44.5%)FET Cycle #5289271810212Blastocysts thawed147267734737571Survived # (rate)137 (93.2%)242(90.6%)67(91.8%)38(80.9%)36(97.3%)520(91.1%)Average ET#2.52.62.523.62.4FET Pregnancy rate34 (65.4%)64 (71.9%)18 (66.7%)10 (55.6%)3 (30%)129 (60.8%)FET CPR31 (59.6%)55 (61.8%)14 (51.9%)9 (50%)2 (20%)111 (52.4%) Open table in a new tab CONCLUSIONS: Fresh CPR was similar to FET CPR in the Donor group (69% vs. 59.6%, P =0.6536). No significant differences in CPR were found in all age groups between fresh and cryopreserved embryo transfer cycles. Effective blastocyst cryopreservation is a highly effective method to increase the cumulative clinical pregnancy rate per ova retrieval.

OBJECTIVE: This is a case report of a frozen-thawed day 7 blastocyst transfer resulting in an ongoing twin pregnancy. DESIGN: Private IVF clinic. MATERIALS AND METHODS: The patient is a 30 year old nulligravida female with two years of primary infertility whose husband has male factor infertility. Semen parameters on the day of ova retrieval revealed a sperm density of 2 million per ml with 20% progressive motility. In January 2008, she received a total of 2025 IU of gonadotropins using a GnRH antagonist protocol, 18 oocytes were retrieved. 12 metaphase-II oocytes were injected via intracytoplasmic injection (ICSI) using her husband's sperm. After ICSI, oocytes were cultured in Life Global (LG) medium supplemented with Serum Substitute Supplement (SSS, Irvine Scientific, Cat #99193) and 3% Human Serum Albumin (HSA, Irvine Scientific, Cat#9988). Eleven two-pronuclear stage embryos were observed 18h after ICSI. On day 3, embryos were transferred into fresh LG medium for continuous culture. On day 5, one early blastocyst and two morula stage embryos were selected for embryo transfer (ET). On day 6 of culture, the leading embryos had reached the early blastocyst stage and were not deemed suitable for cryopreservation. Therefore, the remaining embryos were cultured until Day 7. On Day 7, three expanded blastocysts were cryopreserved using blastocyst freezing media F1 and F2 (Irvine Scientific, Cat#90108) and a slow freezing protocol. RESULTS: The patient did not conceive in the fresh cycle. Forty one days later she completed a frozen embryo transfer cycle following endometrial priming with I.M. estradiol valerate and I.M. progesterone. Three, day 7 blastocysts were thawed on the morning of transfer using blastocyst thawing solution T1 and T2 (Irvine Scientific, Cat#90110). All three blastocysts survived and re-expanded prior to ET. Assisted hatching was performed one hour prior to ET on all embryos using acid Tyrode's solution. 12 days after ET, the patient's serum hCG level was 772 mIU/ml. Thirty-four days after ET, two gestational sacs with fetal cardiac activity were observed via transvaginal ultrasound. Forty-five days after ET, at 10 and 4/7 weeks gestation, a viable diamniotic dizygotic twin gestation was confirmed. The patient was then referred for obstetrical care. CONCLUSIONS: An ongoing clinical diamniotic dizygotic twin gestation was established using cryopreserved-thawed day 7 blastocysts. Day 7 blastocysts may be considered for cryopreservation, especially from patients of young reproductive age.

Objective: To optimize ongoing clinical pregnancy rates in an unselected IVF population, we retrospectively compared two different media formulations (P1/G1/G2 sequential and LifeGlobal medium), contrasted a 6% CO2 in air with a 6% CO2/5% O2/89% N2 gas incubator environment, and finally evaluated the effectiveness of two different types of incubators (Sanyo MCO-5M vs. Hearus 240). Over a 1-year period between April 2006 and March 2007, treatments were applied in quarterly increments. Methods: All patients experienced controlled ovarian hyperstimulation, followed by egg retrieval 35 h after hCG. Eggs were recovered and placed in P1 medium + 5% HSA until insemination. Eggs were moved to a more complex medium containing 5% HSA/5% SS after ICSI or after IVF fertilization check. Embryos were evaluated on day 3 and transfered on day 3 to 5 depending on the number/quality of embryos available and the IVF history of the patient. Transfers were performed under ultrasound guidance, primarily using a Wallace catheter. Results: Tabled 1Age <35 yr + donor cyclesAge <38 yr + donorsCategorynn (%) + b-hCGn (%) OngPregnn (%) + b-hCGn (%) OngPreg6% CO2/air incubation[2ndQrt06]P1/G1/G2 media4940 (82)aSignificant difference (P<.05) within column subsection.31 (63)aSignificant difference (P<.05) within column subsection.7554 (72)42 (56)[4thQrt06]Global medium4929 (59)24 (49)6542 (65)33 (51)6% CO2/5% O2/90% N2 incubation[1stQrt07]Sanyo Mini2922 (76)21 (72)aSignificant difference (P<.05) within column subsection.3825 (66)24 (63)[LG media]Heraeus 2402115 (71)13 (62)3224 (75)aSignificant difference (P<.05) within column subsection.20 (63)Combined TG5037 (74)34 (68)7049 (70)44 (63a Significant difference (P<.05) within column subsection. Open table in a new tab Conclusions: Overall, both the P1/G1/G2 sequential system and the LG all-in-one medium produced good pregnancy rates under standard 6% CO2 in air conditions. In contrast, the LG system with tri-gas incubation significantly improved pregnancy outcomes by reducing SABs and biochemical pregnancies (50% decrease), resulting in higher ongoing clinical pregnancy rates. No difference was observed in the type of incubator used; however, this is one of the first reports validating the clinical effectiveness of the new Sanyo mini-incubators.

OBJECTIVE: To present the first known case of a viable triamniotic/monochorionic triplet pregnancy case after single embryo transfer.DESIGN: Case Report.MATERIALS AND METHODS: A 35-year-old Gravida 1 Para 1 with approximately one year of secondary infertility. Her husband has a history of mild male factor. Her first baby was conceived on the fifth cycle of controlled ovarian hyperstimulation (COH) with intrauterine insemination (IUI). She generally had generated one to three mature follicles at the time of HCG trigger with aggressive doses of gonadotropins (300 to 450 IU daily). The patient breastfed for one year and then began to pursue fertility in 2004. She had an elevated day 3 FSH (12 mIu/mL) in September, 2006. She completed two additional cycles of COH/IUI cycles prior to proceeding to IVF/ Intracytoplasmic Sperm Injection (ICSI) treatment. She received 7195 IU of gonadotropins with a GnRH antagonist protocol. On October 12, 2006 three ova were retrieved. Post wash semen sample revealed 14 million spermatozoa/mL, with 35% progressive motility, with < 5% normal morphology. ICSI was performed on two metaphase-2 oocytes (the third oocyte was atretic). One two-pronuclear embryo was observed 18hrs post-ICSI. The embryo was cultured in Life Global medium with 5% Serum Substitute Supplement (SSS, Irvine Scientific, Cat #99193) and 3% Human Serum Albumin (HSA, Irvine Scientific, Cat#9988). One four-cell good quality embryo was transferred following assisted hatching (with acid Tyrode's solution) 47 hours post ova retrieval.RESULTS: The patient's serum hCG level was 120 mIU/ml on 10/26/2006, twelve days after embryo transfer. On 12/04/2006, at 9 weeks 3 days gestation, a transvaginal ultrasound confirmed a triamniotic/monochorionic triplet pregnancy, each with fetal cardiac activity. The patient subsequently delivered monozygotic female triplets on May 20, 2007 at 33 weeks and 3 days gestation via cesarean section. All three infants were eventually discharged in good condition and have had no identifiable neurological or physical abnormalities.CONCLUSIONS: To our knowledge, this is the first known case of viable triamniotic/monochorionic triplet pregnancy following a single embryo transfer in IVF-ET. OBJECTIVE: To present the first known case of a viable triamniotic/monochorionic triplet pregnancy case after single embryo transfer. DESIGN: Case Report. MATERIALS AND METHODS: A 35-year-old Gravida 1 Para 1 with approximately one year of secondary infertility. Her husband has a history of mild male factor. Her first baby was conceived on the fifth cycle of controlled ovarian hyperstimulation (COH) with intrauterine insemination (IUI). She generally had generated one to three mature follicles at the time of HCG trigger with aggressive doses of gonadotropins (300 to 450 IU daily). The patient breastfed for one year and then began to pursue fertility in 2004. She had an elevated day 3 FSH (12 mIu/mL) in September, 2006. She completed two additional cycles of COH/IUI cycles prior to proceeding to IVF/ Intracytoplasmic Sperm Injection (ICSI) treatment. She received 7195 IU of gonadotropins with a GnRH antagonist protocol. On October 12, 2006 three ova were retrieved. Post wash semen sample revealed 14 million spermatozoa/mL, with 35% progressive motility, with < 5% normal morphology. ICSI was performed on two metaphase-2 oocytes (the third oocyte was atretic). One two-pronuclear embryo was observed 18hrs post-ICSI. The embryo was cultured in Life Global medium with 5% Serum Substitute Supplement (SSS, Irvine Scientific, Cat #99193) and 3% Human Serum Albumin (HSA, Irvine Scientific, Cat#9988). One four-cell good quality embryo was transferred following assisted hatching (with acid Tyrode's solution) 47 hours post ova retrieval. RESULTS: The patient's serum hCG level was 120 mIU/ml on 10/26/2006, twelve days after embryo transfer. On 12/04/2006, at 9 weeks 3 days gestation, a transvaginal ultrasound confirmed a triamniotic/monochorionic triplet pregnancy, each with fetal cardiac activity. The patient subsequently delivered monozygotic female triplets on May 20, 2007 at 33 weeks and 3 days gestation via cesarean section. All three infants were eventually discharged in good condition and have had no identifiable neurological or physical abnormalities. CONCLUSIONS: To our knowledge, this is the first known case of viable triamniotic/monochorionic triplet pregnancy following a single embryo transfer in IVF-ET.

Background: Ectopic pregnancy occurs in approximately 4–11% of pregnancies after IVF. Risk factors for EP after IVF have been studied in several case series and include history of tubal factor infertility, increased age, decreased parity, history of myomectomy, and the use of assisted hatching. Studies of subsequent pregnancies after an EP have suggested that factors predicting unfavorable pregnancy outcomes include increased age, history of pelvic inflammatory disease, history of infertility, and tubal damage.Objective: To study the risk factors for EP in patients undergoing IVF in one center and to evaluate their subsequent pregnancy outcomes.Materials and Methods: After reviewing data from 855 cycles in one center from October, 2004 through September, 2006, 13 consecutive cases of EP were reviewed. Data collected from charts included age; infertility diagnoses; duration of infertility; pregnancy history; in utero DES exposure; tobacco use; history of intrauterine device and oral contraceptive use; history of and current tubal pathology; history of genital infection; surgical history; IVF parameters; location, diagnosis, and treatment of EP; and subsequent pregnancies.Results: The most common risk factors for EP were tubal factor infertility (54%), prior tubal surgery (38%), and tubal pathology at the time of IVF (54%). A previous EP had occurred in 23% of cases. Assisted hatching was used in 23% of all EP cases. Ninety-two percent of EPs were treated with methotrexate, while the remainder was treated by laparoscopy. Of those treated with methotrexate, 33% then required laparoscopy and salpingostomy. Tubal rupture occurred in 8% of cases. Subsequent pregnancy outcomes included spontaneous viable intrauterine pregnancy in 15%, viable pregnancy following IVF in 15%, missed abortions following IVF in 31%, and no further pregnancies in 39%.Conclusion: Pre-existing tubal disease was an important risk factor for the development of an EP following IVF pregnancies. EP rarely recurred, and approximately one-third of patients subsequently had viable pregnancies, either spontaneously or following IVF. This information should facilitate the counseling of patients undergoing IVF regarding their risk of EP and guide their expectations for future fertility when an EP does occur. Background: Ectopic pregnancy occurs in approximately 4–11% of pregnancies after IVF. Risk factors for EP after IVF have been studied in several case series and include history of tubal factor infertility, increased age, decreased parity, history of myomectomy, and the use of assisted hatching. Studies of subsequent pregnancies after an EP have suggested that factors predicting unfavorable pregnancy outcomes include increased age, history of pelvic inflammatory disease, history of infertility, and tubal damage. Objective: To study the risk factors for EP in patients undergoing IVF in one center and to evaluate their subsequent pregnancy outcomes. Materials and Methods: After reviewing data from 855 cycles in one center from October, 2004 through September, 2006, 13 consecutive cases of EP were reviewed. Data collected from charts included age; infertility diagnoses; duration of infertility; pregnancy history; in utero DES exposure; tobacco use; history of intrauterine device and oral contraceptive use; history of and current tubal pathology; history of genital infection; surgical history; IVF parameters; location, diagnosis, and treatment of EP; and subsequent pregnancies. Results: The most common risk factors for EP were tubal factor infertility (54%), prior tubal surgery (38%), and tubal pathology at the time of IVF (54%). A previous EP had occurred in 23% of cases. Assisted hatching was used in 23% of all EP cases. Ninety-two percent of EPs were treated with methotrexate, while the remainder was treated by laparoscopy. Of those treated with methotrexate, 33% then required laparoscopy and salpingostomy. Tubal rupture occurred in 8% of cases. Subsequent pregnancy outcomes included spontaneous viable intrauterine pregnancy in 15%, viable pregnancy following IVF in 15%, missed abortions following IVF in 31%, and no further pregnancies in 39%. Conclusion: Pre-existing tubal disease was an important risk factor for the development of an EP following IVF pregnancies. EP rarely recurred, and approximately one-third of patients subsequently had viable pregnancies, either spontaneously or following IVF. This information should facilitate the counseling of patients undergoing IVF regarding their risk of EP and guide their expectations for future fertility when an EP does occur.

Background: In an attempt to correct for the iatrogenic luteal phase defect induced by IVF, a multitude of studies have been conducted to assess the use of progesterone for luteal supplementation. The preponderance of these studies has shown a significant improvement in implantation and pregnancy rates with luteal progesterone supplementation compared to no supplementation (Pritts and Atwood, 2002). The addition of estradiol (E2) for luteal supplementation is more controversial. Studies investigating the addition of E2 (oral or transdermal) to standard progesterone luteal supplementation have been limited, and the results have been conflicting. Several randomized controlled studies have shown significantly higher implantation and pregnancy rates with addition of oral E2 in the luteal phase vs. placebo (Farhi et al., 2000; Lukaszuk et al., 2005) and that increasing the dose of E2 may further improve the outcomes (Lukaszuk et al., 2005). Recently, a large retrospective study by Leondires et al. (2006) showed that E2 supplementation (vs. no supplementation), regardless of ovarian stimulation protocol, increased pregnancy rates. However, a recent prospective study using transdermal E2 showed no benefit vs. placebo (Serna et al., 2006). The inconsistency between the studies showing improved outcome vs. no improvement with luteal phase E2 supplementation appears to be the route of administration (oral vs. transdermal). Objective: To compare the implantation and pregnancy rates of patients who received a combined regimen of oral and transdermal E2 compared with transdermal only E2 regimen. Materials and Methods: A retrospective chart review was performed. Women (40 years or younger with a minimum of 6 oocytes aspirated) who underwent IVF cycles with luteal oral and transdermal estradiol supplementation were identified during the period of August 2006 – November 2006 (Group 1). Group 1 received intramuscular P in oil, 2-mg E2 tablets orally three times a day, and two 0.1-mg transdermal E2 patches every 48 hours until negative pregnancy test or 10 week gestational age (n = 18). Age-matched women undergoing IVF during the same time period were chosen for controls (Group 2). Group 2 received intramuscular P in oil and two 0.1-mg transdermal E2 (n = 19). Patient characteristics, including, age, parity, number of failed ovulation induction cycles, characteristics of the IVF cycle including number of oocytes retrieved and fertilized, number of embryos implanted, and ongoing pregnancy, were recorded. Results: The demographic data between the two groups were similar. The results expressed as mean ± SD or percentages, as appropriate, are summarized below. Group 1 had significantly higher implantation and multiple pregnancy rates. However, the ongoing pregnancy rate was similar between the two groups.Tabled 1Group 1Transdermal/oral E2/PGroup 2Transdermal E2/PNumber of patients1819Age (years)33.2 ± 4.834.2 ± 4.3Peak E2 (pg/mL)3113.6 ± 1607.42364.6 ± 829.5Number of embryos transferred2.7 ± 1.002.7 ± 0.9Implantation rate∗42 (21/50)23 (12/52)Pregnancy rate55 (10/18)47 (9/19)Multiple pregnancy rate∗38 (7/18)10 (2/19) Open table in a new tab ∗ denotes significant P value (<.05). Conclusions: This preliminary data suggests that for luteal phase E2 supplementation combined regimen of luteal phase transdermal and oral E2 improves implantation rates compared to a transdermal E2 regimen. Although the pregnancy rate between the two groups is comparable, the women treated with the combined regimen of transdermal/oral E2 have a higher rate of implantation and multiple gestation.

Background and Significance: The Sperm Chromatin Structure Assay (SCSA) has become an increasingly popular sperm function test in human infertility over the past three years. Strong correlations have been exhibited between an index value of greater than 30% sperm with fragmented DNA and failure to sustain a pregnancy after IUI and IVF. In turn, the SCSA has been promoted as a diagnostic and prognostic clinical tool. Objective: The aim of this investigation was to show that the careful selection and injection of normal, single spermatozoa from patients with an elevated DNA Fragmentation Index (DFI) of greater than 30% could result in live births. Materials and Methods: The clinical outcomes of six ICSI patients, between January 2002 and April 2003, with elevated DFI % of 30.5 to 57.7% were evaluated. Two men had a history of extreme sperm morphology problems, while one had a mild male factor with <10 x 106 sperm/ml. The other three males had normal sperm parameters with 97 to 165 x 106 sperm/ml. Two patients had experienced repeated spontaneous miscarriages post-natural and IUI pregnancies. Alternatively, the other four women had been unable to achieve a pregnancy. The women ranged in age from 28–40 years old. Five patients underwent standard COH and egg retrievals, while one of two 40 year old women used donor eggs after having a history of repeated egg activation problems. In addition, two women proceeded to perform a single FET cycle. Case outcomes are summarized below. Results: A total of 84 normal zygotes were generated from 98 mature eggs injected (85.7%), 56 embryos cryopreserved and 26 embryos transferred. Four of six women became pregnant following their fresh embryo transfer. The other two patients became pregnant following a frozen ET (n=8 embryos). Each of five women has produced a single, healthy live birth. The sixth patient has an ongoing second trimester pregnancy. Conclusion: The SCSA may have some value as a diagnostic aid in attempting to resolve the basis of repeated miscarriage, but appears to have unreliable predictive value when intracytoplasmic sperm injection is factored into the equation. In turn, any patient experiencing an elevated DFI% with poor fertility potential should be advised to perform an ICSI cycle to optimize the chance of selecting potential normal sperm to produce a successful, full-term pregnancy.

Background and Significance: Schiewe et al. has previously shown that testicular tissue could be effectively cryopreserved as whole biopsy pieces. Interestingly, abnormal sperm were twice as likely to survive freeze-thawing than normal sperm (32% vs 15% viable, respectively). However, in the absence of post-thaw motility, structurally normal late spermatids (i.e., cell wall encasing the spermatozoal head) had the highest post-thaw viability (>60%). Although non-motile, thawed late spermatids have been used to create viable pregnancies, the goal of testicular tissue processing should be to promote and maintain sperm motility pre- and post-cryopreservation, respectively. Objective: The purpose of this study was to determine to what degree in vitro culturing of testicular sperm enhanced the motility of fresh and frozen-thawed specimens. Materials and Methods: Fresh and frozen-thawed testis biopies (n=10 each) were obtained from NOA and OA patients whose spouse was undergoing COH for an ICSI cycle. Testicular sperm extraction was attained by an open biopsy procedure. Specimens were placed into 2ml of H-HTF medium + 10% SS in a 35 × 10mm Falcon dish prior to dissection into 1–2mm3 pieces. Four pieces of each biopsy were placed into each of four 150ul droplets of H-HTF/SS under oil and minced by needle every other day. The dishes were maintained under ambient conditions (22–27°C) and evaluated daily for motility and progression (I= twitching, II=undulating, III= forward, linear movement to IV= rapid motility). Differences in percent motility between intervals was assessed by chi-square analysis. Results: Initial sperm motility varied in fresh and frozen-thawed biopies (10 to 60% and 2 to 25%, respectively), with a majority of sperm having a progession index of I-III for fresh tissue and I-II for frozen biopies. In fresh biopies, motility and progression steadily increased over 96hr (1.5 to 5-fold, P>0.01) in all specimens. Whereas, sperm motility peaked by 24 hr in the frozen-thawed specimens. Conclusion: Good testicular sperm motility post-thaw: 1) decreases processing and ICSI intervals; 2) enhances ICSI outcomes; and 3) increases the probability of achieving a successful pregnancy. In this study we determined that testicular sperm motility in vitro increases over time for fresh tissue, suggesting that cryopreserving a biopsy four days after retrieval may optimize frozen-thawed motility outcomes. Furthermore, thawing samples 1 day prior to egg retrieval will increase the efficacy of using actively motile sperm for ICSI.

Purpose: To improve quality control issues in gamete/embryo cryopreservation, a new, FDA approved, "high security straw" from IMV-Cryo Bio Systems (CBS™) has been produced. The CBS™ straw/system: 1) completely eliminates pathogen-container contamination issues; 2) provides "tamper-proof" internalized labeling; and 3) produces a consistent, repeatable hermetic seal. The objective of this study was to determine the effectiveness of human embryo cryopreservation using CBS™ straws. Design: Fifty-two infertile patients consented to participate. In Expt. I, 58 triploid zygotes (3PN) were frozen-thawed to assess recovery and survival rates. In Expt. II, normal zygotes (2PN) were randomly divided per patient into 0.25ml conventional straws (TS Scientific, Perkasie, PA) or 0.3ml CBS™ straws (Conception Technologies, San Diego, CA) prior to cryopreservation. FET cycles equally subdivided embryo treatments and mixed transfers were performed. Differences in embryo survival post-thaw were compared using a Chi-square test. Methods: Embryos were cultured (Day 0–3.5) in Enhance Day 3 (eD3; Conception Technologies) and Cleavage (Sage Biopharma, Pasadena, CA) media supplemented with 10% synthetic serum (SS; Irvine Scientific, Santa Ana, CA) in a humidified, CO2 gas (5.0–6.0%) atmosphere maintained at 37°C. Pronuclear stage zygotes were diluted into 1.5M propylene glycol/0.2M sucrose in H-HTF with 20% SS and loaded into straws over a 25 minute interval. CBS™ straws were sealed using a SYMS sealing device. Embryos were conventionally frozen in CryoLogic Freeze Control units, seeded at −7°C and plunged into LN2 at −30°C. Embryos were thawed, diluted in 0.2M and 0.1M sucrose solutions (5 min each) and rehydrated in H-HTF/SS. Frozen embryo transfers (FETs) were performed on hatched Day 3–4 embryos using a Wallace catheter. Results: In Expt. I, 3PN recovery rates in CBS™ straws was 100%. A high proportion of zygotes survived post-thaw (51 of 58, 88%) and at +24h (49 of 58, 84.5%). In Expt. II, 274 2PNs were cryopreserved (n = 34 patients). Sixty-six 2PNs were thawed in 13 FET cycles, to-date. Recovery rates were 100% in both 0.25 ml (n = 30 2PN) and CBS™ (n = 36 2PN) straws. Embryo survival tended (P = 0.07) to be higher using CBS™ straws (n = 31; 86.1%) than 0.25ml straws (n = 23; 76.7%). Six of 13 FETs (46.2%) produced clinical pregnancies. Conclusion: CBS™ straws are effective containers for the cryostorage of human embryos. The "high security" design of CBS™ straws make them a superior container for the cryostorage of embryos.

Objectives: To review our cc/hCG/IUI cycles to determine ultrasound and patient parameters that predict successful treatment.Design: A retrospective analysis of all cc/hCG/IUI cycles done through the University Center for Reproductive Endocrinology and Fertility in 1995.Materials and Methods: All cc/hCG/IUI cycles performed in 1995 with fresh sperm were reviewed.Patient, ultrasound, and cycle specific data were recorded.Cycles resulting in pregnancy were then compared to those that did not result in pregnancy.Results: There were 544 cycles of cc/hCG/IUI performed.From these 544 cycles there were 43 clinical pregnancies (8%), 6 blighted ova (1%), 4 ectopic pregnancies (0.7%), and 3 biochemical pregnancies (0.5%).The average age of those who became pregnant and those who did not was identical (33 years old).There was no significant difference in the duration of their infertility.Among the patients with endometriosis, there was only one pregnancy (p < 0.05 for endometriosis hindering the achievement of pregnancy).There were no other significant differences for any of the other diagnoses.Patients who became pregnant were more likely to have higher parity (p < 0.05).When the day-of-hCG ultrasound data were examined, there was a statistically significant increase in the number of 18-20 mm follicles seen (p < 0.005) in the cycles that resulted in pregnancy.There was a trend towards more 21 to 23 mm follicles (p = 0.07).When the total number of follicles on the ultrasound was compared, there were more follicles in the pregnancy cycles (p < 0.05) with the vast majority having three or more follicles.There were no pregnancies when the endometrial lining had a homogeneous pattern.The thickness of the lining, however, had no significant effect.There was a highly significant difference (p < 0.00000005) in the total number of motile sperm inseminated in pregnancy vs. non-pregnancy cycles.Conclusions: The regimen of cc/hCG/IUI has a clinical pregnancy rate of 8% per cycle.Couples with low sperm counts or endometriosis may be poor candidates, while multiparous couples may be the ideal candidates.The goal of therapy should be to generate three or more follicles, and the ultrasound criteria for giving hCG should include a trilaminar lining and follicles in the 18-20 mm range.

Insulin and insulin-like growth factor I (IGF-I) have been implicated in ovarian androgen production. Insulin is closely related to IGF-I and cross-reacts with its receptor. The 34K IGF-binding protein (34K IGF-BP) has been shown to inhibit the binding of IGF-I to its receptor. The authors evaluated the role of insulin in the regulation of serum levels of 34K IGF-BP in patients with polycystic ovarian disease (PCOD). 34K IGF-BP levels during an oral glucose tolerance test (OGTT) were measured in 15 PCOD (8 obese and 7 nonobese) patients and in 10 healthy control subjects. The fasting level of 34K IGF-BP was decreased in nonobese PCOD patients (2.4 +/- 0.3 micrograms/l) (mean +/- standard error) (P = 0.02) and obese PCOD patients (0.59 +/- 0.2 micrograms/l) (P less than 0.001) as compared with healthy controls (4.8 +/- 0.9 micrograms/l). Both nonobese PCOD patients and normal controls demonstrated a significant decrease in 34K IGF-BP following OGTT. An insulin-related decrease in 34K IGF-BP may allow an increased pool of IGF-I able to bind to its receptor. This would provide a mechanism for increased ovarian androgen production via IGF-I stimulation of its receptor.