Administration of daily late follicular phase low-dose hCG does not enhance endometrial receptivity

DESIGN: Retrospective analysis (5-years period). Main outcome measure: clinical pregnancy rate. MATERIALS AND METHODS: All single embryo transfer (SET) IVF/ ICSI cycles from January 1999 to December 2003 at a teaching hospital ART facility. Univariate analysis was performed to evaluate each observed parameter and multivariate analysis were conducted with logistic regression to select the best prognostic factor(s) for clinical pregnancy rate. RESULTS: 318 cycles were reviewed, no multiple pregnancy was obtained after SET in our program. Female age (mean ⫽ 34.3 years old [18 to 45 years old]), type and duration of infertility, rank of attempt, ovarian stimulation protocol, ART method (FIV/ICSI), number of mature oocytes obtained, day of transfer (Day 2 or 3), endometrial pattern and endometrial thickness at the day of ovulation triggering did not correlate individually with pregnancy. Clinical pregnancy rate was significantly correlated (p⬍.05) with the number of obtained diploid embryos, the possibility of embryo cryoconservation, and embryo quality (i.e. number and regularity of blastomers, fragmentation rate and cleavage chronology). Multivariate analysis showed type I endometrial pattern, 0 –20% fragmentation rate, respect of cleavage chronology and number of blastomers (4 on Day 2, 6 – 8 on Day 3) of the transferred embryo to be the best prognostic factors for clinical pregnancy outcome (p⬍.05). When considering all SET cycles, we obtained a clinical pregnancy rate of 19.1%. When selecting a group based on the best prognostic factors (90 cycles with high embryo quality and top endometrial pattern), we obtained a significantly higher clinical pregnancy rate of 31.1% (p⫽.001). Furthermore, when selecting top embryos without fragment, we defined a sub-group of 32 cycles with an even higher clinical pregnancy rate of 46.9% (p⫽.001). CONCLUSION: This study permitted to validate selection criteria for candidates to ESET. An evidence-based policy of transfer could thus be organized, using simple and basic observation parameters, available in any ART facility. Supported by: None.

P-154 Genetic screening of oocyte donors. Z. Powis, K. P. Peters, S. Bhatt. Genzyme Genetics, Orange, CA. OBJECTIVE: The American Society of Reproductive Medicine has outlined recommendation for genetic screening of gamete donors (June 2002). We decided to survey various infertility clinics regarding their genetic screening practices for oocyte donors, that do not have family history of a genetic condition and do not receive genetic counseling. DESIGN: We surveyed 297 infertility clinics from 36 different states, obtained from the Society of Assisted Medicine Technology website, regarding their screening practices for their oocyte donors. Information was obtained from a nurse, nurse coordinator, and/ or physician. Clinics were excluded from study participation if donors were routinely referred for genetic counseling, or if the clinics used an external oocyte donor program. The clinics which could not complete questionnaire by telephone were faxed the questionnaire and asked to fax their responses. MATERIALS AND METHODS: The questionnaire contained questions regarding the screening practices for seven different genetic disorders. Five of the seven disorders ascertained were based on ASRM Guidelines (June 2002) and included ethnicity-based screening for Thalassemia, Sickle cell anemia, Cystic Fibrosis, Tay-Sachs disease and Canavan disease. The survey also included questions regarding screening for chromosome rearrangement by peripheral blood chromosome analysis and Fragile X carrier status. Respondents were asked to indicate the methods of testing routinely utilized and which ethnic groups were routinely tested. RESULTS: Of the 175 clinics eligible for participation in the study, 77 clinics completed questionnaires (44.00% response rate). 19 clinics reported no genetic screening for oocyte donors (24.66%). 15 clinics reported screening practices that met established ASRM guidelines (19.48%), with 3 clinics exceeding these requirements, with screening for Fragile X and/or chromosome rearrangements (3.09%). Of the remaining clinics, screening practices varied considerably. 19 clinics failed to screen for one of the recommended disorders (24.66%). 13 clinics failed to screen for two of the recommended disorders (16.88%). 13 clinics failed to screen for three of the recommended disorders (16.88%). The most commonly missed disorders were Canavan and Thalassemia, with 30 clinics failing to screen appropriately for each disorder (38.96%).

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CONCLUSION: Genetic screening allows couples planning a pregnancy to assess their risk of having a child with a particular genetic disorder. Currently couples planning a pregnancy or currently pregnant are offered ethnicity-based genetic screening, even in absence of family history as per the ACMG / ACOG guidelines. Advances in the ART field have allowed infertile couples alternative means to have much wanted normal offspring by way of gamete donors. Genetic screening of these donors is therefore just as important. Our results indicate that the screening of oocyte donors’ for genetic disorders remains inconsistent. Majority of the clinics do not follow the established guidelines. Although a number of clinics may screen for a disorder, many of their policies for ethnic based screening do not follow established guidelines. Screening for genetic disorders should be part of every oocyte donor screening and each infertility clinic review their screening protocols to ensure that the appropriate genetic screening is utilized. Supported by: None

P-155 Administration of daily late follicular phase low-dose hCG does not enhance endometrial receptivity. I. Yadid, P. C. Serafini, M. Coslovsky, S. Cha, A. L. Beltrame, E. L. Motta. Centro Reproduc¸ ao Huntington Brazil, Rio de Janeiro, Brazil; Centro Reproduc¸ ao Huntington Brazil, Sao Paulo, Brazil; Laboratorio Fleury, Sao Paulo, Brazil. OBJECTIVE: Evidence suggests that LH and its surrogate hormone, hCG, may have a direct beneficial effect on the uterus while administered during both follicular and luteal phases of the cycle. We examined whether 200 IU of hCG when administered daily during the late follicular phase affect ultrasonic endometrial thickness and sonolucent patterns, as well as implantation rates in women undergoing OI. DESIGN: Prospective and randomized study MATERIALS AND METHODS: 255 women, aged 23–39 (33.2⫾3.6) yr with BMI ⬍25 kg/m2were recruited for the study during 07/02 and 11/03. Eligibility criteria: standard indication women had ⬍2 previous treatments, and partner produced ejaculated spermatozoa ⬎1% strict morphology. Treatment was determined according to a computer-generated randomization. 233 women underwent OI, OPU, and ET procedures. The patients were grouped according to the OI protocol: A) rhFSH began on cycle D3 and continued until ⱖ2 dominant follicles reached 14 mm when rhFSH dose was lowered to 75 IU and sc injections of 200 IU hCG were began along with 0.25 mg of Cetrorelix (CTD) (n⫽84); B) similar to A, but dose of rhFSH was continued after the introduction of CTD (n⫽74); and C) rhFSH was initiated after midluteal down-regulation with Leuprolide acetate. Endometrial thickness was measured by transvaginal ultrasound in longitudinal axis of uterine body on the day of final hCG. Echogenic patterns were classified as trilaminar and isoechoic. The study endpoints were endometrial thickness, echotexture, serum E2 on the day of ovulatory hCG, and # of morphologic superior embryos (ⱖ 8-cell grade I) at ET. Statistical analyses were done using ANOVA, Kruskal-Wallis and chi-square. Levels ⬍0.05 were considered significant. RESULTS: 200 IU hCG was administered during 3.6⫾0.9 days for women of group A. There were no differences for endometrial thickness: A) 10.4⫾1.7; B) 10.1⫾1.9; and C) 10.1⫾1.9 mm (p⫽0.471). Similarly, the frequency of trilaminar endometrium was comparable in all groups 88%, 95% and 91%, respectively. CONCLUSION: The findings of this study suggest that daily administration of 200 IU of hCG in the mid-late folliculogenesis does not enhance endometrial receptivity. While hCG might have a direct endometrial effect, a straight relationship of hCG administration in a daily basis in the late follicular phase with endometrial growth was not substantiated. In addition, maximum serum estradiol levels on the day of final follicle maturation neither stimulated the growth nor the frequency of trilaminar endometrium. The fact that the number of resulting superior quality embryos and the number of embryos transferred were identical in all groups further validates a lack of a direct sizeable hCG effect on the endometrium. Nevertheless, the findings of this study neither negate a direct nor a modulatory effect of hCG on human endometrium which can not be measures by current clinical tools. Supported by: None

Vol. 82, Suppl. 2, September 2004

P-156 The grade of blastocysts that should be selected to achieve a high pregnancy rate and implantation rate, while decreasing the rate of multiple pregnancy. T. Kusuda, T. Hara, T. Katsuki, A. Toyofuku, K. Ohama. Hiroshima Univercity, Hiroshima City, Japan. OBJECTIVE: Decreasing the rate of multiple pregnancy is an urgent issue for in vitro fertilization and assisted reproduction technology (ART). While the implantation rate is a critical factor for successful outcome of human ART, we studied whether the multiple pregnancy rate could be decreased without decreasing the pregnancy rate after transferring two high grade blastocysts to all patients, and investigated which grade of blastocysts should be transferred to achieve a high implantation rate. DESIGN: Prospective study MATERIALS AND METHODS: Sixty-four cycles of conventional ART program in our department were registered to December in 2003 with written consent. ICSI and frozen the thaw-embryo cycles were not included in this series. Mean patient age was 34.3⫾3.8 years. The retrieved and fertilized oocytes were cultured in sequential medium for blastocyst under 37°C/ 5%CO2/ 5%O2/ 90%N2 for 5 days. Two embryos, or one embryo when two embryos were not available, were transferred after evaluating the grade of embryos by the criteria proposed by Gardner for blastocysts. Pregnancy was defined as positive serum hCG test and a sac seen on ultrasound scan. The difference in pregnancy and implantation rates to the number of retrieved oocytes and grade of embryos were analyzed by ␹-square methods. P⬍0.05 was considered significant. RESULTS: Five hundred and two oocytes were retrieved. Of these, 342 (68.1%) embryos were fertilized, 172 embryos developed into blastocysts, and 89 embryos were evaluated as 3AA or higher grade. The blastocyst rate and 3AA or higher blastocyst rate per fertilized egg were 50.3% and 26.0%, respectively. Pregnancy was achieved in 25 patients. The pregnancy rate per transfer was 39.1%, and the implantation rate per embryo was 26.5%. A significantly high pregnancy and implantation rate per transfer could be reached at cycles of 6 or more oocytes retrieved (56.4% vs. 12.5%, 35.1% vs. 10.3%; p⬍0.01 respectively) or following the transfer of two 3AA or higher blastocysts (65.0% vs. 27.3%, 45% vs. 16.4%; p⬍0.01 respectively). The overall multiple pregnancy rate was 24%. The multiple pregnancy rate was critically high, 38.5%, following transfer of two 3AA or higher blastocysts. In other situations, however, there were no multiple pregnancies recognized except for one set of monochorionic twins. CONCLUSION: The pregnancy rate and implantation potential of morphologically good blastocysts, especially 3AA or higher embryos, were significantly high, when two or more 3AA or higher grade blastocysts were developed. Transfer of two high-grade blastocysts could achieve a high pregnancy and implantation rate, but could not reduce the multiple pregnancy rate. These findings suggest that single embryo transfer could be performed when two or more 3AA or higher grade blastocysts have been developed. Supported by: None

P-157 Chromosomal analysis of villous tissues obtained from spontaneous abortions after ART. C. Yamashiro, T. Miyakawa, S. Furuya, H. Kamiyama, M. Izuta, Y. Kato. Toranomon, Tokyo, Japan. OBJECTIVE: Chromosomal abnormalities are one of major causes of spontaneous abortions. We aimed for analyzing the frequency of different chromosomal abnormalities in early spontaneous abortions after ART. DESIGN: we examined the differences between non ART and ART group, IVF and ICSI group, mild and severe oligozoospermia group in ICSI. MATERIALS AND METHODS: Between 1999 and 2003, 297 early spontaneous abortions (6 to 12 gestational weeks) were analyzed cytoge-

FERTILITY & STERILITY威

netically by the direct preparation method using chorionic villi, among which 78 ART cases [1](46;conventional IVF cases [2], 32;ICSI cases [3]) and 218 non ART cases [4] were enrolled. ICSI cases were compared with total sperm count, 6 cases under [5] and 26 cases over [6] 5 million/ml. The cases with parents’ translocation carrier and uterine anomaly were excluded. RESULTS: The overall frequency of chromosomal abnormality was [1] 74.4%, [2] 67.4%, [3] 84.4%, [4] 80.7%. In abnormal cases, autosomal trisomy type was observed in [1] 82.8%, [2] 83.9%, [3] 81.5%, [4] 68.8%. In autosomal trisomy type, there was the relation to maternal age in non ART group, but in ART group. Trisomy was seen in 85.7% of younger than 35 years old women and 81% of over 36 years old women, there was no differences between the two groups. Among cases with trisomy, trisomy 22 and 16 were prevalent both in ART and non ART groups. Polyploidy was observed in [1] 8.6%, [4] 11.9%, and 45, X, [1] 1.7%, [4] 10.8%, respectively. In ICSI cases, there was no difference in frequency of chromosomal abnormalities between [5] 83.3% and [6] 84.6%. Autosomal trisomy type was observed in [5] 40%, [6] 90.9%, polyploidy, [5] 40%, [6] 0%, 45, X, [5] 20%, [6] 0%, respectively. CONCLUSION: The frequency of chromosomal abnormalities in spontaneous abortions was higher in ICSI than IVF (P⬍0.05). In ART cases, various trisomy types were observed in younger women. This study suggests that chromosomal abnormalities are major cause of early pregnancy loss in ART as well as spontaneous pregnancy, and some factors other than maternal age contribute to the occurence of trisomy seen in ART. Supported by: None

P-158 A comparison between the outcome of conventional IVF and ICSI in sibling oocytes among couples with unexplained infertility. F. Azem, O. Bernholtz, R. Kapustiansky, I. Wagman, J. B Lessing, A. Amit. Tel-Aviv Sourasky Medical Center, Tel-Aviv 64239, Israel. OBJECTIVE: The group of couples defined as “unexplained infertility”is a common indication for different fertility interventions. This group includes those couples who do not achieve a clinical pregnancy after two years, despite normal findings in their evaluation which includes: endocrine profile, hysterosalpingogram, semen analysis and midluteal phase progesterone level. Since the definition of this group is per exclusion, it is composed of heterogenic etiologies for infertility. Nevertheless, as long as the basic problem is not well defined, this group carries a special therapeutic challenge, and there is a difficulty in determining the ideal fertilization protocol. The objective of this study is to evaluate the outcome of ICSI compared with IVF among sibling oocytes of couples with unexplained infertility. DESIGN: Retrospective study MATERIALS AND METHODS: The study included 75 couples diagnosed as unexplained infertility that underwent 89 cycles of IVF-ICSI split. Conventional IVF and ICSI were performed in sibling oocytes .49⫾1.6% of the oocytes were allocated to IVF compared to 50⫾1.6% for ICSI (mean⫾SEM). Rate of fertilization, total fertilization failure, embryo quality and clinical pregnancies outcome were monitored. RESULTS: We found that the fertilization rate of ICSI oocytes was 66⫾3%, compared to 36⫾0.4% in IVF. 24.6⫾2.9% of the ICSI oocytes failed to fertilize compared to 58.8⫾4.1% in the IVF group. However, total fertilization failure occurred only in two cycles in which both ICSI and IVF were applied in sibling oocytes. The embryo quality was not influenced by the fertilization technique. Among the group of ICSI only transferred embryos, the sperm motility was 25⫾3, million/ml, compared with 15.7⫾2.3 in the IVF only transferred embryos. Pregnancy rate was found to be related to the rate of good quality of of the IVF only embryos. CONCLUSION: We conclude that the fertilization rate was improved, and the rate of total fertilization failure was minimized by using ICSI in the group of patients with unexpected borderline semen parameters at day of fertilization. Pregnancy rate was superior in cases in which IVF sibling oocytes, were transferred compared to ICSI oocytes. Supported by: None

P-159 Post-implantation viability does not correlate with implantation rate in patients under 35 years of age. S. P. Gonc¸ alves, D. Dozortsev, V.

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