- Email: [email protected]
Management of pregnancy hypertension — Methods of screening
14
TUESDAY,
SS2.06.02 TEACHING CHINESE YOUTH ABOUT AIDS/STD/SAFER Yu Yue Jin, Shanghai second Medical University, Department Preventive Medicine, Shanghai, P. R. China
SEX of
We carried out an AIDS/STD/Safes sex peer education programme in Beijing and Shanghai, China from August 1998. This programme is based on the peer education model which is novel and lively, making it easily acceptable. The modules consist of basic scientific information, games, stories, slide shows, quizzes, miniplays, discussions and questions. The education content consisted of six modules, Module 1 on HIV/AIDS; Module 2 on sexually trammitted diseases; Module 3 on self-protection (safer sex); Module 4 on facing the challenge AIDS; Module 5 on self-esteem, confidence and responsibility; Module 6 on contraception. By now, this education programme has been carried out at 8 Universities, in Beijing and Shanghai. About 2000 students have received our peer education. After completion of all the six modules. We carried out spot evolution and questionnaire surveys. From the process evaluation and research after education, it is clear that all the students approved of and praised this peer group education.They thought this method was relevant to the lives of young people.It should be widely used for high school and universally students in sex education,and may even be applied to other educational subjects. Beyond the peer education at Universities, we also brought it to middle schools in Shanghai and we were warm welcomed. The programme was well received by the students, the school authorities. I think the peer education to youth about AIDS/STD/Safer sex is extremely successful, and could very easily be popularized.
EN2.02 IAPAROSCOPIC
SURGERY:
SAFE ENTRY
EN2.02.02 THE STEP SYSTEM (THE RADIALLY EXPANDING ACCESS SYSTEM) D. Dept. Of Ob/Gyn, Santa Barbara Associates, Santa Barbara, CA, United States Laparoscopy is inherently difficult, involving precise hand and eye coordination, two-dimensional imaging through the video screen, a diminished tactile sense, and the entry problems associated with a blind procedure. The true incidence of complications is hard to determine because the data comes from either malpractice cases, surveys, medical device reports or practitioners and very little, unfortunately, from prospective controlled studies. What appears clear, however, is that the access materials and methods in operative laparoscopy are the causes of the vast majority of complications. Vascular injuries, visceral injuries and hernias are all associated with this part of the procedure. In fact, the problems can be further isolated to accessing the intraabdominal space by the primary port. In a study of malpractice cases associated with cholecystectomy, 86% of the visceral injuries were caused by the trocar. In the case of malpractice concerning gynecological laparoscopy, it has been shown the primary port is the site of 50% of the major vascular injuries. The secondary port and Veress needle are each involved in 10% of the injuries and miscellaneous injuries account for the remaining 30% To date there has been no consensus to the correct way to enter the abdomen with either the Veress needle, trocar or other access device. This paper is intended to submit an argument for the use of the radially expanding access system. This system is itself first described followed by the data supporting its efficacy and finally a description of the clinical applications.
EN2.02.03 CAN VISUAL ACCESS CANNULAS IMPROVE LAPAROSCOPIC SAFETY? Artin M. Ternamian, Department of Obstetrics and Gynecology, St. Joseph’s Health Centre, University of Toronto, Canada Laparoscopic complications is a growing global concern, and absolute prevention of technical misadventure though medico-legally desirable as
SEPTEMBER
5
a standard of care, may be clinically unachievable, given our present day endoscopic knowledge, training and technology. It is accepted that about half of these injuries are access related. In order to improve laparoscopic access safety, tissue dynamics at port site was studied during application of conventional First Generation pushthrough trocars. Specific Performance Shaping Factors (PSFs) were identified that individually and collectively infers added risk to access cannula insertion and removal. Having determined system weaknesses of conventional Closed and Open laparoscopy, a new interactive visual port system is re-engineered and ergonomic access cannula designed. This Second Generation access system avoids the identified PSF’s, and allows error recovery before harm occurs. Surgeons can anticipate danger, avoid error or recognize mishap. It is anticipated that when uncontrolled axial penetration force is not applied at port site, sharp or pointed trocars are not required, and port creation is visual and interactive, the process becomes less dangerous. With the recent White House initiative to curb medical errors, Congress just passed legislation ordering the Agency for Health Care Policy and Research to design strategies to reduce medical mistakes. Our culture of “blaming the human” must change as it is increasingly evident that most serious laparoscopic access injuries are more a system problem and less of a surgeon or instrument issue.
EN2.02.04 GASLESS LAPAROSCOPY IN GYNECOLOGY HOW TO AVOID COMPLICATIONS DUE TO CARBONDIOXIDE INSUFFLATION? Daniel Institute for Gynaecologic Endoscopy, University Witten / Herdecke, Germany
of
Purpose: Pneuoperitoneum laparoscopy has some disadvantages, e.g. complications at the time of Veres or trocar entry as well as physiologic alterations and complications. To exclude complications due to carbondioxide insufflation and “blind” abdominal entry gasless laparoscopy is beeing used. Methods: 1039 gasless laparoscopic operative laparoscopic procedures, e.g. total laparoscopic hysterectomies, myomectomies, operations on ovarian tumors and severe endometriosis were performed during the period of 1990 2000, for the last five years only with reusable abdominal wall lifting systems which were developed by our Institute. Results: There was no complication at the time of abdominal entry and any complication related to carbondioxide insufflation. All surgeries could be performed with conventional surgical instruments. There were no side effects of carbon dioxide like an increase of arterial PO,, metabolic acidosis, hypercarbia or hypoxemia, an increase of the intra-abdominal pressure, a compression of the diaphragm, hypoventilation, compression of the vena cava with reduction of cardiac output, high central venous pressure and an increase of the peripheral resistance. There was no decrease of the body temperature and no decrease of the intra-abdominal temperature. Postoperative pain, especially shoulder pain and its intensity was beeing reduced significantly by gasless laparoscopy in comparison to carbondioxide. Conclusions: Gasless laparoscopy with reusable abdominal wall lift combines the advantages of laparoscopy (small incisions, short hospitalisation) and of laparotomy (conventional instruments and standard procedures) but excluding the disadvantages of both methods. Complications of gas laparoscopy due to blind punctures at the time of abdominal entry with the Veres needle or first trocar insertion like lesions of bowel or vessels could be eliminated.
FM2.08 MANAGEMENT
OF PREGNANCY
HYPERTENSION
FM2.08.01 MANAGEMENT OF PREGNANCY HYPERTENSION METHODS SCREENING K. University of Zimbabwe, Harare, Zimbabwe
OF
Hypertension in pregnancy complicates up to 10% of pregnancies and contributes significantly to both maternal and perinatal mortality and morbidity. Despite extensive research to elucidate origin of pre eclampsia there is currently no well validated prophylactic treatment; nor is there any effective method of identifying women at risk for pre eclampsia. At present therefore predicting the risk will identify women for more careful monitoring and may also identify population or women for research into its etiology and then possible prevention or treatment.
TUESDAY, SEPTEMBER 5 Previous clinical history and epidemiological factors (chronic hypertension, gestational diabetes, multiple pregnancy and previous pre eclampsia in multiparous women; family history and body mass index in nulliparous women), may identify individuals or populations at increased risk but their sensitivity and specificity is not very high. Markers may be used for diagnosis of disease before clinical appearance. Some potential markers include those related to renal function (creatinine), to vascular dysfunction (fbronectin), to oxidative stress (homocysteinaemia), hypertriglyceridaemia, plaental peptides (inhibin and hCG), to vascular resistance (doppler velocity waveforms) and to genetic markers. There is need to validate in prospective longitudinal studies the usefulness of any test.
FM2.08.03 MANAGEMENT OF HYPERTENSIVE PREGNANCY IN THE DEVELOPING WORLD R.L. Khan, Dept. of OB/GYN, Postgraduate Medical Institute, Lahore, Pakistan Population of Pakistan is estimated to be over 140 million and women of childbearing age constitute about 20% of the total population. Hypertensive disorders in pregnancy are the second major contributor towards maternal mortality in Pakistan. Eclampsia remains a serious obstetrical emergency in the developing world. To review the current management status of hypertension a retrospective analysis of obstetrical population shows its overall incidence of 6.3%. Pregnancy induced hypertension, preeclampsia, eclampsia and essential hypertension account for 41%, 5.1%, 8.7% and 45.2% respectively. Antihypertensive in use are mainly methyldopa and nifedipine orally, however, in imminent eclampsia and eclampsia infusion of methyldopa and diazepam are used as primary antihypertensive and anticonvulsant respectively. Nifedipine is given sublingually as an adjuvant to methldopa. Timing and mode of delivery vary according to clinical presentation. Around 70% of deliveries occur at term whereas 30% deliver preterm. Vaginal route is considered to be the preferable one, with 68.4% delivering by this route and the rest by caesarean section. This paper highlights the need for improvement in antenatal services to ensure prevention rather than cure. Emphasis will be made on the need for better primary health care services for early detection and rapid referral in order to reduce maternal mortality from these conditions.
FM2.08.04 MANAGEMENT OF PREGNANCY HYPERTENSION V.TsaDanos. Dept. OB/GYN, University Hospital, Patras, Rion, Greece Management of Pregnancy Hypertension is mainly alike in all obstetrical departments in Greece. To our knowledge, the protocols used are quite similar in Balkan countries, Central and S.E.Europe and in many Mediterranean countries. They are updated and revised permanently according to the peers suggestions and the main European and American Health Organizations. Prevention of preeclampsia is considered for high-risk patients upon the pregnancy diagnosis. Low dose aspirin is initiated and diet of olive-oil and little Mediterranean fishes or dietary supplementation with fish-oil rich in N-3 polyunsaturated fatty acids is recommended. Alpha-methyldopa or the calcium channel blocker Nifedipine are commonly used for chronic hypertension treatment or mild preeclampsia after having ruled out concealed diseases. Hydralazine IV is reserved for eclampsia or severe preeclampsia where anticonvulsant prophylactic therapy with MgSO, IV is routinely used. Acceleration of lung maturation with betaMethasone is always induced before 35th week and delivery is performed as soon as fetal maturation has been established, or immediately if the maternal condition is getting worse and the fetal wellbeing is rapidly deteriorating. Cesarean section with regional anesthesia is usually performed especially when cervix is unripe and a laborious vaginal delivery is anticipated. MgSO,, which is also reserved for management of convulsions during eclampsia, is continued for three days after delivery.
15
In our institution the incidence of preeclampsia was 3.25% of all advanced pregnancies for the decade 1981-1990 and 1.26% for the last decade 1991. 1999 and eclampsia occurred in 4.3% and 2.3% of these preeclampsias respectively. In similar studies raised in Greece for the years before, eclampsias occurred in 14.9% of preeclampsias.
RM2.06 EFFECTIVENESS RM2.06.01 IVF Allan Temuleton, University
OF ASSISTED
CONCEPTION
of Aberdeen, Aberdeen, UK
It has been estimated that the total number of IVF cycles world-wide is now half a million each year, including more than 50 thousand cycles in the U.S. and more than 30 thousand cycles in the U.K. Reported live birth rates vary widely, with rates of 10 50% now being commonly reported. Outcomes depend on medical and scientific expertise in the management and selection of patients, the characteristics of the individual women being treated (crucially), and less clearly on the number of embryos transferred. Success rates still tend to be regarded in the rather restricted sense of pregnancy rates per treatment, and less on the medical, social and financial outcomes. Multiple birth remains the major frequent complication of IVF and it has to be seriously considered whether treatment that has a 30 40% risk of multiple birth can be considered appropriate. Furthermore the effectiveness of treatment has to be considered, not against the pregnancy rate itself, but the enhanced likelihood that IVF will result in a pregnancy compared to no treatment. These issues are dependent mainly on the age and parity of the woman as well as the duration of infertility of the couple. There may in addition be other techniques which enhance pregnancy rates, and many have entered into clinical practice without being scientifically tested in clinical trials. These include assisted hatching and blastocyst transfer. There can be no doubt, however, that IVF will continue to develop to meet the needs of an increasingly wide group of individuals with reproductive problems. Basically this is because the technique allows direct access to the gametes and embryos. However, it is worth remembering that these modifications and developments are all derived from the basic technique that was first shown to be feasible by Edwards and Steptoe more than 20 years ago.
RM2.06.03 BLASTOCYST TRANSFER A WAY AHEAD M. Hansotia, S. Desai,V.Mangoli, R.Mangoli, T.Koli, Fertility Clinic & IVF Centre, Gamdevi, Mumbai, India Objectives: The essence of advances in contemporary ART is to maximize success while minimizing complications. Blastocyst transfers dramatically improves pregnancy rates, reduces incidence of multiple births and enables transfer of only the good viable embryos thus avoiding the temptation of transferring multiple embryos. Study Methods: From 15th February 1999 the Fertility Clinic, Mumbai switched over to sequential transfer from conventional Day2 transfers. This was a prospective study. Results: 143 subjects were selected for the study. 416 embryos were allowed to grow to the blastocyst stage. Of these 185 (44.47%) grew into a blastocyst. 137 (32.9%) grew to Grade I blastocyst and 48(11.5%) grew to Grade II blastocyst.Clinical pregnancy rates were highest when Grade I blastocysts were transferred (47.05%) followed by Grade II blastocysts(l4.8%) and just 9.67% pregnancy rate during morula stage transfer. There were 12 multiple pregnancies, majority of which were twins (8). Of the 94 thawed embryos that were kept, only 20 reached the blastocyst stage with pregnancy rate of 17.39%. During the same period, 106 subjects underwent single Day2 transfer, pregnancy rate was only 23%. Conclusions: Sequential transfers have significantly improved our results. By changing over to sequential transfers we had the security of conventional results coupled with the advantages of newer techniques. It has given us confidence to upgrade our services to the use of exclusive blastocyst transfers. Dramatic difference in pregnancy rate proves that we must have courage to transfer only Grade I blastocyst.
TUESDAY,
SS2.06.02 TEACHING CHINESE YOUTH ABOUT AIDS/STD/SAFER Yu Yue Jin, Shanghai second Medical University, Department Preventive Medicine, Shanghai, P. R. China
SEX of
We carried out an AIDS/STD/Safes sex peer education programme in Beijing and Shanghai, China from August 1998. This programme is based on the peer education model which is novel and lively, making it easily acceptable. The modules consist of basic scientific information, games, stories, slide shows, quizzes, miniplays, discussions and questions. The education content consisted of six modules, Module 1 on HIV/AIDS; Module 2 on sexually trammitted diseases; Module 3 on self-protection (safer sex); Module 4 on facing the challenge AIDS; Module 5 on self-esteem, confidence and responsibility; Module 6 on contraception. By now, this education programme has been carried out at 8 Universities, in Beijing and Shanghai. About 2000 students have received our peer education. After completion of all the six modules. We carried out spot evolution and questionnaire surveys. From the process evaluation and research after education, it is clear that all the students approved of and praised this peer group education.They thought this method was relevant to the lives of young people.It should be widely used for high school and universally students in sex education,and may even be applied to other educational subjects. Beyond the peer education at Universities, we also brought it to middle schools in Shanghai and we were warm welcomed. The programme was well received by the students, the school authorities. I think the peer education to youth about AIDS/STD/Safer sex is extremely successful, and could very easily be popularized.
EN2.02 IAPAROSCOPIC
SURGERY:
SAFE ENTRY
EN2.02.02 THE STEP SYSTEM (THE RADIALLY EXPANDING ACCESS SYSTEM) D. Dept. Of Ob/Gyn, Santa Barbara Associates, Santa Barbara, CA, United States Laparoscopy is inherently difficult, involving precise hand and eye coordination, two-dimensional imaging through the video screen, a diminished tactile sense, and the entry problems associated with a blind procedure. The true incidence of complications is hard to determine because the data comes from either malpractice cases, surveys, medical device reports or practitioners and very little, unfortunately, from prospective controlled studies. What appears clear, however, is that the access materials and methods in operative laparoscopy are the causes of the vast majority of complications. Vascular injuries, visceral injuries and hernias are all associated with this part of the procedure. In fact, the problems can be further isolated to accessing the intraabdominal space by the primary port. In a study of malpractice cases associated with cholecystectomy, 86% of the visceral injuries were caused by the trocar. In the case of malpractice concerning gynecological laparoscopy, it has been shown the primary port is the site of 50% of the major vascular injuries. The secondary port and Veress needle are each involved in 10% of the injuries and miscellaneous injuries account for the remaining 30% To date there has been no consensus to the correct way to enter the abdomen with either the Veress needle, trocar or other access device. This paper is intended to submit an argument for the use of the radially expanding access system. This system is itself first described followed by the data supporting its efficacy and finally a description of the clinical applications.
EN2.02.03 CAN VISUAL ACCESS CANNULAS IMPROVE LAPAROSCOPIC SAFETY? Artin M. Ternamian, Department of Obstetrics and Gynecology, St. Joseph’s Health Centre, University of Toronto, Canada Laparoscopic complications is a growing global concern, and absolute prevention of technical misadventure though medico-legally desirable as
SEPTEMBER
5
a standard of care, may be clinically unachievable, given our present day endoscopic knowledge, training and technology. It is accepted that about half of these injuries are access related. In order to improve laparoscopic access safety, tissue dynamics at port site was studied during application of conventional First Generation pushthrough trocars. Specific Performance Shaping Factors (PSFs) were identified that individually and collectively infers added risk to access cannula insertion and removal. Having determined system weaknesses of conventional Closed and Open laparoscopy, a new interactive visual port system is re-engineered and ergonomic access cannula designed. This Second Generation access system avoids the identified PSF’s, and allows error recovery before harm occurs. Surgeons can anticipate danger, avoid error or recognize mishap. It is anticipated that when uncontrolled axial penetration force is not applied at port site, sharp or pointed trocars are not required, and port creation is visual and interactive, the process becomes less dangerous. With the recent White House initiative to curb medical errors, Congress just passed legislation ordering the Agency for Health Care Policy and Research to design strategies to reduce medical mistakes. Our culture of “blaming the human” must change as it is increasingly evident that most serious laparoscopic access injuries are more a system problem and less of a surgeon or instrument issue.
EN2.02.04 GASLESS LAPAROSCOPY IN GYNECOLOGY HOW TO AVOID COMPLICATIONS DUE TO CARBONDIOXIDE INSUFFLATION? Daniel Institute for Gynaecologic Endoscopy, University Witten / Herdecke, Germany
of
Purpose: Pneuoperitoneum laparoscopy has some disadvantages, e.g. complications at the time of Veres or trocar entry as well as physiologic alterations and complications. To exclude complications due to carbondioxide insufflation and “blind” abdominal entry gasless laparoscopy is beeing used. Methods: 1039 gasless laparoscopic operative laparoscopic procedures, e.g. total laparoscopic hysterectomies, myomectomies, operations on ovarian tumors and severe endometriosis were performed during the period of 1990 2000, for the last five years only with reusable abdominal wall lifting systems which were developed by our Institute. Results: There was no complication at the time of abdominal entry and any complication related to carbondioxide insufflation. All surgeries could be performed with conventional surgical instruments. There were no side effects of carbon dioxide like an increase of arterial PO,, metabolic acidosis, hypercarbia or hypoxemia, an increase of the intra-abdominal pressure, a compression of the diaphragm, hypoventilation, compression of the vena cava with reduction of cardiac output, high central venous pressure and an increase of the peripheral resistance. There was no decrease of the body temperature and no decrease of the intra-abdominal temperature. Postoperative pain, especially shoulder pain and its intensity was beeing reduced significantly by gasless laparoscopy in comparison to carbondioxide. Conclusions: Gasless laparoscopy with reusable abdominal wall lift combines the advantages of laparoscopy (small incisions, short hospitalisation) and of laparotomy (conventional instruments and standard procedures) but excluding the disadvantages of both methods. Complications of gas laparoscopy due to blind punctures at the time of abdominal entry with the Veres needle or first trocar insertion like lesions of bowel or vessels could be eliminated.
FM2.08 MANAGEMENT
OF PREGNANCY
HYPERTENSION
FM2.08.01 MANAGEMENT OF PREGNANCY HYPERTENSION METHODS SCREENING K. University of Zimbabwe, Harare, Zimbabwe
OF
Hypertension in pregnancy complicates up to 10% of pregnancies and contributes significantly to both maternal and perinatal mortality and morbidity. Despite extensive research to elucidate origin of pre eclampsia there is currently no well validated prophylactic treatment; nor is there any effective method of identifying women at risk for pre eclampsia. At present therefore predicting the risk will identify women for more careful monitoring and may also identify population or women for research into its etiology and then possible prevention or treatment.
TUESDAY, SEPTEMBER 5 Previous clinical history and epidemiological factors (chronic hypertension, gestational diabetes, multiple pregnancy and previous pre eclampsia in multiparous women; family history and body mass index in nulliparous women), may identify individuals or populations at increased risk but their sensitivity and specificity is not very high. Markers may be used for diagnosis of disease before clinical appearance. Some potential markers include those related to renal function (creatinine), to vascular dysfunction (fbronectin), to oxidative stress (homocysteinaemia), hypertriglyceridaemia, plaental peptides (inhibin and hCG), to vascular resistance (doppler velocity waveforms) and to genetic markers. There is need to validate in prospective longitudinal studies the usefulness of any test.
FM2.08.03 MANAGEMENT OF HYPERTENSIVE PREGNANCY IN THE DEVELOPING WORLD R.L. Khan, Dept. of OB/GYN, Postgraduate Medical Institute, Lahore, Pakistan Population of Pakistan is estimated to be over 140 million and women of childbearing age constitute about 20% of the total population. Hypertensive disorders in pregnancy are the second major contributor towards maternal mortality in Pakistan. Eclampsia remains a serious obstetrical emergency in the developing world. To review the current management status of hypertension a retrospective analysis of obstetrical population shows its overall incidence of 6.3%. Pregnancy induced hypertension, preeclampsia, eclampsia and essential hypertension account for 41%, 5.1%, 8.7% and 45.2% respectively. Antihypertensive in use are mainly methyldopa and nifedipine orally, however, in imminent eclampsia and eclampsia infusion of methyldopa and diazepam are used as primary antihypertensive and anticonvulsant respectively. Nifedipine is given sublingually as an adjuvant to methldopa. Timing and mode of delivery vary according to clinical presentation. Around 70% of deliveries occur at term whereas 30% deliver preterm. Vaginal route is considered to be the preferable one, with 68.4% delivering by this route and the rest by caesarean section. This paper highlights the need for improvement in antenatal services to ensure prevention rather than cure. Emphasis will be made on the need for better primary health care services for early detection and rapid referral in order to reduce maternal mortality from these conditions.
FM2.08.04 MANAGEMENT OF PREGNANCY HYPERTENSION V.TsaDanos. Dept. OB/GYN, University Hospital, Patras, Rion, Greece Management of Pregnancy Hypertension is mainly alike in all obstetrical departments in Greece. To our knowledge, the protocols used are quite similar in Balkan countries, Central and S.E.Europe and in many Mediterranean countries. They are updated and revised permanently according to the peers suggestions and the main European and American Health Organizations. Prevention of preeclampsia is considered for high-risk patients upon the pregnancy diagnosis. Low dose aspirin is initiated and diet of olive-oil and little Mediterranean fishes or dietary supplementation with fish-oil rich in N-3 polyunsaturated fatty acids is recommended. Alpha-methyldopa or the calcium channel blocker Nifedipine are commonly used for chronic hypertension treatment or mild preeclampsia after having ruled out concealed diseases. Hydralazine IV is reserved for eclampsia or severe preeclampsia where anticonvulsant prophylactic therapy with MgSO, IV is routinely used. Acceleration of lung maturation with betaMethasone is always induced before 35th week and delivery is performed as soon as fetal maturation has been established, or immediately if the maternal condition is getting worse and the fetal wellbeing is rapidly deteriorating. Cesarean section with regional anesthesia is usually performed especially when cervix is unripe and a laborious vaginal delivery is anticipated. MgSO,, which is also reserved for management of convulsions during eclampsia, is continued for three days after delivery.
15
In our institution the incidence of preeclampsia was 3.25% of all advanced pregnancies for the decade 1981-1990 and 1.26% for the last decade 1991. 1999 and eclampsia occurred in 4.3% and 2.3% of these preeclampsias respectively. In similar studies raised in Greece for the years before, eclampsias occurred in 14.9% of preeclampsias.
RM2.06 EFFECTIVENESS RM2.06.01 IVF Allan Temuleton, University
OF ASSISTED
CONCEPTION
of Aberdeen, Aberdeen, UK
It has been estimated that the total number of IVF cycles world-wide is now half a million each year, including more than 50 thousand cycles in the U.S. and more than 30 thousand cycles in the U.K. Reported live birth rates vary widely, with rates of 10 50% now being commonly reported. Outcomes depend on medical and scientific expertise in the management and selection of patients, the characteristics of the individual women being treated (crucially), and less clearly on the number of embryos transferred. Success rates still tend to be regarded in the rather restricted sense of pregnancy rates per treatment, and less on the medical, social and financial outcomes. Multiple birth remains the major frequent complication of IVF and it has to be seriously considered whether treatment that has a 30 40% risk of multiple birth can be considered appropriate. Furthermore the effectiveness of treatment has to be considered, not against the pregnancy rate itself, but the enhanced likelihood that IVF will result in a pregnancy compared to no treatment. These issues are dependent mainly on the age and parity of the woman as well as the duration of infertility of the couple. There may in addition be other techniques which enhance pregnancy rates, and many have entered into clinical practice without being scientifically tested in clinical trials. These include assisted hatching and blastocyst transfer. There can be no doubt, however, that IVF will continue to develop to meet the needs of an increasingly wide group of individuals with reproductive problems. Basically this is because the technique allows direct access to the gametes and embryos. However, it is worth remembering that these modifications and developments are all derived from the basic technique that was first shown to be feasible by Edwards and Steptoe more than 20 years ago.
RM2.06.03 BLASTOCYST TRANSFER A WAY AHEAD M. Hansotia, S. Desai,V.Mangoli, R.Mangoli, T.Koli, Fertility Clinic & IVF Centre, Gamdevi, Mumbai, India Objectives: The essence of advances in contemporary ART is to maximize success while minimizing complications. Blastocyst transfers dramatically improves pregnancy rates, reduces incidence of multiple births and enables transfer of only the good viable embryos thus avoiding the temptation of transferring multiple embryos. Study Methods: From 15th February 1999 the Fertility Clinic, Mumbai switched over to sequential transfer from conventional Day2 transfers. This was a prospective study. Results: 143 subjects were selected for the study. 416 embryos were allowed to grow to the blastocyst stage. Of these 185 (44.47%) grew into a blastocyst. 137 (32.9%) grew to Grade I blastocyst and 48(11.5%) grew to Grade II blastocyst.Clinical pregnancy rates were highest when Grade I blastocysts were transferred (47.05%) followed by Grade II blastocysts(l4.8%) and just 9.67% pregnancy rate during morula stage transfer. There were 12 multiple pregnancies, majority of which were twins (8). Of the 94 thawed embryos that were kept, only 20 reached the blastocyst stage with pregnancy rate of 17.39%. During the same period, 106 subjects underwent single Day2 transfer, pregnancy rate was only 23%. Conclusions: Sequential transfers have significantly improved our results. By changing over to sequential transfers we had the security of conventional results coupled with the advantages of newer techniques. It has given us confidence to upgrade our services to the use of exclusive blastocyst transfers. Dramatic difference in pregnancy rate proves that we must have courage to transfer only Grade I blastocyst.