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Selective reduction after gamete intrafallopian transfer
59
Int J Gynecol Obstet. 1991, 36: 59-61
International Federation of Gynecology and Obstetrics
Selective reduction V. Vlaisavljevic
after gamete intrafallopian
transfer
and E. Borko
Department of Gynecology, Reproductive Unit, Hospital Mahbor. Maribor ( Yugoslavia)
(Received November 5th. 1989) (Revised and accepted August 15th, 1990)
Abstract Selective reduction was performed in a patient with triplet pregnancy in the 9th week of gestation. Selective reduction of the fetuses to two was performed by puncture using vaginal ultrasound probe. No complications occurred and the patient was delivered of healthy twins.
Keywords: Multiple pregnancy;
Transvaginal puncture/ultrasonically guided; Selective reduction; GIFT/complications. Introduction
The technique of gamete intrafallopian transfer (GIFT), first described by Asch et al. [2], is now accepted as a relatively successful method of assisted reproductive technology. Multiple pregnancy is one of the most undesired complications of this method. For this reason, in well established IVF/GIFT programs replacement of only two eggs per tube is usually the accepted protocol. Case report
A 36-year-old woman was recommended for the IVF program after 6 years of evalua0020-7292/g I /$03.50 0 1991 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
tion of her primary infertility. Her HSG and laparoscopy showed normal tubes. In November 1988, follicular development was induced by clomiphene citrate (CC), human menopausal gonadotropin (HMG) and human chorionic gonadotropin (hCG). was Stimulation protocol completely monitored by ultrasound. At the time of hCG administration, five follicles larger than 17 mm in mean diameter were identified by ultrasound vaginal visualization. A total of 9 eggs were obtained. Four were loaded in a GIFT teflon catheter (TIK Kobarid, YU) with 200 000 motile sperm per tube in a total volume of 50 ~1. Sixteen days later, positive beta hCG (> 200 IU/l) was recorded. Two weeks after the onset of the menstrual period, three gestational sacs were observed on the vaginal scan (Fig. 1). Because of personal problems related with triple pregnancy, the patient wanted to terminate the pregnancy. We advised fetal reduction in the 9th week of gestation. Obesity was the reason for choosing the transvaginal route using a 5 MHz vaginal probe (Ultramark 4, Squibb Medical Systems, BRD). On the day of puncture, the vagina was washed with a bethadine iodine solution. A sterile condom and needle guide were used. Puncture was done with a 25 mm long needle, 0.95 mm in diameter (TIK Kobarid, YU). No Case Report
60
Vlaisavljevic
and Borko
Fig. 1. Three gestational sacs in the uterus after GIFT procedure.
mandrain was used. The needle was connected with the syringe and both were tilled up with potassium chloride and introduced into the needle guide of the probe. In accor-
Fig. 2. Scan of gravid uterus after reduction. Two intact em-
bryos and one lifeless embryo in resorption are visible. Int J Gynecol Obsrer 36
dance with the patient’s wishes, no analgesic or local anesthetic was applied. Under ultrasonographic guidance, the needle was introduced within the fetal cardiac region, followed by an injection of 2.0 ml of potassium chloride (2 mEquiv/ml). After cardiac activity disappeared, the amniotic fluid was evacuated. No vaginal bleeding was observed during the hospitalization in the first 3 days after the puncture nor during the weeks following it. In the following 2 weeks, continued viability and growth of the remaining two embryos were observed (Fig. 2). After that period, the third embryo disappeared completely. No complications were recognized during the gestation. In the 37th week of gestation the because of pregnancy was terminated premature membrane rupture. Two healthy boys with a birthweight of 2530 g and 2280 g were delivered by cesarean section. The twins are alive and well. Discussion
GIFT procedure is now accepted as a successful treatment of some cases of infertility where at least one fallopian tube is patent. Unlike the transvaginal route for gamete replacement after cannulation of tubal ostia, usually reported in the literature as single cases [9,12], the transabdominal technique recommended by Asch et al. [2] is accepted worldwide as a successful method. Its pregnancy rate varies from 20% to 40%, depending on the number of transferred oocytes, patient’s age and sperm quality. Craft and Brinsden [6] reported 1071 GIFT cases and established that pregnancy occurred in 21.4% of patients receiving up to four oocytes compared with 40.3% in whom five or more were transferred. Multiple pregnancy rates were higher in the second group (32% vs. 17%). The major factor influencing the chances of success was age over 40. Similar reports have been published by other authors ]5,131. Selective termination of multiple gestation was first described by Hansmann et al. [8]
Selective
who used the transabdominal approach. Lopes et al. [l l] described the removal of embryos by transcervical vacuum aspiration under ultrasonographic guidance. Kanhai et al. [lo] advocate the transabdominal approach and selective termination of embryos by direct fetal trauma. Recently the transabdominal route for potassium chloride application for fetal cardiac arrest was recommended [3], but we chose the method of transvaginal puncture through the uterus wall. We believe that the transvaginal approach is superior because the probe target distance is shorter and puncture of the object can be done more precisely in all, and specially in obese patients. With this method we can empty the highest sac in the uterus and not compromise the membranes over the internal cervical OS which may predispose the patient to premature membrane rupture. The only risk is that of infection, which probably cannot be higher than in transcervical aspiration of chorion villus sampling procedure. Although recently published review articles about selective fetal reduction list only 34 published cases, of which 8 resulted in spontaneous abortion [l], we believe that this procedure is carried out more frequently than is apparent from published reports. Without doubt the method is reasonable in cases with quadruplets and pregnancies with more than four fetuses. There are cases with serious perinatologic problems where reduction of the number of embryos can reduce the risk for the remaining embryos. In cases of triplet pregnancies,. and specially in twins, there are many ethical and medical dilemmas for the patient and her gynecologist. In these cases, the decision must be made on an individual basis, specially in cases where selective abortion is discussed as a possible alternative of unwanted multiple pregnancy. The medical benefits for the mother and the newborn cannot be clearly evaluated because no studies including a long-term followup of parents and children involved in the fetal reduction procedure exist as yet.
reduction
ufter
GIFT
61
References ii:
I
Anonymous: 1988.
2
3
Asch RH, Ellsworth IR, Balmaceda JP. Wong PC: Pregnancy after translaparoscopic gamete intrafallopian transfer. Lancet ii: 1034, 1984. Batzer FR. Gocial B, Corson SL. Weiner S, Wapner RJ:
4
Multiple pregnancies with gamete intrafallopian transfer (GIFT). Complications of a new technique. J In Vitro Fertilization Embryo Transfer 5: 35. 1988. Berkowitz RL, Lynch L. Chitkara U. Wilkins IA,
5
Mehalek KE, Alvarez E: Selective reduction of multifetal pregnancies in the first trimester. N Engl J Med 3/8: 1043, 1988. Borrero C, Ord T. Balmaceda JP, Rojas FJ. Asch RH:
6
7
8
9
Selective
fetal
reduction.
Lancet
773.
The GIFT experience: an evaluation of the outcome of I IS cases. Human Reprod 3: 227, 1988. Craft I. Brinsden P: Alternatives to IVF: the outcome of 1071 first GIFT procedures. Human Reprod 4(Supp/): 29. 1989. Farquharson DF, Wittmann BK, Hansmann M. Yen BH. Baldwin VJ, Lindhal S: Management of quintuplet pregnancy by selective embryiocide. Am J Obstet Gynecol 158: 413. 1988. Hansmann M, Hackeloer BJ. Staudach A: Ultrasound Diagnosis in Obstetrics and Gynecology, p 73. SpringerVerlag. Berlin, 1985.
10
Jansen RPS, Anderson JC. Sutherland PD: Nonoperative embryo transfer to the fallopian tube. N Engl J Med 319: 288, 1988. Kanhai HHH, van Rijssel EJC, Meerman RJ. Ben-
II
nebroek Gravenhorst J: Selective termination in quintuplet pregnancy during first trimester. Lancet i: 1447. 1986. Lopes P. Talmant C. Thiery M et al: Partial termination
I2
13
of quintuplet pregnancy. Z Geburtshilfe Perinatol 189. 239, 1985. Lucena E, Ruiz JA, Mendoza JC, Ortiz JA. Lucena C. Gomez M. Arano A: Vaginal intratubal insemination (VITI) and vaginal GIFT, endosonographic technique early experience. Human Reprod 4; 658, 1989. Wong PC. Ng SC, Hamilton MPR. Anandakumar C. Wong YC. Ratnam SS: Eighty consecutive cases of gamete intra-fallopian transfer. Human Reprod 3: 231. 1988.
Address for reprints: V. Vlaisavljevic Department of Gynecology Reproductive Unit Hospital Maribor Mar&or Yugoslavia
Cusr Report
Int J Gynecol Obstet. 1991, 36: 59-61
International Federation of Gynecology and Obstetrics
Selective reduction V. Vlaisavljevic
after gamete intrafallopian
transfer
and E. Borko
Department of Gynecology, Reproductive Unit, Hospital Mahbor. Maribor ( Yugoslavia)
(Received November 5th. 1989) (Revised and accepted August 15th, 1990)
Abstract Selective reduction was performed in a patient with triplet pregnancy in the 9th week of gestation. Selective reduction of the fetuses to two was performed by puncture using vaginal ultrasound probe. No complications occurred and the patient was delivered of healthy twins.
Keywords: Multiple pregnancy;
Transvaginal puncture/ultrasonically guided; Selective reduction; GIFT/complications. Introduction
The technique of gamete intrafallopian transfer (GIFT), first described by Asch et al. [2], is now accepted as a relatively successful method of assisted reproductive technology. Multiple pregnancy is one of the most undesired complications of this method. For this reason, in well established IVF/GIFT programs replacement of only two eggs per tube is usually the accepted protocol. Case report
A 36-year-old woman was recommended for the IVF program after 6 years of evalua0020-7292/g I /$03.50 0 1991 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
tion of her primary infertility. Her HSG and laparoscopy showed normal tubes. In November 1988, follicular development was induced by clomiphene citrate (CC), human menopausal gonadotropin (HMG) and human chorionic gonadotropin (hCG). was Stimulation protocol completely monitored by ultrasound. At the time of hCG administration, five follicles larger than 17 mm in mean diameter were identified by ultrasound vaginal visualization. A total of 9 eggs were obtained. Four were loaded in a GIFT teflon catheter (TIK Kobarid, YU) with 200 000 motile sperm per tube in a total volume of 50 ~1. Sixteen days later, positive beta hCG (> 200 IU/l) was recorded. Two weeks after the onset of the menstrual period, three gestational sacs were observed on the vaginal scan (Fig. 1). Because of personal problems related with triple pregnancy, the patient wanted to terminate the pregnancy. We advised fetal reduction in the 9th week of gestation. Obesity was the reason for choosing the transvaginal route using a 5 MHz vaginal probe (Ultramark 4, Squibb Medical Systems, BRD). On the day of puncture, the vagina was washed with a bethadine iodine solution. A sterile condom and needle guide were used. Puncture was done with a 25 mm long needle, 0.95 mm in diameter (TIK Kobarid, YU). No Case Report
60
Vlaisavljevic
and Borko
Fig. 1. Three gestational sacs in the uterus after GIFT procedure.
mandrain was used. The needle was connected with the syringe and both were tilled up with potassium chloride and introduced into the needle guide of the probe. In accor-
Fig. 2. Scan of gravid uterus after reduction. Two intact em-
bryos and one lifeless embryo in resorption are visible. Int J Gynecol Obsrer 36
dance with the patient’s wishes, no analgesic or local anesthetic was applied. Under ultrasonographic guidance, the needle was introduced within the fetal cardiac region, followed by an injection of 2.0 ml of potassium chloride (2 mEquiv/ml). After cardiac activity disappeared, the amniotic fluid was evacuated. No vaginal bleeding was observed during the hospitalization in the first 3 days after the puncture nor during the weeks following it. In the following 2 weeks, continued viability and growth of the remaining two embryos were observed (Fig. 2). After that period, the third embryo disappeared completely. No complications were recognized during the gestation. In the 37th week of gestation the because of pregnancy was terminated premature membrane rupture. Two healthy boys with a birthweight of 2530 g and 2280 g were delivered by cesarean section. The twins are alive and well. Discussion
GIFT procedure is now accepted as a successful treatment of some cases of infertility where at least one fallopian tube is patent. Unlike the transvaginal route for gamete replacement after cannulation of tubal ostia, usually reported in the literature as single cases [9,12], the transabdominal technique recommended by Asch et al. [2] is accepted worldwide as a successful method. Its pregnancy rate varies from 20% to 40%, depending on the number of transferred oocytes, patient’s age and sperm quality. Craft and Brinsden [6] reported 1071 GIFT cases and established that pregnancy occurred in 21.4% of patients receiving up to four oocytes compared with 40.3% in whom five or more were transferred. Multiple pregnancy rates were higher in the second group (32% vs. 17%). The major factor influencing the chances of success was age over 40. Similar reports have been published by other authors ]5,131. Selective termination of multiple gestation was first described by Hansmann et al. [8]
Selective
who used the transabdominal approach. Lopes et al. [l l] described the removal of embryos by transcervical vacuum aspiration under ultrasonographic guidance. Kanhai et al. [lo] advocate the transabdominal approach and selective termination of embryos by direct fetal trauma. Recently the transabdominal route for potassium chloride application for fetal cardiac arrest was recommended [3], but we chose the method of transvaginal puncture through the uterus wall. We believe that the transvaginal approach is superior because the probe target distance is shorter and puncture of the object can be done more precisely in all, and specially in obese patients. With this method we can empty the highest sac in the uterus and not compromise the membranes over the internal cervical OS which may predispose the patient to premature membrane rupture. The only risk is that of infection, which probably cannot be higher than in transcervical aspiration of chorion villus sampling procedure. Although recently published review articles about selective fetal reduction list only 34 published cases, of which 8 resulted in spontaneous abortion [l], we believe that this procedure is carried out more frequently than is apparent from published reports. Without doubt the method is reasonable in cases with quadruplets and pregnancies with more than four fetuses. There are cases with serious perinatologic problems where reduction of the number of embryos can reduce the risk for the remaining embryos. In cases of triplet pregnancies,. and specially in twins, there are many ethical and medical dilemmas for the patient and her gynecologist. In these cases, the decision must be made on an individual basis, specially in cases where selective abortion is discussed as a possible alternative of unwanted multiple pregnancy. The medical benefits for the mother and the newborn cannot be clearly evaluated because no studies including a long-term followup of parents and children involved in the fetal reduction procedure exist as yet.
reduction
ufter
GIFT
61
References ii:
I
Anonymous: 1988.
2
3
Asch RH, Ellsworth IR, Balmaceda JP. Wong PC: Pregnancy after translaparoscopic gamete intrafallopian transfer. Lancet ii: 1034, 1984. Batzer FR. Gocial B, Corson SL. Weiner S, Wapner RJ:
4
Multiple pregnancies with gamete intrafallopian transfer (GIFT). Complications of a new technique. J In Vitro Fertilization Embryo Transfer 5: 35. 1988. Berkowitz RL, Lynch L. Chitkara U. Wilkins IA,
5
Mehalek KE, Alvarez E: Selective reduction of multifetal pregnancies in the first trimester. N Engl J Med 3/8: 1043, 1988. Borrero C, Ord T. Balmaceda JP, Rojas FJ. Asch RH:
6
7
8
9
Selective
fetal
reduction.
Lancet
773.
The GIFT experience: an evaluation of the outcome of I IS cases. Human Reprod 3: 227, 1988. Craft I. Brinsden P: Alternatives to IVF: the outcome of 1071 first GIFT procedures. Human Reprod 4(Supp/): 29. 1989. Farquharson DF, Wittmann BK, Hansmann M. Yen BH. Baldwin VJ, Lindhal S: Management of quintuplet pregnancy by selective embryiocide. Am J Obstet Gynecol 158: 413. 1988. Hansmann M, Hackeloer BJ. Staudach A: Ultrasound Diagnosis in Obstetrics and Gynecology, p 73. SpringerVerlag. Berlin, 1985.
10
Jansen RPS, Anderson JC. Sutherland PD: Nonoperative embryo transfer to the fallopian tube. N Engl J Med 319: 288, 1988. Kanhai HHH, van Rijssel EJC, Meerman RJ. Ben-
II
nebroek Gravenhorst J: Selective termination in quintuplet pregnancy during first trimester. Lancet i: 1447. 1986. Lopes P. Talmant C. Thiery M et al: Partial termination
I2
13
of quintuplet pregnancy. Z Geburtshilfe Perinatol 189. 239, 1985. Lucena E, Ruiz JA, Mendoza JC, Ortiz JA. Lucena C. Gomez M. Arano A: Vaginal intratubal insemination (VITI) and vaginal GIFT, endosonographic technique early experience. Human Reprod 4; 658, 1989. Wong PC. Ng SC, Hamilton MPR. Anandakumar C. Wong YC. Ratnam SS: Eighty consecutive cases of gamete intra-fallopian transfer. Human Reprod 3: 231. 1988.
Address for reprints: V. Vlaisavljevic Department of Gynecology Reproductive Unit Hospital Maribor Mar&or Yugoslavia
Cusr Report