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Spontaneous embryo reduction in multiple gestations from assisted reproductive technologies
IVF-embryo transfer (ET) has consistently been associated with lower pregnancy rates than when cetrorelix was used in gonadotropin releasing hormone (GnRH) antagonist protocols or when the GnRH agonist leuprolide acetate was used. The objective of the present study was to evaluate the pregnancy rates following frozen ET according to the use of these three agents. The finding of lower pregnancy rates with ganirelix following frozen ET would suggest an adverse effect on the embryo rather than the endometrium. DESIGN: Retrospective comparison. MATERIALS AND METHODS: Clinical (viable at 8 weeks) and live delivered pregnancy and implantation rates following frozen ET were compared in two age groups %35 and 36-39 according to use of ganirelix, cetrorelix or luteal phase leuprolide acetate. Single embryo transfers were excluded. TABLE 1. Pregnancy rates based on luteinizing hormone surge suppressing drugs
Ganirelix Age at retrieval # transfers Avg. size blastomere % clinical preg./ transfer % live birth Avg. # embryos transferred Implantation rate
%35 116 6.6 28.4 23.3 2.8
Cetrorelix
Luteal phase lueprolide acetate
36-39 %35 57 179 6.5 6.5 33.3 42.5
36-39 %35 65 369 6.2 6.4 41.5 43.6
28.1 3.4
36.9 3.1
30.7 2.6
13.4% 12.8% 21.5% 16.7%
36-39 67 6.3 37.3
36.9 2.8
29.9 3.2
22.4%
17.6%
RESULTS: Overall, the clinical pregnancy rate per frozen embryo transfer in women aged %39 whose embryos were formed using ganirelix was 30.0% (52/173) vs. 42.5% (289/680) for cetrorelix and leuprolide acetate combined (p¼ .0038). The respective live delivered pregnancy rates were 24.8% (43/ 173) vs. 34.5% (235/680) (p¼ .019). Similarly the implantation rates were lower with ganirelix showing a 13.1% (69/525) level vs. 20.9% (406/1931 (p< .0001). CONCLUSIONS: The adverse effect that some IVF centers notice when using ganirelix in the COH protocol vs. cetrorelix or leuprolide acetate following fresh ET seems to be an embryo defect rather than an endometrial abnormality. This did not seem to be related to the development of embryos with more blastomeres and a factor that appears to correlate with success of implantation. Supported by: None.
A-251 SPONTANEOUS EMBRYO REDUCTION IN MULTIPLE GESTATIONS FROM ASSISTED REPRODUCTIVE TECHNOLOGIES. A. Petracco, J. Michelon, M. Badalotti, L. Volpato, L. Okada, R. Azambuja. Fertilitat-Centro de Medicina Reprodutiva, Porto Alegre, Brazil. OBJECTIVE: To determine the frequency of spontaneous embryo reduction in multiple gestations from Assisted Reproductive Technologies (ART) and its relation with maternal age, infertility cause, embryo quality, sperm source and endometrial thickness. DESIGN: A retrospective study from patients submitted to ART that resulted in multiple gestation followed by spontaneous embryo reduction was performed. MATERIALS AND METHODS: Artificial Insemination (AI), In Vitro Fertilization (IVF) and Intracytoplasmic sperm injection (ICSI) data were compared. In order to identify factors that could influence the frequency of embryo reduction, this phenomenon was compared to maternal age, infertility cause, ART used, embryo quality, sperm source (ejaculated, testis, epididimys) and endometrial thickness at the moment of embryo transfer. Data was analyzed statistically by Student T-test, Qui square, and Odds Ratio. RESULTS: One hundred and twenty one multigestational cycles were analyzed. One hundred and three cycles from ICSI (85.1%), 13 from IVF (10.7%) and 5 from AI (4.2%). The sperm obtained from ejaculated were 85.9%, epididimys (PESA) 8.3%, and testicle (TESA) 5.8%. The ART indications were male factor 48.8%; endometriosis 24.8%; tubal factor 11.6%; Infertility with no apparent cause 9.9%; male immunological factor 2.5%; advanced maternal age 1.7%; and cervical factor 0.8%. Fe-
S456
Abstracts
male age varied between 23-47 years old, and average age was 33 years. The embryo reduction occurred in 20% of the cycles from AI, 21.4% in IVF and 37.2% in ICSI. This comparison was not statiscally different between the technologies. The sperm source, infertility cause, embryo quality and endometrial thickness did not result in statistical difference when compared to spontaneous embryo reduction, however female age affected significantly (p¼0.03). It was observed that women with 35-37 years had a relative risk of 1.78 while women with 38 and over had a relative risk of 2.6. CONCLUSIONS: As ART demonstrated, high spontaneous embryo reduction was observed specially with the ICSI technique. No statistical significance was observed between the technologies, especially because of the low number of AI, and IVF data. Maternal age was the only variable that affected significatively the embryo reduction data, information that might help during counseling women with advanced reproductive age. Supported by: Fertilitat-Centro de Medicina Reprodutiva.
A-252 A TRIAMNIOTIC/MONOCHORIONIC TRIPLET PREGNANCY ESTABLISHED AFTER DAY 2 SINGLE EMBRYO TRANSFER WITH IN VITRO FERTILIZATION/EMBRYO TRANSFER (IVF-ET). R. Buyalos, M. Li, F. Miller, A. Kumar, G. Hubert. Fertility & Surgical Associates of California, Thousand Oaks, CA. 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. Supported by: None.
A-253 THE BODY MASS INDEX OF RECIPIENTS DOES NOT AFFECT THE PREGNANCY DERIVED FROM DONOR OOCYTES. W. Zhang, A. Del Valle, T. Tao, S. Tellez. The Toronto Institute for Reproductive Medicine, Toronto, ON, Canada. OBJECTIVE: Previous studies have shown that a high body mass index (BMI) is associated with poor IVF outcome. If obesity does indeed have an adverse effect on the IVF ouccome, then the next question that needs to be addressed is whether this is due to an adverse effect on the endometrium
Vol. 90, Suppl 1, September 2008
Ganirelix Age at retrieval # transfers Avg. size blastomere % clinical preg./ transfer % live birth Avg. # embryos transferred Implantation rate
%35 116 6.6 28.4 23.3 2.8
Cetrorelix
Luteal phase lueprolide acetate
36-39 %35 57 179 6.5 6.5 33.3 42.5
36-39 %35 65 369 6.2 6.4 41.5 43.6
28.1 3.4
36.9 3.1
30.7 2.6
13.4% 12.8% 21.5% 16.7%
36-39 67 6.3 37.3
36.9 2.8
29.9 3.2
22.4%
17.6%
RESULTS: Overall, the clinical pregnancy rate per frozen embryo transfer in women aged %39 whose embryos were formed using ganirelix was 30.0% (52/173) vs. 42.5% (289/680) for cetrorelix and leuprolide acetate combined (p¼ .0038). The respective live delivered pregnancy rates were 24.8% (43/ 173) vs. 34.5% (235/680) (p¼ .019). Similarly the implantation rates were lower with ganirelix showing a 13.1% (69/525) level vs. 20.9% (406/1931 (p< .0001). CONCLUSIONS: The adverse effect that some IVF centers notice when using ganirelix in the COH protocol vs. cetrorelix or leuprolide acetate following fresh ET seems to be an embryo defect rather than an endometrial abnormality. This did not seem to be related to the development of embryos with more blastomeres and a factor that appears to correlate with success of implantation. Supported by: None.
A-251 SPONTANEOUS EMBRYO REDUCTION IN MULTIPLE GESTATIONS FROM ASSISTED REPRODUCTIVE TECHNOLOGIES. A. Petracco, J. Michelon, M. Badalotti, L. Volpato, L. Okada, R. Azambuja. Fertilitat-Centro de Medicina Reprodutiva, Porto Alegre, Brazil. OBJECTIVE: To determine the frequency of spontaneous embryo reduction in multiple gestations from Assisted Reproductive Technologies (ART) and its relation with maternal age, infertility cause, embryo quality, sperm source and endometrial thickness. DESIGN: A retrospective study from patients submitted to ART that resulted in multiple gestation followed by spontaneous embryo reduction was performed. MATERIALS AND METHODS: Artificial Insemination (AI), In Vitro Fertilization (IVF) and Intracytoplasmic sperm injection (ICSI) data were compared. In order to identify factors that could influence the frequency of embryo reduction, this phenomenon was compared to maternal age, infertility cause, ART used, embryo quality, sperm source (ejaculated, testis, epididimys) and endometrial thickness at the moment of embryo transfer. Data was analyzed statistically by Student T-test, Qui square, and Odds Ratio. RESULTS: One hundred and twenty one multigestational cycles were analyzed. One hundred and three cycles from ICSI (85.1%), 13 from IVF (10.7%) and 5 from AI (4.2%). The sperm obtained from ejaculated were 85.9%, epididimys (PESA) 8.3%, and testicle (TESA) 5.8%. The ART indications were male factor 48.8%; endometriosis 24.8%; tubal factor 11.6%; Infertility with no apparent cause 9.9%; male immunological factor 2.5%; advanced maternal age 1.7%; and cervical factor 0.8%. Fe-
S456
Abstracts
male age varied between 23-47 years old, and average age was 33 years. The embryo reduction occurred in 20% of the cycles from AI, 21.4% in IVF and 37.2% in ICSI. This comparison was not statiscally different between the technologies. The sperm source, infertility cause, embryo quality and endometrial thickness did not result in statistical difference when compared to spontaneous embryo reduction, however female age affected significantly (p¼0.03). It was observed that women with 35-37 years had a relative risk of 1.78 while women with 38 and over had a relative risk of 2.6. CONCLUSIONS: As ART demonstrated, high spontaneous embryo reduction was observed specially with the ICSI technique. No statistical significance was observed between the technologies, especially because of the low number of AI, and IVF data. Maternal age was the only variable that affected significatively the embryo reduction data, information that might help during counseling women with advanced reproductive age. Supported by: Fertilitat-Centro de Medicina Reprodutiva.
A-252 A TRIAMNIOTIC/MONOCHORIONIC TRIPLET PREGNANCY ESTABLISHED AFTER DAY 2 SINGLE EMBRYO TRANSFER WITH IN VITRO FERTILIZATION/EMBRYO TRANSFER (IVF-ET). R. Buyalos, M. Li, F. Miller, A. Kumar, G. Hubert. Fertility & Surgical Associates of California, Thousand Oaks, CA. 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. Supported by: None.
A-253 THE BODY MASS INDEX OF RECIPIENTS DOES NOT AFFECT THE PREGNANCY DERIVED FROM DONOR OOCYTES. W. Zhang, A. Del Valle, T. Tao, S. Tellez. The Toronto Institute for Reproductive Medicine, Toronto, ON, Canada. OBJECTIVE: Previous studies have shown that a high body mass index (BMI) is associated with poor IVF outcome. If obesity does indeed have an adverse effect on the IVF ouccome, then the next question that needs to be addressed is whether this is due to an adverse effect on the endometrium
Vol. 90, Suppl 1, September 2008