Standardizing embryo transfer technique results in significant improvements in pregnancy rates: a prospective study.

zygotes were placed on AECC until a day 3 ET was performed. A clinical pregnancy refers to the presence of a fetal heart beat at seven weeks of gestation. In patients with a previous IVF cycle at our institution, day 3 embryo quality was compared between the treatment (AECC) and previous cycle. Results: Table 1 illustrates the findings for the study. An age dependent outcome association was found. When comparing embryos grown on AECC to a previous IVF cycle, the embryos on AECC were of better quality (Increased number of blastomeres and decreased fragmentation). All embryos were compared on day three after retrieval. Embryos grown in AECC demonstrated more blastomeres (6.8 vs. 5.5 blastomeres, p ⬍ 0.01; Wilcoxon sign-rank test) and less fragmentation (15% vs. 24%, p ⬍ 0.01; Wilcoxon sign-rank test) as compared to the prior cycle at our institution. Autologous endometrial coculture: delivery outcome by age. Age ⱕ35 years (n ⫽ 144)

Age 36–39 years (n ⫽ 192)

Age 40⫹ Years (n ⫽ 148)

2.4 3.3 68.1 59.7 52.8 24.0

3.3 3.6 46.4 40.0 25.0 7.8

3.1 4.0 37.8 30.4 17.6 3.4

Previous failed IVF cycles Mean # ET Pregnancy (%) Clinical pregnancy (%) Delivery (%) Multiple pregnancy (%)

Conclusions: In this large report of delivery outcome, we have demonstrated that the use of Autologous Endometrial Coculture is an effective tool in the treatment of patients with multiple failed IVF cycles. P-210 Different assisted hatching (AH) methods yield similar implantation and pregnancy rates following IVF/ICSI. B. Urman, B. Balaban, C. Alatas, S. Aksoy, A. Isiklar, R. Mercan. American Hosp of Istanbul, Istanbul, Turkey. Objective: To compare four different methods of AH in IVF/ICSI cycles. Design: Retrospective case series. Materials/Methods: Four different AH methods were performed prior to embryo transfer in 794 IVF/ICSI cycles. Indications for AH were 1) female age ⬎35 years, 2) previous implantation failure in an IVF/ICSI cycle, 3) zona pellucida thickness ⬎15 microns, 4) the presence of only poor quality cleavage stage embryos, and 5) an elevated day 3 FSH level. AH was performed by partial zona dissection (PZD) in 239, by acid tyrode in 191, by a diode laser in 219, and by pronase zona thinning in 145 embryo transfer cycles. All AH procedures were performed on day 3 and embryo transfer was performed approximately 4 – 6 hours later. The method was selected by the embryologists’ preference and method availability. Results: Patient and embryo characteristics were similar throughout the groups. Similar implantation and pregnancy rates were obtained regardless of the method used to perform AH. Patient and embryo characteristics and the outcome of embryo transfer related to different methods of AH.

PZD No. of ET cycles Mean female age Basal FSH level Oocytes retrieved 2 PN fertilization Cleavage rate Embryos transferred

Acid tyrode

Diode laser

239 191 219 34.4 34.6 35.0 6.9 7.1 7.4 1791 1445 1624 70% 69% 70% 98 98.4 98 932 763 876 (mean 3.8) (mean 3.9) (mean 4.0) Implantation/embryo 18.6% 17.4% 18.9% Clinical PR/ET 49.3% 46% 48.4% Abortion rate 18.6% 20.4% 19.8%

Pronase zona thinning 145 34.5 7.1 1126 70% 98 537 (mean 3.7) 19.1% 46.8% 17.6%

Conclusions: Different methods of AH yielded similar implantation and pregnancy rates. Definitive conclusions, however, can be reached in a randomized study.

FERTILITY & STERILITY威

P-211 Developmental potential and blastocyst formation rate in human embryos with early stage development delay, arrest, or with multinucleated blastomere (MNB). L. Chi, E. DeJesus, C. McCaffery, J. A. Grifo, A. S. Berkeley, L. C. Krey. New York Univ Sch of Medicine, White Plains, NY; Program for In Vitro Fertilization, Reproductive Surg and Infertility, New York Univ Sch of Medicine, New York, NY. Objective: Correlations between early embryo development rate, morphology, and embryo development potential have been described. Morphology and progression during early development stage are often used as markers to select embryos for day 3 transfer. In this study, we extended culture to day 5 and calculated subsequent developmental competence to blastocyst (Bl) in embryos with cleavage delay, arrest, or with MNB visible during the first two to three mitoses. Our goal was to identify the correlations and assess the predictive value of these markers in an extended culture system. Design: Retrospective analysis of the subsequent development competence and Bl formation rate of embryos with cleavage delay, arrest, or MNB during the first two to three cell cycles. Materials/Methods: We studied all IVF cycles with Day 5 transfer (4 – 8/2000). After insemination in HTF⫹ 10% Plasmanate威, normally fertilized (2pn) zygotes were cultured in G1 medium and then group-cultured in G2 medium for day 3–5. Embryos were examined at 41– 46 h, 61– 67 h and 109 –115 h post insemination. We studied only these embryos: Group 1: 2-cell embryos at 41– 46 h; Group 2: Embryos not cleaving between 41– 46 h and 61– 67 h; Group 3: Embryos with MNB at 41– 46 h. On day 5 (109 –115 h) embryo progression to Bl was graded using Gardner’s system. Results: The developmental stages observed on day 5 and the% distribution of embryos reaching each stage is shown below. Progression to blastocyst was low in Group 1 (17%), Group 2 (14%) and Group 3 (5%). In Group 2 this rate was influenced by the cell stage at which the embryos arrested on day 2. Developmental stages of embryos exhibiting anomalous progression on day 2 (%)

Study group 2-cell stage on day 2 (244) Embryos arresting on day 2 (99) Arresting at 2–3 cell stage (25) Arresting at 4 cell stage (42) Arresting at 5 cell stage (20) Arresting at 6–8 cell stage (12) Embryo with MNB on day 2 (63)

Early Degenerated Cleavage Compact Morula BI

BI

Full Expand. BI BI

5.3%

42.2%

12.3% 23.4% 9.0% 5.7% 1.6% 0.4%

8.1%

59.6%

1.0% 17.2% 6.1% 5.1% 2.0% 1.0%

8.0%

88.0%

4.0%

2.4%

40.5%

—

33.3% 9.5% 7.1% 4.8% 2.4%

10.0%

65.0%

—

10.0% 5.0% 10.0% —

—

25.0%

58.3%

—

16.6% —

3.2%

50.8%

9.5% 31.7% 3.2%

—

—

—

—

—

—

—

—

—

1.6%

—

Conclusions: Embryos that exhibit anomalous progression during the first two or three mitosis displayed low blastocyst formation rates with few reaching full or expanded blastocyst stage. Such features imply poor developmental competence and can be used as markers for embryo selection in extended culture system. The findings could also be utilized to help guide decisions on early freezing. P-212 Standardizing embryo transfer technique results in significant improvements in pregnancy rates: a prospective study. B. M. Berger, S. P. Oskowitz, S. R. Bayer, M. J. Berger, M. M. Alper. Boston IVF, Brookline, MA. Objective: Many IVF programs do not have a standard method of embryo transfer (ET). Most programs have relied on feel by the clinician placing the

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transfer catheter and embryos within the uterine cavity at a point 1 cm below the fundus. The purpose of this study was to determine if standardizing the ET technique could lead to increased pregnancy rates (PR). Design: A five-month prospective study of ET technique was performed from June 1, 2000, to October 20, 2000. ET’s for the previous five-month period were analyzed and the data were compared. Materials/Methods: All IVF patients undergoing a fresh ET with the exception of donor egg cycles were included. The new technique guidelines were as follows: No mock transfer was performed prior to the day of ET. A mock transfer using a trial Wallace catheter was performed immediately prior to the ET for (a) all patients without a previous ET, and (b) all patients with a history of a previous difficult transfer. A Wallace catheter (Cooper Surgical, Shelton, CT, USA) was used for all transfers. A pre-loaded catheter was introduced into the uterine cavity. If this was unsuccessful then the outer sheath was introduced past the internal os, followed by the loaded internal catheter. In all cases, the embryos were placed at 5.5 cm. Pregnancy was documented by a positive serum ␤hCG measurement 11 days after ET. All 12 physicians completed a questionnaire documenting adherence to the new transfer technique. Physician specific embryo transfer rates were compared for all patients and patients ⬍38 years old, with and without outlier physicians. Outliers were defined as physician specific PR’s ⫾ 2 SD from the mean. The data obtained were compared to data from ET’s performed between January 1, 2000 and May 31, 2000, using ␹2 analyses and Student’s t-test (SYSTAT SPSS Inc., Chicago, IL, USA, software). P ⬍ 0.05 was considered to be statistically significant. Results: A total of 1,234 ET’s using the old protocol were performed between January 1, 2000 and May 31, 2000, and 1,036 ET’s using the new protocol were performed between June 1, 2000 and October 20, 2000. Thirty seven percent of the patients had never had a previous ET. A mock transfer was performed with 52.3% of transfers. Difficult previous transfer was the indication for a mock transfer in 12.7% of ET’s. Self-reported physician adherence to the new transfer technique was 89.1%. A comparison of all patients before and after the new ET technique showed a significant difference in mean PR, 30.1% and 36.9%, respectively (P ⬍ 0.02). A comparison of mean PR in patients under age 38 showed a PR of 35.3% (n ⫽ 741) and 42.0% (n ⫽ 641) before and after the new ET technique, respectively (P ⫽ 0.07). Three physicians were defined as outliers. Analysis of mean PR’s in patients under 38 without outliers, before and after the new ET technique, showed a significant difference in PR of 34.9% (n ⫽ 575) and 44.0% (n ⫽ 512), respectively (P ⬍ 0.01). No differences were noted in the mean age of patients, the indications for IVF treatment, mean number of eggs retrieved or mean number of embryos transferred for the two 5-month periods. Conclusions: Standardizing ET technique results in a significant improvement in PR (30.1% to 36.9%, P ⬍ 0.02). This study supports the development of a strictly adhered-to transfer technique to help improve PR’s.

CLINICAL FEMALE INFERTILITY AND GYNECOLOGY P-213 Successful pregnancies after medical management of endometrial adenocarcinoma in infertile patients. I. Kang, K. Yang, Y. Chun, I. Song, M. Koong, H. Kim. Div of Reproductive Endocrinology and Infertility, Dept of Ob/Gyn, Samsung Cheil Hosp, Sungkyunkwan Univ Sch of Medicine, Seoul, Korea, Seoul, Korea; Dept of Pathology, Samsung Cheil Hosp, Sungkyunkwan Univ Sch of Medicine, Seoul, Korea, Seoul, Korea. Objective: Endometrial adenocarcinoma diagnosed in infertile patients poses a dilemma in recommending an optimal therapy: medical treatment vs. definitive surgery. Type I endometrial adenocarcinoma is more common in younger aged infertile patients with obesity and hyperestrogenism. It is commonly associated with endometrial hyperplasia and shows low grade with little myometrial invasion and favorable prognosis. Herein, we report two cases of successful delivery of the babies after progesterone therapy in early stage of endometrial adenocarcinoma. Design: Case report. Materials/Methods: Retrospective analysis of two patients. Results: A 31 year old, having normal body mass index (19 kg/m2), with a two year of infertility visited. She had polycystic ovary syndrome with oligomenorrhea. She failed to get pregnant by several cycles of ovulation induction and one cycle of superovulation and IUI was done. The endometrial thickness was 17 mm and diagnostic hysteroscopy with dilatation and curettage (D&C) were done. Histologic diagnosis was atypical hyperplasia

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Abstracts

with focal well differentiated adenocarcinoma. Progesterone receptor was positive. Oral progesterone therapy with a daily dose of 160 mg megestrol acetate was done for four months. Two times of follow up curettages showed no residual hyperplasia or adenocarcinoma. After two cycles of unsuccessful IVF-ET, she got pregnant by transferring frozen-thawed embryos and delivered a healthy baby at term. 30 year-old infertile woman had polycystic ovary syndrome with severe oligomenorrhea. Endometrial thickness was 12 mm and D&C was performed, which revealed focal well differentiated adenocarcinoma with the background of atypical hyperplasia. 150 mg Depo-Provera was injected intramuscularly for four months. Subsequent histologic examination revealed no residual hyperplasia or adenocarcinoma. One cycle of superovulation with IUI was attempted but she failed to get pregnant. IVF-ET was performed and four embryos were transferred. Pregnancy was established and the patient delivered a healthy female baby at 39 weeks of gestation. Later on, she spontaneously delivered a second baby. Diagnostic curettage was done, which showed no evidence of neoplasm. Conclusions: Medical management with progesterone in patients with atypical hyperplasia and early well differentiated adenocarcinoma should be considered as a primary treatment in young infertile patients with a desire to preserve the fertility.

P-214 Effects of the vaginal progesterone gel crinone 8% on uterine cramps and bleeding associated with threatened abortion. C. Bulletti, D. De Ziegler, M. Maini, E. Del Ferro, V. Polli, C. Flamigni. Infirmary Hosp, Rimini, Italy; Nyon Medical Ctr, Nyon, Switzerland; Univ of Bologna, Bologna, Italy. Objective: Threatened 1st trimester abortion commonly features uterine cramping and bleeding. Irrespective of the etiology however, there are no other therapeutic measure than waiting and observing the clinical outcome through successive ultrasounds. During this stressful waiting period lasting from days to weeks, no treatment is available other than bed rest for reliving women from their symptoms of uterine cramping and bleeding. Prior work suggesting that the vaginal progesterone gel Crinone 8% decreases uterine contractility even when endogenous progesterone is elevated (Fanchin et al, 1999) led us test the utero-relaxing properties of Crinone 8% for treating the symptoms of threatened abortion, uterine cramping and bleeding. Materials/Methods: We studied 38 women presenting the symptoms of threatened abortion, uterine cramping and/or bleeding, at 6 to 12 weeks of pregnancy and whose fetus was alive (ultrasound). Participants were either offered bed rest alone (n ⫽ 19) or bed rest and daily administration of one applicator of Crinone 8% (90 mg of progesterone) /day (n ⫽ 19), for 5 days. Uterine bleeding and contractility (UC) were assessed daily for 5 days, UC were assessed by ultrasounds and subjectively, by recording the perception of cramping. Results: Uterine cramps and uterine bleeding decreased more rapidly in women receiving daily administration of the vaginal gel Crinone 8% than in those treated with bed rest alone. Yet despite this subjective difference, the frequency of uterine contractions recorded during the observation period was similar in women treated with bed rest or bed rest and Crinone, showing in both a decrease from approximately 2 to 1 UC/min.

Conclusions: Uterine cramps decreased progressively with bed rest over the 5-day observation period but more rapidly so, in women receiving daily administration of Crinone 8%. Hence, the vaginal progesterone gel offers an effective treatment for the symptoms of threatened abortion, uterine cramping and bleeding. This is particularly helpful clinically as women threatening to abort must wait until repeated ultrasounds indicate whether the clinical outcome is favorable or not. Further work is needed to determine

Vol. 76, No. 3, Suppl. 1, September 2001