The Value of Estradiol and Progesterone Levels Before and After Human Chorionic Gonadotropin Administration in Predicting in Vitro Fertilization

Objective: Recent studies have correlated different aspects of zygote morphology with embryo quality and pregnancy rates. We have designed a simple zygote morphology scoring, based on pronuclear size, pronuclear synchronization, pronuclear orientation and presence of vacuoles, in order to analyze human zygotes and define the value of any of these parameters in embryo selection. Design: Zygotes (n5581) of 25 cycles of conventional in-vitro fertilization (IVF) and 75 cycles of intracytoplasmic sperm injection (ICSI) were scored. The scoring was compared with embryo quality (number of blastomeres and fragmentation score) and fertilization technique (IVF or ICSI). Materials and Methods: The zygotic morphology was registered 14 –17 hours after insemination taking into account pronuclear size (1 5 normal; 0 5 abnormal), pronuclei synchronicity (1 5 same number and distribution of nucleolar precursor bodies; 0 5 different number or distribution), pronuclei alignment (1 5 pronuclei aligned with polar bodies; 0 5 no alignment) and vacuolation (1 5 absence of vacuoles; 0 5 presence of vacuoles). Results: The following table summarizes the main results (means and standard deviations). No significant differences were found.

Mean blastomere number Mean fragmentation score IVF mean score ICSI mean score

Pron. size

Pron. synch

1 0 3.7 6 1.3 3.7 6 1.1 1.7 6 0.3 2.0 6 0.2 0.85 6 0.3 0.86 6 0.3

1 0 3.7 6 1.3 3.6 6 1.3 1.9 6 0.3 1.9 6 0.3 0.71 6 0.3 0.56 6 0.3

Pron. alignment 1 4.0 6 1.3 2.0 6 0.3

0.41 6 0.3 0.41 6 0.3

0 3.4 6 1.2 1.9 6 0.3

Vacuolization 1 3.5 6 1.0 2.1 6 0.2

0.93 6 0.1 0.92 6 0.2

0 3.6 6 1.1 1.9 6 0.3

Conclusion: Our zygote morphology score does not correlate with embryo quality.

P-227 The Value of Estradiol and Progesterone Levels Before and After Human Chorionic Gonadotropin Administration in Predicting in Vitro Fertilization. M. L. Matthews, B. S. Hurst, M. Papadakis, T. Loeb, T. Norton, P. B. Marshburn. Division of Reproductive Endocrinology, Carolinas Medical Center, Charlotte, North Carolina. Objective: To determine if serum estradiol (E2) and progesterone (P4) levels before and after the administration of exogenous human chorionic gonadotropin (hCG) are predictive of outcome in IVF cycles. If changes in E2 and/or P4 levels after hCG predicted IVF failure, then criteria for cycle cancellation prior to oocyte retrieval could be developed. Design: E2 and P4 levels before and after exogenous hCG administration were prospectively collected in consecutive IVF patients undergoing oocyte retrieval for IVF between 1996 and 1999. Materials and Methods: IVF patients received an ovarian stimulation regimen with either long luteal Lupron down regulation (n5171) or with a microdose flare protocol (n525). E2 and P4 levels the day of and the day after hCG were determined by Immulite immunofluorescent antibody assays. Changes in E2 and P4 levels were compared with outcome variables including number of oocytes retrieved, % oocytes fertilized, and pregnancy rate (PR) per cycle. Other variables independently evaluated in predicting pregnancy included patient age, diagnosis, day 3 FSH, and number of embryos transferred. Results: A total of 196 cycles were performed in 168 patients, with 56% of the cycles resulting in pregnancy. A rise in P4 levels the day after hCG by greater than 400% significantly predicted pregnancy (PR 5 67%, .400% vs. PR 5 43%, ,400%). Logistic regression revealed % rise in P4 post-hCG as the strongest predictor of pregnancy (p5.01) followed by stimulation with luteal Lupron vs. microdose flare (p5.05). The % rise in P4 showed a weak but significant correlation with the number of oocytes retrieved (R 5 .36). However, the absolute levels of E2 and P4 on the day of hCG and the day after were not correlated with cycle outcome. The rise or decline in E2

FERTILITY & STERILITYt

on these days likewise did not correlate with success after IVF. Other cycle variables and patient demographics were not significantly different between those patients who became pregnant and those who did not. Conclusion: Pregnancy occurred in two thirds of the IVF cycles in which P4 levels increased by more than 400% the day after hCG. Despite this observation, E2 and P4 dynamics after hCG would not appear to be useful for cycle cancellation criteria. Perhaps higher ovarian P4 production after hCG is a favorable index for oocyte quality or induces an enhancement of endometrial receptivity for embryo implantation in IVF cycles.

P-228 Elective Single Blastocyst Transfer (BT): A Case Series. 1,2B. T. Miller, 3 L. A. Scott, 1,2M. P. Leondires, 1,2J. L. Frattarelli, 1R. Alvero, 1,2J. H. Segars. 1Combined Federal Program in Reproductive Endocrinology, and the 2Pediatric & Reproductive Endocrine Branch, NIH, Bethesda, MD; 3 ART Institute of Washington, Washington DC. Objectives: A morphological grading system was used to select a blastocyst with the highest implantation potential. Our goal was to maintain pregnancy rates while decreasing the incidence of multiples. For couples that desired the lowest possible risk of a multiple gestation or in whom a multiple pregnancy would impose a serious obstetrical risk, a single blastocyst transfer was offered. Design: A case series involving all patients who had a blastocyst available for transfer, ,40 years old, having no more than one previous failed IVF cycle, or those patients having a Mullerian anomaly, who underwent a single blastocyst transfer. Materials and Methods: All patients undergoing an elective single BT after counseling between January 1998 to January 2000 were included. Oocyte retrieval (OR) was performed 35 hrs post-hCG, inseminations 4 hrs later with all scoring of embryos at 24 hr intervals after OR. A grading system based on the total number of cells, morphology of the inner cell mass, and rate of blastocyst development was used to select a single blastocyst for transfer on day 5 of culture. An expanded blastocyst was selected preferentially. The BT was performed using a Wallace catheter under ultrasound guidance. Pregnancy tests were performed 14 and 16 days post-OR and a clinical pregnancy was confirmed by ultrasound at 4 and 6 wks post-OR. Statistical analysis performed by Fisher’s exact test. Results: Ten couples elected to have single blastocyst transfer. Six had a clinical pregnancy and 5 have an ongoing or delivered singleton. All 10 had IVF with .2 yrs of infertility. All but 3 had an expanded blastocyst available for transfer. Diagnoses included: tubal factor (n53), 3 with uterine factor (didelphis, unicornuate, fibroid), idiopathic (n52), 1 endometriosis and 1 anovulation. Only 3 patients did not have high quality blastocysts cryopreserved, but all 3 became pregnant. The 4 not pregnant were: 28 y.o. with a unicornuate uterus and suboptimal blastocysts; 33 y.o. with PCOS complicated by ovarian hyperstimulation syndrome; 28 y.o. with a 5cm fibroid; 37 y.o. with uterine didelphis. Table 1 provides cycle characteristics of the 10 patients. Clinical/ongoing pregnancy rates and implantation rates did not differ between those having 1, 2, or $3 BT transferred in the entire program, however there were no multiples in the 1 BT group (Table 2). Table 1: Cycle parameters for the study group. N 5 10

Mean

6 SEM

Range

Age (yrs) Cycle # # Oocyte # 2 PN

30.6 1.4 22.9 15.1

6 0.98 6 0.16 6 2.57 6 2.15

27–37 1–2 13–42 8–30

Table 2: Outcomes based on the number of blastocysts transferred. # of blastocyst(s) transferred

Only 1

Only 2

$3

P value

Number of transfers Clinical pregnancy rate (%) Ongoing/delivered PR (%) Number of multiples (%)

10 60.0 50.0 0

212 67.0 56.6 44.2

27 48.1 33.3 55.5

— NS NS NS

Conclusions: The transfer of a single blastocyst in selected patients can result in high pregnancy rates minimizing the risks of multiples. Based on

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