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Objective To report a clinical pregnancy resulting from intracytoplasmic sperm injection of prematurely ovulated oocytes retrieved from the posterior cul-de-sac. Design Case report. Setting Academic center. Patient(s) A 40-year-old nulligravid woman underwent ovarian stimulation for in vitro fertilization (IVF). Daily injections of gonadotropin-releasing hormone antagonist were initiated on cycle day 8. A 10,000 IU dose of human chorionic gonadotropin was administered on cycle day 15 to trigger follicular maturation. The estradiol and luteinizing hormone levels on the trigger day were 1528 pg/mL and 2.4 mIU/mL, respectively. The patient underwent oocyte retrieval 35 hours after the trigger. Transvaginal sonography at the time of the retrieval revealed a large pocket of free fluid in the posterior cul-de-sac. Only 3 follicles measuring 10–12 mm were noted in both ovaries. No lead follicles were visualized. Intervention(s) Aspiration of free fluid from the posterior cul-de-sac. Main Outcome Measure(s) Clinical pregnancy. Result(s) The fluid in the posterior cul-de-sac was aspirated, and 3 mature oocytes were retrieved. Aspiration of the smaller ovarian follicles measuring 10–12 mm did not yield oocytes. All mature oocytes retrieved from the posterior cul-de-sac were fertilized with intracytoplasmic sperm injection. Three cleavage-stage embryos were transferred 3 days later. A single intrauterine pregnancy with cardiac activity was confirmed at a gestational age of 7 weeks. Conclusion(s) In the setting of premature ovulation, aspiration of free fluid from the posterior cul-de-sac can result in the retrieval of mature oocytes, which may result in clinical pregnancies.

STUDY QUESTION Do the length of follicular phase estradiol exposure and the total length of the follicular phase affect pregnancy and live birth outcomes in natural frozen embryo transfer (FET) cycles? SUMMARY ANSWER An estradiol level >100 pg/ml for ≤4 days including the LH surge day is associated with worse pregnancy and live birth outcomes; however, the total length of the follicular phase is not associated with pregnancy and live birth outcomes. WHAT IS KNOWN ALREADY An estradiol level that increases above 100 pg/ml and continues to increase is indicative of the selection and development of a dominant follicle. In programmed FET cycles, a limited duration of follicular phase estradiol of STUDY DESIGN, SIZE, DURATION This retrospective cohort study included infertile patients in an academic hospital setting who underwent their first natural frozen autologous Day-5 embryo transfer cycle in our IVF clinic between 01 January 2013 and 31 December 2018. Donor oocyte and gestational carrier cycles were excluded. PARTICIPANTS/MATERIALS, SETTING, METHODS The primary outcomes of this study were pregnancy and live birth rates. Patients were stratified into two groups based on the cohorts’ median number of days from the estradiol level of >100 pg/ml before the LH surge: Group 1 (≤4 days; n = 1052 patients) and Group 2 (>4 days; n = 839 patients). Additionally, patients were stratified into two groups based on the cohorts’ median cycle day of LH surge: Group 1 (follicular length ≤15 days; n = 1287 patients) and Group 2 (follicular length >15 days; n = 1071 patients). A subgroup analysis of preimplantation genetic testing for aneuploidies (PGT-A) embryo transfer cycles was performed. Logistic regression analysis, adjusted a priori for patient age, number of embryos transferred, and use of PGT-A, was used to estimate the odds ratio (OR) with a 95% CI. MAIN RESULTS AND THE ROLE OF CHANCE In the length of elevated estradiol analysis, the pregnancy rate per embryo transfer was statistically significantly lower in patients with an elevated estradiol to surge of ≤4 days (65.6%) compared to patients with an elevated estradiol to surge of >4 days (70.9%; OR 1.30 (95% CI 1.06–1.58)). The live birth rate per embryo transfer was also statistically significantly lower in patients with an elevated estradiol to surge of ≤4 days (46.6%) compared to patients with an elevated estradiol to surge of >4 days (52.0%; OR 1.23 (95% CI 1.02–1.48)). In the follicular phase length analysis, the pregnancy rate per embryo transfer was similar between patients with a follicular length of ≤15 days (65.4%) and patients with a follicular length of >15 days (69.0%; OR 1.12 (95% CI 0.94–1.33)): the live birth rate was also similar between groups (45.5% vs 51.5%, respectively; OR 1.14 (95% CI 0.97–1.35)). In all analyses, once a pregnancy was achieved, the length of the follicular phase or the length of elevated oestradiol >100 pg/ml no longer affected the pregnancy outcomes. LIMITATIONS, REASONS FOR CAUTION The retrospective design of this study is subject to possible selection bias in regard to which patients at our clinic were recommended to undergo a natural FET compared to a fresh embryo transfer or programmed FET. To decrease the heterogeneity of our study population, we only included patients who had blastocyst embryo transfers; therefore, it is unknown whether similar results would be observed in patients with cleavage-stage embryo transfers. The retrospective nature of the study design did not allow randomized to a specific ovarian stimulation or ovulation trigger protocol. However, all patients were managed with the standardized protocols at a single center, which strengthens the external validity of our results when compared to a study that only evaluates one specific stimulation protocol. WIDER IMPLICATIONS OF THE FINDINGS Our observations provide cycle-level characteristics that can be applied during a natural FET cycle to help optimize embryo transfer success rates. Physicians should consider the parameter of number of days that oestradiol is >100 pg/ml prior to the LH surge when determining whether to proceed with embryo transfer in a natural cycle. This cycle-specific characteristic may also help to provide an explanation for some failed transfer cycles. Importantly, our findings should not be used to determine whether to recommend a natural or a programmed FET cycle for a patient, but rather, to identify natural FET cycles that are not optimal to proceed with embryo transfer STUDY FUNDING/COMPETING INTEREST(S) No financial support, funding, or services were obtained for this study. The authors do not report any potential conflicts of interest. TRIAL REGISTRATION NUMBER N/A.

Study question Can whole exome sequencing (WES) of spermatozoal DNA provide insight into understanding the different steps that lead to inability of a couple to reproduce? Summary answer The identification of germline mutations can clarify different aspects of reproductive failure in couples with unexplained infertility. What is known already The limitation of a routine semen analysis in evaluating sperm characteristics, even according to the most stringent criteria, lies in its inability to provide substantial information on spermatozoa performance in ART. As a result, ancillary tests are being used to further assess the male gamete’s reproductive potential. More recently, WES of the male genome, carried out on somatic cells, has become a powerful technique that can potentially shed light on the genetic causes of infertility. Here, we aim to preferentially detect germline mutations by sequencing spermatozoal DNA to pinpoint genes related to different underlying etiologies for reproductive failure. Study design, size, duration In a 5-year period, 25 couples subdivided according to their ICSI outcomes were included in this study. Sperm aneuploidy assessment by fluorescent in situ hybridization (FISH) and copy number variant (CNV) analysis by WES were carried out on ejaculated specimens from consenting male partners. Following CNV analysis, gene mutation profiles were compared between the fertile (n = 10) and infertile cohorts (n = 15), as well as in relation to the reasons for reproductive failure. Participants/materials, setting, methods FISH was performed on at least 1,000 sperm cells with a threshold of > 1.6%. DNA was extracted and amplified from at least 500 spermatozoa (DNA concentration, 605±137 ng/ul; quality, 1.7±0.1 nm) for CNV analysis by WES. Mutations corresponding to the CNV were annotated and assessed using the CLC Genomic Server 9.0. Genes were considered duplicated or deleted when their read depth was >1.5 or Main results and the role of chance Couples (n = 25) (maternal age, 38.6±3yrs; paternal age, 39.7±5yrs) had normal somatic karyotypes with normal semen parameters (59.2±30x106/mL concentration, 44.8±18% motility) by WHO standards. The fertile (n = 10) cohort underwent 12 ICSI cycles, achieving an 82.6% (57/69) fertilization rate and 10/12 (83.3%) term pregnancies. The infertile cohort (n = 15) underwent 21 ICSI cycles, achieving a 66% (62/84) fertilization rate and 5/17 (29.4%) clinical pregnancies, all resulting in pregnancy loss. Sperm aneuploidy was consistently higher in the infertile (8.4%) versus fertile (4.0%) cohort (P For both cohorts, WES detected deletions responsible for sperm–egg fusion (ADAM3A) and acrosomal development (SPACA, SPATA), explaining the necessity for ICSI in these couples. The infertile cohort was characterized by 4 reasons for cycle failure: complete fertilization failure, poor embryo development, implantation failure, and pregnancy loss. Couples with complete fertilization failure (n = 4) had deletions (PLCZ1, PIWIL1) indicating a sperm-related oocyte-activating deficiency. Those with poor embryo development (n = 5) had mutations (HAUS1, KIF4A, XRN1) essential for centrosome integrity and spindle/microtubular stabilization. Couples who did not achieve pregnancy (n = 7) had a mutation (IL9R) in common related to cytokine constituents in the implantation pathway. Those with pregnancy losses (n = 5) had mutations (NLRP7, TP53) on post-implantation genes. Limitations, reasons for caution Several germline mutations, related to the different reasons for these couples’ reproductive failure, were identified. Although intriguing, these findings are still new and need to be validated in a larger study population. In addition, while maternal age was controlled for, we cannot definitively exclude other confounding female factors. Wider implications of the findings Additional screening methods for infertile couples, particularly those with unexplained infertility, can be used to clarify elusive factors underlying their reproductive ability. A genetic screening of spermatozoal DNA may therefore be considered a potential tool in precision medicine for the treatment of subtle male factor infertility. Trial registration number n/a

Objective To report the utility of combined transvaginal and transabdominal oocyte retrieval in a patient with an ectopic ovary and unicornuate uterus. Design Video case report with demonstration of oocyte retrieval technique. Setting(s) University-affiliated fertility center. Patient(s) A 35-year-old woman, gravida 0, with a 6-month history of infertility who presented to our center for fertility evaluation. Hysterosalpingography revealed a left unicornuate uterus and patent left fallopian tube magnetic resonance imaging and laparoscopy showed a right ectopic ovary located in the upper abdomen. Her partner was a 36-year-old male with isolated teratozoospermia. The couple did not conceive with intrauterine insemination. Intervention(s) Ovarian stimulation for in vitro fertilization (IVF). Transvaginal retrieval of oocytes from the right ovary was not deemed possible due the anatomic location of the ovary, intervening blood vessels, and limited mobility of the ovary. Institutional review board approval was not required for this case report as per our institution’s policy; patient consent was obtained for publication of the case. Main Outcome Measure(s) Transabdominal retrieval of oocytes from the right ovary and transvaginal retrieval of oocytes from the left ovary. Result(s) The couple underwent two IVF cycles. Nine oocytes were retrieved during the first IVF cycle: seven transabdominal (right ovary) and two transvaginal (left ovary). All oocytes were mature, and five blastocysts were cryopreserved. Eight oocytes were retrieved during the second IVF cycle, of which five oocytes were retrieved transabdominally from the right ovary, and three oocytes were retrieved transvaginally from the left ovary. All oocytes were mature, and four blastocysts were cryopreserved. A single thawed embryo was transferred in the natural menstrual cycle, which resulted in the live birth of a full-term baby boy weighing 2,410 grams. Conclusion(s) The current case highlights the safety and feasibility of combined transvaginal and transabdominal oocyte retrieval in patients with an ectopic ovary located in the upper abdomen.

Trocar-site hernias are rare complications of laparoscopic surgery. Although trocar-site hernias occur more often at >10-mm sites, hernias can still develop at 5-mm sites after laparoscopy and can lead to serious complications. The primary objective of this review is to summarize the current medical literature pertaining to the clinical presentation and predisposing risk factors of trocar-site hernias at 5-mm sites after laparoscopy. A total of 295 publications were identified, 17 (5.76%) of which met the inclusion criteria. Twenty-seven patients with trocar-site hernias were identified after laparoscopic cases. The median age (interquartile range) for all adult patients with trocar-site hernias was 63 years (interquartile range, 39.5-66.5 years). Eight of the 18 patients (44.4%) undergoing gynecologic laparoscopy were parous although details of parity were not reported in most publications. Simple manual reduction or laparoscopic reduction with fascial closure (21 patients [84%]) was used more often compared with exploratory laparotomy (4 patients [16%], p

This retrospective cohort study investigates the risk factors and beta-human chorionic gonadotropin (β-hCG) trends in patients with ruptured tubal ectopic pregnancies (EPs) despite methotrexate (MTX) treatment. All patients receiving MTX for sonographically confirmed tubal EPs at our fertility center between 2004 and 2014 were included. Baseline demographics and β-hCG trends of patients with EP rupture after MTX were compared to patients with resolved EPs after MTX. One-hundred-thirty-seven patients with EPs were treated with MTX during the study duration; 27 experienced EP rupture and 110 EP resolution. There was no difference in the baseline demographics or β-hCG levels on the day of MTX between the groups. Patients with ruptured EPs after MTX had higher β-hCG levels on day-4 (1223.9 ± 243.5 vs. 1111.2 ± 179.7 mIU/mL; p .001) and day-7 (1156.9 ± 206.2 vs. 872.4 ± 690.2 mIU/mL; p .001). The odds of EP rupture compared to EP resolution was 6.2 (95% CI 2.1-19.1), 13.7 (95% CI 4.8-38.9), and 3.0 (95% CI 1.2-7.2) times higher when the change in β-hCG levels was5% between day-7 vs. day of MTX, day-7 vs. day-4, and day-4 vs. day of MTX, respectively. Our results demonstrate that ruptured tubal EPs despite MTX have5% change in β-hCG levels between the day of MTX and day-4 or day-7 after MTX.

Jaundice is caused by an accumulation of bilirubin in the blood. The presentation in infants and children can be indicative of a wide range of conditions, with some self-limiting and others potentially life-threatening. This article aims to provide a concise review of the common medical and surgical causes in children and discuss their diagnosis and management.

The primary objective of this study is to investigate the effect of transvaginal ultrasonogram (TVUS)-guided cyst aspiration or gonadotropin releasing hormone antagonist (GnRH-ant) administration for the management of solitary ovarian cysts detected at the start of in vitro fertilization (IVF) cycles on the outcomes of the same cycles. This is a single-center, retrospective, cohort study of patients who had TVUS-guided cyst aspiration or GnRH-ant treatment for ovarian cysts detected at the start of IVF during a 5-year period. Four hundred and three patients met inclusion criteria: 41 (10.2%) underwent cyst aspiration and 362 (89.2%) were treated with GnRH-ant. There was no difference in the demographics or baseline IVF cycle characteristics of the two groups. Patients treated with GnRH-ant had a longer duration of ovarian stimulation (10.8 ± 3.45 days versus 9.05 ± 4.06 days, p = 0.003) and required higher gonadotropin doses (3887.7 ± 1097.8 IU versus 3293.7 ± 990.5 IU; p = 0.01) compared with the cyst aspiration group. There was no difference in the clinical pregnancy (43.9% versus 41.4%), spontaneous miscarriage (9.76% versus 8.01%) and live birth (34.1% versus 33.4%) rates between the groups. Our findings suggest that cyst aspiration is comparable to GnRH-ant administration for the management of solitary ovarian cysts detected at the start of IVF cycles.

The pathophysiology of isolated pleural effusion in ovarian hyperstimulation syndrome (OHSS) is not well defined. The objective of the current review is to delineate the pathophysiology, risk factors, preventive measures, and therapeutic options of isolated pleural effusion in severe OHSS. Major databases were searched until June 2016. Studies evaluating women who presented with pleural effusion as the sole extra-ovarian manifestation of severe OHSS were included. Data were extracted from 24 articles encompassing 30 reported cases. Values were expressed as mean ± SEM. Patients were young (31.5 ± 0.8 years old) and 29.1% of them were diagnosed with polycystic ovary syndrome. All the patients received human chorionic gonadotropin to trigger oocyte maturation. Estradiol level was 3110 ± 330 pg/mL on the day of the ovulatory trigger. Dyspnea was the presenting symptom in 86.6% of the patients. Pleural effusion was predominantly on the right side (80%). Ninety percent of the patients underwent thoracentesis (4332 ± 769 mL): 66.7% exudate and 33.3% transudate. Fluid initially accumulates in the peritoneal cavity then enters the pleural space due to the pressure gradient through the thoracic duct and diaphragmatic defects, which are more common on the right side. The risk factors, prevention, and management, which are also discussed in this review, are similar to those of severe OHSS.

Objective To identify the optimal lead follicle size for hCG trigger in clomiphene citrate (CC)–intrauterine insemination (IUI) cycles. Design Retrospective cohort study. Setting University-affiliated center. Patient(s) Patients Intervention(s) Ovulation induction, hCG trigger, and IUI. Main Outcome Measure(s) Clinical pregnancy rate (CPR) was the primary outcome and was plotted against lead follicle size in increments of 1 mm. Odds ratios with 95% confidence intervals for associations between lead follicle size and CPR were calculated from a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated for CPR as a function of lead follicle size. Result(s) 1,676 cycles were included. The overall CPR was 13.8% (232/1,676). There was no difference in baseline demographics or ovulation induction parameters of patients who did or did not conceive. The odds of clinical pregnancy were 2.3 and 2.2 times higher with lead follicle sizes of 21.1–22.0 mm and >22.0 mm, respectively, compared with the referent category of 19.1–20.0 mm. Lead follicle size was an independent predictor of CPR, even after accounting for confounders. A lead follicle size of 22.1 mm corresponded to a sensitivity and specificity of 80.1% and 90.4% for clinical pregnancy, respectively, with an area under the ROC curve of 0.89. Conclusion(s) hCG administration at a lead follicle size of 21.1–22.0 mm is associated with higher odds of clinical pregnancy in patients undergoing their first CC-IUI cycles for ovulatory dysfunction or unexplained infertility.

Objective To determine whether patients who failed an in vitro fertilization (IVF) cycle can proceed with a subsequent IVF cycle after waiting only one menstrual cycle, or whether there is a benefit to allowing two or more menstrual cycles to elapse before proceeding. Design Retrospective cohort study. Setting Academic medical center. Patient(s) All patients undergoing IVF cycles at The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, from January 1, 2002 to November 1, 2011, in whom two consecutive gonadotropin-releasing hormone (GnRH)-antagonist IVF cycles with identical stimulation protocols took place 35–140 days apart, excluding patients in whom the first cycle resulted in a clinical pregnancy. Intervention(s) None. Main Outcome Measure(s) IVF outcomes were compared for 164 patients who initiated a cycle after waiting only one menstrual cycle (35–55 days from previous oocyte retrieval) versus 557 patients waiting two or more menstrual cycles (56–140 days) from their last retrieval before proceeding with their successive cycle start, stratifying for age. Result(s) No differences were detected regarding E 2 response, oocyte yield, fertilization, or embryo development when comparing patients waiting only one cycle with those waiting two or more cycles, nor were those parameters different when comparing patients' index cycles with their immediate preceding failed cycles. Moreover, clinical outcomes regarding clinical pregnancy, live birth, and cycle cancellation were similar between both study groups. Conclusion(s) Delaying successive IVF cycle start for two or more menstrual cycles likely offers no advantage over pursuing repeated IVF after one menstrual cycle.

Objective To determine whether the presence of a Y microdeletion confers any adverse effects on in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) outcome. Design Retrospective case–control study. Setting Academic infertility center. Patient(s) A total of 17 patients with Y microdeletions who attempted IVF/ICSI cycles at our center between March 1996 and March 2002 were studied. Study patients were analyzed in two groups: those who underwent testicular sperm extraction (TESE) and those for whom ejaculated sperm was used. Intervention(s) The two patient study groups were matched to controls treated at the same time who had either nonobstructive severe oligozoospermia or azoospermia with normal Y chromosomes. Controls were matched for age of the female partner, sperm concentration, and number of embryos transferred. Main outcome measure(s) Fertilization and clinical pregnancy rates. Result(s) Sperm was only obtained from patients with azoospermic factor (AZF)c microdeletions (and from one patient with a partial AZFb microdeletion). A trend toward lower fertilization rates in patients with Y microdeletions was noted, which did not reach statistical significance. Clinical pregnancy rates per cycle and per transfer were similar to those for controls. Conclusion(s) Patients with AZFc microdeletions seem to have IVF/ICSI outcomes comparable to those of controls with normal Y chromosomes.

Objective To review existing scientific rationale and clinical data in the utilization of acupuncture in the treatment of female infertility. Design A MEDLINE computer search was performed to identify relevant articles. Result(s) Although the understanding of acupuncture is based on ancient medical theory, studies have suggested that certain effects of acupuncture are mediated through endogenous opioid peptides in the central nervous system, particularly β-endorphin. Because these neuropeptides influence gonadotropin secretion through their action on GnRH, it is logical to hypothesize that acupuncture may impact on the menstrual cycle through these neuropeptides. Although studies of adequate design, sample size, and appropriate control on the use of acupuncture on ovulation induction are lacking, there is only one prospective randomized controlled study examining the efficacy of acupuncture in patients undergoing IVF. Besides its central effect, the sympathoinhibitory effects of acupuncture may impact on uterine blood flow. Conclusion(s) Although the definitive role of acupuncture in the treatment of female infertility is yet to be established, its potential impact centrally on the hypothalamic-pituitary-ovarian axis and peripherally on the uterus needs to be systemically examined. Prospective randomized controlled studies are needed to evaluate the efficacy of acupuncture in female fertility treatment.

Purpose: To evaluate implantation rate as a function of age. Methods: A total of 1621 consecutive cycles of IVF wereevaluated for implantation as a function of age at The NewYork Hospital/Cornell Medical Center. Results: An overall implantation rate of 23.3% (1328/5691)was found. The implantation rate as a function of agedecreased in a nonlinear fashion. Implantation remainedconstant until the age of 35 and then decreased in a significantly,linear fashion by 2.77% per year (P < 0.001, R2 =0.975). A formula to predict implantation rates for a givenage was developed: Implantation rate = −119.352 + (9.985× Age − (0.164 × Age2)). Conclusions: We have demonstrated that implantation ratesremain constant until the age of 35 at which time a lineardecrease of 2.77% per year is observed.

Electroejaculation has been successfully used for sperm procurement in anejaculatory men desiring fertility. However, electroejaculates typically have normal sperm numbers but poor motility, morphology, and functional deficiencies. Here we report the pregnancy outcome of a series of couples undergoing combined electroejaculation and in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). In all, 13 couples underwent a total of 18 cycles. The aetiologies of anejaculation included history of retroperitoneal lymph node dissection for testicular cancers, spinal cord injury and psychogenic causes. ICSI was performed on 192 oocytes, resulting in a fertilization rate of 75.5%. A total of 15 embryo transfers were performed using a total of 51 embryos. Clinical pregnancy rate, as defined by positive fetal heart rate(s) using vaginal sonography, was 55.6% per retrieval; implantation rate was 33.3% per embryo. These rates appear to be similar to those obtained in standard IVF for non-male factor infertility, or ICSI for male factor infertility. The use of ICSI for electroejaculates undoubtedly provides these couples with the highest chance of pregnancy.

Steroidogenic acute regulatory (StAR) protein mediates the rapid increase in steroid hormone biosynthesis in response to tropic hormones by facilitating transport of cholesterol into the inner mitochondrial membrane. Although our laboratory has recently reported on the hormonal regulation of StAR mRNA in the rat ovary, the same regulation in the human corpus luteum requires analysis. To this end, a human StAR complementary DNA (cDNA) probe of 858 bp was generated using reverse transcriptase-PCR and RNA from human corpora lutea. The StAR sequence was confirmed by dideoxy chain-termination sequence analysis. Northern blot analysis using the StAR cDNA probe on human corpora lutea mRNA showed that the probe hybridized to a major 1.6-kb transcript and a minor 4.4-kb transcript. Examination of corpora lutea of different luteal phases revealed that the basal expression of the 1.6-kb transcript was significantly more abundant in the early (days 15-19) luteal phase than in the middle (days 20-23) or late (days 24-28) phases. To examine the hormonal regulation of StAR mRNA, corpora lutea were treated in vitro with increasing concentrations of human chorionic gonadotropin (hCG) or prostaglandin F2 alpha (PGF2 alpha). Following hCG stimulation, both 1.6- and 4.4-kb StAR transcripts were increased. A statistically significant increase of 2.2- and 1.8-fold in the 1.6-kb transcript was seen with hCG concentrations of 50 and 100 mIU/mL, respectively. This increase was coupled with a significant elevation in media progesterone levels. In contrast, PGF2 alpha treatment significantly decreased both StAR messenger ribonucleic acid (mRNA) expression and media progesterone levels at concentrations of 500 and 5000 ng/mL. This investigation demonstrated that StAR mRNA is regulated by tropic hormones and prostaglandins in the human corpus luteum. The parallel change in StAR mRNA in conjunction with a change in progesterone levels further supports StAR's putative role in the regulation of steroidogenesis.

Objective To review the effectiveness of rectal probe electroejaculation in terms of pregnancy in treatment of anejaculatory males due to spinal cord injury. The characteristics of electroejaculates also are examined. Data Identification All English language studies reporting pregnancies as a result of electroejaculation from men with spinal cord injury and related publications on electroejaculation were identified through MEDLINE search and manual scanning of recent relevant journals. Results Electroejaculation has become an accepted mode of semen procurement in anejaculatory individuals, with a success rate of approximately 60% to 90% varying among different centers. In general these electroejaculates exhibit high sperm counts but low motility and poor sperm function. Retrograde ejaculation is also common. Pregnancies using electroejaculates have been documented since 1975 in the form of case reports and small series. Assisted reproductive technology recently has been used in conjunction with electroejaculation. Although results are encouraging, pregnancy rates, however, cannot be accurately estimated because of the lack of large series in the literature. Conclusions An increasing number of spinal cord-injured patients desiring fertility can achieve pregnancy through combined use of electroejaculation and assisted reproductive techniques. Larger series are needed to establish an accurate pregnancy rate. Elucidation by further studies on etiology of sperm dysfunction of these individuals may improve their prognosis.

Publisher Summary The desire to procreate and have one's own genetically descended offspring is an extremely visceral desire. Understanding of reproductive physiology is essential to the treatment of such patients. Assisted reproduction has evolved immensely during the past decade. The development of GnRH antagonists, sequential media for blastocyst culture, assisted fertilization (especially ICSI), and advances in cryopreservation have contributed to the increased success rates of IVF. Additionally, ancillary techniques such as preimplantation genetic diagnosis allow us not only to “cure” infertility, but also to prevent potentially devastating and tragic diseases. Oocyte donation allows couples who cannot conceive with their own oocytes to gestate and deliver a pregnancy. Multiple births from IVF are a significant issue. One problem is that in a capitalistic society where medicine is a private and competitive industry, success rates are reported by pregnancy rate per transfer procedure or retrieval. A second problem is that patients, often anxious for success and perhaps because of misinformation or lack of patient education, feel that multiple birth is a more palatable option than a negative pregnancy test. With advances in the successes of blastocyst transfer, embryo cryopreservation, physician and patient education about the complications of multiple births, and hopefully a more responsible reporting system that accounts for all pregnancies achieved from a single IVF cycle (either by fresh or frozen embryo transfer), high-order multiple pregnancies can be prevented. In fact, in some countries, the governments limit the number of pre-embryos to be transferred to one or two with the remainder of concepti frozen for later cycles.

Objective To investigate whether the time interval between hysteroscopic polypectomy and the start of IVF-ET cycles affect IVF cycle outcomes. Design Retrospective cohort. Setting Academic center. Patient(s) All patients diagnosed with endometrial polyps undergoing hysteroscopic polypectomy before fresh IVF-ET. Intervention(s) Hysteroscopic polypectomy. Main Outcome Measure(s) Patients were divided into three groups based on the time interval between hysteroscopic polypectomy and the start of a fresh IVF-ET cycle. Group 1 consisted of patients who underwent IVF-ET after their next menses, group 2 after two or three menstrual cycles, and group 3 after more than three menstrual cycles. Demographics, baseline IVF characteristics, controlled ovarian stimulation response, and pregnancy outcomes after ET were compared among the groups. Result(s) A total of 487 patients met inclusion criteria: 241 in group 1 (49.5%), 172 in group 2 (35.3%), and 74 in group 3 (15.2%). There were no differences in the baseline characteristics of the three groups. Ovarian stimulation outcomes, specifically total stimulation days, total gonadotropins administered, and number of oocytes retrieved, were similar between groups. There were no differences in the mean number of embryos transferred. The overall pregnancy outcomes were similar for groups 1, 2, and 3: implantation rate (42.4%, 41.2%, and 42.1%, respectively), clinical pregnancy rate (48.5%, 48.3%, and 48.6%), spontaneous miscarriage rate (4.56%, 4.65%, and 4.05%), and live birth rate (44.0, 43.6%, and 44.6%). Conclusion(s) Because waiting for two or more menstrual cycles after hysteroscopic polypectomy does not necessarily yield superior outcomes, patients can undergo ovarian stimulation after their next menses without affecting IVF-ET outcomes.

OBJECTIVE: To explore whether assisted reproductive technology (ART) increase the molecular karyotype abnormality rate of miscarriage. DESIGN: Retrospective study. MATERIALSANDMETHODS: IRB approval was obtained. Miscarriage tissues underwent DNA extraction and 23-chromosome SNP microarray analysis using humanCytoSNP-12 DNA beadchips and GenomeStudio software. RESULTS: 618 coupes were enrolled. The mean age was 31.9 5.1 years. 144 experienced natural conception (NC) and 474 were pregnant by ART. Of the 474 cases, 36 underwent artificial insemination (AI), 244 fresh in vitro fertilization-embryo transfer (IVF-ET), 66 fresh intracytoplasmic sperm injection (ICSI)-embryo transfer and 128 thawed embryo transfer. The total abnormal molecular karyotype rate was 70.9% (438/618). There was no significant difference in the abnormal molecular karyotype rate between ART (70.5%) and NC (72.%). The abnormal molecular karyotype rate in the subgroup of ICSI was 65.6%,which was lower than that of AI+NC( 71.7%) and IVF( 72.2%) ,However, there was no significant difference between them. In the cases aged over 35 years, the abnormal molecular karyotype rate was 83.3%,which was higher than 66.4% in the cases aged 35 years and under . CONCLUSIONS: ART does not increase abnormal molecular karyotype rate of abortion tissue. Moreover, in terms of fertilization mode, compared with the IVF and AI+NC, ICSI does not increase abnormal molecular karyotype rate of miscarriage. Abnormal molecular karyotype rate is increased in the cases aged over 35 years in both NC and ART. To our knowledge, this is the largest and most comprehesive trial conducted evaluating SNP molecular karyotyping of spontaneous miscarriage after ART.

BACKGROUND: The objective of this study is to determine if ultrasound-guide d trial transfer (UTT) in the office in preparation for an IVF cycle can be utilized as an altern ative and/or adjunct to ultrasound-guided embryo transfer (UGET). METHODS: Patients planning to undergo an IVF cycle at an academic centre were included. Each patient underwent an UTT in the office by the same practitioner. Th e difference in length (DL), if any, was measured from the perceived top of the uterine cavity (c atheter tip) to the actual cavity apex as visualized by ultrasound. RESULTS: Of the 64 patients enrolled, 19 patients (29.7%) had a measurable DL, of which 14 (21.9%) had a DL � 0.5 cm, and nine (14.1%) had a DL � 1.0 cm. Significant differences were noted between patients when comparing DL to previous pregnancy status and the total cavity depth (sounding depth + DL) (P < 0.05). CONCLUSION: UTT in the office setting appears to be beneficial in preparation for an IVF cycle with embryo transfer.

Approximately 50 to 60% of couple infertility is because of a female factor, while male factors account for another 40 to 50% of infertility. This chapter mainly addresses female infertility. Among female factors for infertility, about 40% are anatomic reasons (uterine and tuboperitoneal diseases), while another 40% reason can be ovulatory dysfunction. Other factors may include immunologic factors, impenetrable cervical mucous, luteal phase defect, or medical conditions (e.g., diabetes mellitus), which may interfere with implantation. Uterine defects can be identified by hysterosalpingogram (HSG), saline infusion sonography, or hysteroscopy. Hysterosalpingogram has traditionally been the gold standard for tubal evaluation. Laparoscopy, however, has the advantage of more precise observation and documentation. Appropriate sperm-cervical mucus interaction is necessary for spontaneous conception, which is determined by post coital test. Adequacy of the luteal phase can be measured by the sum of three postovulatory progesterone levels (days 5, 7, and 9 postovulation). An endometrial biopsy is the gold standard. Thyroid disorders, particularly hypothyroidism, may be associated with anovulation. Thyroid-stimulating hormone (TSH) should be screened and thyroid supplements administered where appropriate.

Objective: To investigate whether any parameter in the routine semen analysis of electroejaculates is correlated with success in achieving pregnancy by IUI. Design: Retrospective observational study. Setting: An Assisted Reproductive Program at a tertiary care university center. Patient(s): Twenty-seven anejaculatory men with spinal cord injury (n = 24) or history of retroperitoneal lymph node dissection (n = 3), thirteen of whom attempted conception with their wives. Intervention(s): Anejaculatory men underwent rectal probe electroejaculation and electroejaculates were used for IUI. Main Outcome Measure(s): Statistical correlation of semen parameters between electroejaculates that resulted in pregnancy and those that did not. Result(s): Seven pregnancies resulted from 56 IUIs using electroejaculates (pregnancy rate=12.5% per IUI). The total motile sperm count and percentage of normal morphology were significantly higher in the specimens that resulted in pregnancies than those that did not. However, there was no statistically significant difference observed in pH, sperm concentration, or percentage of motility between the two groups. Swim-up techniques used to process electroejaculates significantly improved the motility of the specimens. No pregnancy occurred beyond the fifth IUI attempt. Repeated electroejaculation and duration of spinal cord injury had no effect on the quality of the ejaculates. Conclusion(s): The total motile sperm count and the percentage normal morphology of electroejaculates correlate with success in achieving pregnancy by IUI. Because repeated electroejaculation does not improve quality of ejaculate, the initial semen analysis of electroejaculates is not only useful in counseling couples undergoing such treatment program but should be planned for use as an inseminate.

Objective To report our experience with electroejaculation combined with intrauterine inseminations (IUI) and other assisted reproductive technologies. Methods Anejaculatory men desirous of fertility were evaluated in our Assisted Reproductive Program. Between March 1991 and December 1994, 26 men (age 24–48) underwent a total of 84 electroejaculations. Causes of anejaculation included spinal cord injury ( n = 23) and retroperitoneal lymph node dissection ( n = 3). Female partners were superovulated to improve the pregnancy rate. The success in sperm retrieval and pregnancy rates were determined, and the quality of electroejaculates was evaluated. Results Seventy-seven of 84 (92%) electroejaculations were successful, defined by retrieval of more than 10 × 10 6 total and more than 10 6 motile spermatozoa. Mean sperm count was 65 million/mL (range 0–569), but mean motility was only 16% (range 0–66). Mean normal morphology was 27% (range 0–71). Ten couples attempted conception. Fifty cycles of IUIs were performed, resulting in four normal term infants and one spontaneous abortion (pregnancy rate 10% per IUI). One patient failed to conceive with eight cycles of IUIs but became pregnant with in vitro fertilization-embryo transfer with micromanipulation using electroejaculates; she delivered a set of healthy twins. Two couples elected donor sperm insemination after failing to conceive by IUI with electroejaculates; both became pregnant. Conclusion Electroejaculation offers an encouraging pregnancy opportunity for anejaculatory men who otherwise are considered infertile. Marked asthenospermia is observed in electroejaculates, the etiology of which remains obscure. Further studies to elucidate the cause may improve pregnancy rates.

The goal of this retrospective study was to determine the rate of miscarriage in in vitro fertilization (IVF) pregnancies after sonographic confirmation of cardiac activity at 7 weeks gestation. The study included 2014 consecutive IVF pregnancies, from the years 1991 to 1996, in which fetal cardiac activity was documented. Standard ovulation induction protocols were used to prepare for IVF-embryo transfer. Selected embryos were transferred into the uterine cavity approximately 72 hours after being retrieved. The number of embryos transferred increased with advancing age, up to 5 for women more than 40 years of age. Pregnancy loss (spontaneous abortion [SAB]) occurred in 233 patients, 11.6% of the total. Losses clearly increased with advancing age, from 5.3% in women 30 years of age and younger to 22.2% in those aged 40 and older. Pregnancy loss was more likely in women with singleton pregnancies compared with those with multiple gestations (16.1% vs. 5.4%), but the former women were significantly older. More than one fourth of women aged 40 years and older failed to deliver a live-born infant. An age effect was also noted in women with SAB, but the SAB rate for multiple gestations was lower than in singleton pregnancies for all age groups. Cytogenetic analysis was carried out in 74 pregnancy losses and an abnormal karyotype was identified in 52 of them (71.2%). The rate of chromosomal aneuploidy was 82% in women aged 40 and older and 65% in those less than 40 years of age (odds ratio, 3.35). Approximately 4 in every 5 fetuses with an abnormal karyotype had trisomies, most frequently in chromosomes 21, 16, 22, 15, and 18 (in descending order). These data are from a single institution, and fetal age was precisely documented in all cases. A significant risk of pregnancy loss must be taken into account when counseling women about how many embryos will be transferred after IVF. Chromosomal aneuploidy appears to be the major underlying cause of these losses.

Much has been written recently on the increasing incidence of multiple pregnancies as a consequence of the use of gonadotropins for fertility enhancement. Although few experts would argue that these drugs do not increase cycle fecundity, several have suggested that the dire medical and socioeconomic consequences of high-order multiple pregnancies associated with their administration in ovulation induction should preclude their use, except when the ultimate goal is IVF where the number of embryos to be transferred can be controlled (1).

Obstructive renal failure due to an overdistended uterus is a very rare complication of pregnancy. Most previously reported cases have involved twin gestations, the majority occurring in the presence of polyhydramnios. We describe a patient with a twin gestation who developed acute obstructive renal failure despite only very mild physiological pregnancy-induced dilation of the urinary collecting system in the absence of polyhydramnios. This case suggests that acute obstructive uropathy should be considered as a rare cause of acute renal failure even in cases with seemingly normal pregnancy-induced physiological urinary tract dilation.