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Objective: To analyze the reproductive outcome in infertile couples which underwent intraperitoneal insemination (IPI). Methods: We analyzed a series of 216 couples who underwent IPI. Indications for treatment were unexplained infertility in 51 couples and male factor in 165. The 51 couples with unexplained infertility underwent a total of 71 cycles (20 couples underwent a second IPI cycle). The 165 couples with male factor underwent 243 cycles (165 first cycles and 78 second cycles). Results: Out of the 314 cycles performed, a total of 41 clinical pregnancies were observed, with a corresponding conception rate of 13.1%. The values of conception rates for unexplained and male factor infertility were 21.1 (based on 15 pregnancies) and 10.7% (based on 26 pregnancies), respectively. Out of the 41 pregnant women, 26 gave birth to a child, thus the overall livebirth rate was 8.3% (12.7 and 7.0%, respectively, for unexplained infertility and male factor diagnostic subgroups). Considering the couples with unexplained infertility, the conception rates were 9.0, 30.8 and 20.0% for strata of 10 millions of inseminated spermatozoa. The corresponding values were 6.8, 12.5 and 18.5%, respectively, in couples with male factor infertility (χ21 trend p Conclusion: In conclusion, this series provides quantitative estimates of pregnancy rates after IPI in Italian couples with unexplained infertility or male infertility and suggested that the number of motile sperm inseminated is a determinant of pregnancy with this technique.

The efficiency of spermatozoa prepared by swim-up or by Percoll centrifugation was assessed in an in-vitro fertilization programme on 71 semen samples of a well-defined quality [total number of type A (WHO criteria) motile spermatozoa]: category I (n = 21) with > 100 x 10(6), II (n = 31) with 15-100 x 10(6), III (n = 11) with 5-15 x 10(6) and IV (n = 8) with < 5 x 10(6) type A motile spermatozoa. Oocytes were inseminated 4 h after oocyte retrieval, alternately with spermatozoa derived from swim-up and Percoll preparation. Both selection procedures resulted in a significantly higher (P < 0.001) percentage motility as compared to fresh semen. For low-quality samples (III and IV), however, swim-up was more effective in selecting highly motile (P = 0.004) and morphologically normal spermatozoa (P < 0.05). For high-quality samples, this difference might have been masked by introducing a swim-up step to remove Percoll particles. Regardless of the initial sperm quality, the mean fertilization rate was significantly higher (P = 0.003) when Percoll-treated spermatozoa were used for insemination (51.3 versus 37.8%). For semen of groups I and II, no difference in fertilization capacity was observed according to the sperm preparation method. Despite the lower percentage motility and normal morphology for the Percoll compared to the swim-up treatment in groups III and IV, fertilizing capacity was significantly (P < 0.001) in favour of this selection method (65.3 versus 26.5% in group III, 47.6 versus 11.6% in group IV).(ABSTRACT TRUNCATED AT 250 WORDS)

Correct controlled ovarian stimulation is of paramount importance in assisted reproductive technologies. Therefore, analysis of the ovarian reserve of the patient is mandatory to tailor the best ovarian stimulation regimen. When the ovarian reserve is reduced, the induction of a multifollicular growth remains a challenge. Several factors could be associated with reduced ovarian response. However, reduced ovarian reserve either in older patients or in young patients represents the most frequent aetiological factor. Whatever is the aetiology, one of the main problems is how to predict a reduced ovarian response, and although several tests have been suggested, no very accurate predictive test is available. A variety of different stimulation protocols have been suggested but the lack of any large-scale, prospective, randomized, controlled trials of the different management strategies and the lack of a uniform definition of the population may result in comparisons of heterogeneous groups of patients, making it difficult to draw any definitive conclusions. Natural cycle IVF may represent an easy and cheap approach in the management of this group of patients. Although no controlled large prospective randomized studies are available to compare the natural IVF procedure with ovarian stimulation IVF in poor responder patients, the efficacy of natural cycle IVF is hampered by high cancellation rates mainly due to untimely LH surge. The use of gonadotrophin-releasing hormone antagonists in the late follicular phase, which reduces the premature LH rise rate, and the improvements in laboratory conditions and fertilization techniques, increase the embryo transfer rates, making this procedure more cost-effective.

Frozen-thawed embryo transfer is an effective procedure that allows further possibilities of pregnancy in addition to those obtained after the fresh in vitro fertilization (IVF). In our follow-up study we analysed all fresh embryo transfer procedures and every frozen-thawed embryo transfer performed from January 2000 to December 2001 evaluating the cumulative pregnancy rates. The study population was divided into two groups according to the female age: 38 years (group II). All the best embryos were chosen for transfer and all the supernumerary good quality embryos were cryopreserved on the day of transfer. The embryos were then thawed and manipulated using a new technique. In group I, 527 patients (619 cycles) underwent fresh embryo transfer and in 232 of them (238 cycles) the embryos were frozen (44% per patients and 38.4% per cycle). In group II, 156 patients (193 cycles) underwent fresh embryo transfer and in 14 of them (15 cycles) the embryos were frozen (9% per patient and 7.8% per cycle). The pregnancy rate of group I patients that had their supernumerary embryos frozen (232 patients and 238 cycles) was 47.4% per cycle and 48.7% per patient whereas in the same population of group II patients (14 patients and 15 cycles) the clinical pregnancy rate was 35.7% per cycle and 38.5% per patients. The cumulative clinical pregnancy rate after transfer of fresh and thawed embryos was: group I, 74% per cycle and 76% per patients; group II, 42.8% per cycle and 46.1% per patient. Frozen-thawed embryo transfer is a cost-effective practice.

There is an evident decline of female fertility with age. This decline is mainly due to increased risk of pregnancy termination either after conception or after embryo implantation. Very likely the major cause of this embryo and pregnancy loss is chromosomal aneuploidies caused mostly by increasing rates of ‘poor quality’ oocytes. This phenomenon can be explained either by an age dependent accumulation of damage and/or by the hypothesis that the defective oocytes are there in the ovaries from the fetal life. ‘Good quality’ oocytes are ovulated first, leaving ‘poor quality’ oocytes to be ovulated later in life. Besides the quality of the oocytes which is mainly responsible of the embryo quality (we have not to forget a paternal effect) the process of implantation is dependent upon two variables: the probability of a viable embryo and that of a receptive uterine environment. From the oocyte donation model it seems that the endometrium also plays a minor role in human reproductive ageing as it does in some laboratory animals. However, besides some macroscopic possible causes which may play a role in the reduction of the age-related endometrial receptivity, there are so many endometrial factors possibly related to its receptivity which need to be further studied especially in older women.