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Purpose: To evaluate age related ovarian response to controlled ovarian hyperstimulation, clinical pregnancy and ongoing pregnancy rates beyond 20 weeks in women undergoing assisted reproduction treatment (ART) with antimullerian hormone (AMH) levels of 38 years of age. Non parametric variables were expressed as median (Interquartile range) and compared by Kruskal-Wallis test. Categorical variables were expressed as numbers with proportions (%) and compared by Fisher’s exact test. Results: There was no statistical difference in body max index, level of antimullerian hormone (AMH), follicle stimulating hormone (FSH), dose of gonadotrophins used and cycles cancellation rate in two groups. Although number of oocytes retrieved (median 5), clinical pregnancy (18.4%) and ongoing pregnancy rate beyond 20 weeks (18.4%) was higher in group 1, there was no statistical difference between the two groups. There was one miscarriage in group 2. Conclusion: Women with extremely low-serum AMH levels can still have clinical pregnancy and ongoing pregnancies beyond 20 weeks after ART, though chances will be lower than women with normal ovarian reserve.

To determine knowledge retention 1 year after training for intrapartum emergencies.Training was undertaken in 6 hospitals and the Bristol Medical Simulation Centre, UK, between November 2004 and March 2005. Participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were randomly recruited from participating hospitals and underwent practical training at their local hospital or simulation center with or without additional teamwork training. The primary outcome was change in factual knowledge over time, as assessed by a 185-question multiple-choice questionnaire before and after training.Mean scores at 6 (97.6 ± 23.0; n = 107) and 12 (98.2 ± 21.6; n = 98) months remained higher than those before training (79.6 ± 21.9, n = 140; both P0.001), but were slightly lower than those immediately after training (101.0 ± 21.3, n = 133; P0.001 and P = 0.007, respectively). The type of training had no effect on retention of knowledge.Training was associated with sustained retention of factual knowledge of obstetric emergencies care for at least 1 year. The decay in knowledge was small compared with the original gain in knowledge. Neither training location nor inclusion of teamwork training affected knowledge retention. Annual training seemed to be satisfactory for all staff groups.

The timing of human chorionic goadotropin (hCG) injection and oocyte retrieval in women undergoing in vitro fertilization and intracytoplasmic sperm injection is crucial. If not properly timed, premature spontaneous luteinizing hormone surge or even premature ovulation may lead to cancellation of the treatment cycle. Commonly, oocyte retrieval is planned 32-36 hours after hCG injection. This time interval is of relevance because a number of essential processes, including the start of luteinization and resumption of the reduction division of the oocytes, should be well established before oocyte retrieval.We present a rare case in which, due to patient misunderstanding of timing of hCG injection, oocytes were retrieved 50 hours after hCG injection. On the morning of the oocyte retrieval at 08.00 hours it became apparent that, by mistake, the patient had taken the hCG injection at 09.15 hours rather than at 21.15 hours, 12 hours earlier than advised. It was therefore already 48 hours post-hCG injection. Nineteen good- quality, mature oocytes were retrieved, resulting in 11 good-quality embryos. A single expanded blastocyst was transferred, resulting in pregnancy and delivery of a healthy female infant.This is the first reported case of successful pregnancy after oocyte retrieval 5o hours after hCG injection. This case could be a stimulus for others to conduct further studies of prolonged exposure of hCG to oocyte retrieval to show the improved outcome of assisted reproduction treatment.

Chlamydia trachomatis infection of the genital tract is the most common sexually transmitted infection and has a world-wide distribution. The consequences of infection have an adverse effect on the reproductive health of women and are a common cause of infertility. Recent evidence also suggests an adverse effect on male reproduction. There is a need to standardise the approach in managing the impact of C. trachomatis infection on reproductive health. We have surveyed current UK practice towards screening and management of Chlamydia infections in the fertility setting. We found that at least 90% of clinicians surveyed offered screening. The literature on this topic was examined and revealed a paucity of solid evidence for estimating the risks of long-term reproductive sequelae following lower genital tract infection with C. trachomatis. The mechanism for the damage that occurs after Chlamydial infections is uncertain. However, instrumentation of the uterus in women with C. trachomatis infection is associated with a high risk of pelvic inflammatory disease, which can be prevented by appropriate antibiotic treatment and may prevent infected women from being at increased risk of the adverse sequelae, such as ectopic pregnancy and tubal factor infertility. Recommendations for practice have been proposed and the need for further studies is identified.

The advent of a 1-stop approach to managing women with early pregnancy problems led to the development of early pregnancy clinics. Such clinics progressed to providing a patient centered approach, minimising inpatient admissions while providing women with an early diagnosis of miscarriage or extrauterine pregnancy by a multiprofessional group of individuals with expertise in this area. The clinic structure, referral process, and ongoing challenges are discussed.

In this study, we examined whether the proportion of tubal factor infertility (TFI) that is attributable to Chlamydia trachomatis, the population excess fraction (PEF), can be estimated from serological data using finite mixture modeling. Whole-cell inclusion immunofluorescence serum antibody titers were recorded among infertile women seen at St. Michael's Hospital in Bristol, United Kingdom, during the period 1985-1995. Women were classified as TFI cases or controls based on laparoscopic examination. Finite mixture models were used to identify the number of component titer distributions and the proportion of serum samples in each, from which estimates of PEF were derived. Four titer distributions were identified. The component at the highest titer was found only in samples from women with TFI, but there was also an excess of the second-highest titer component in TFI cases. Minimum and maximum estimates of the PEF were 28.0% (95% credible interval: 6.9, 50.0) and 46.8% (95% credible interval: 23.2, 64.1). Equivalent estimates based on the standard PEF formula from case-control studies were 0% and over 65%. Finite mixture modeling can be applied to serological data to obtain estimates of the proportion of reproductive damage attributable to C. trachomatis Further studies using modern assays in contemporary, representative populations should be undertaken.

Opinion remains divided as to whether finding endometriotic lesions in the absence of adhesions has an adverse effect on the likelihood of conception.This was a retrospective study of 192 fully investigated infertile couples, followed up for up to 3 years following laparoscopy. Women studied were ovulating,40 old years and their partners had normal sperm parameters. All 117 women with unexplained infertility and 75 with minimal/mild endometriosis without adhesive disease were managed conservatively.Women with endometriosis were found to have a lower probability of pregnancy compared with women with unexplained infertility (36% versus 55%; P0.05). Other factors adversely associated with pregnancy were primary infertility, smoking and longer duration (3 years) of infertility. However, the effects of duration of infertility and primary infertility were not observed to be statistically significant for women with endometriosis.The findings, although undertaken in a select population undergoing laparoscopy, suggest the likelihood of pregnancy is reduced in infertile women with minimal/mild endometriosis compared with those infertile women with a normal pelvis. Duration of infertility and a previous history of pregnancy are important in predicting the likelihood of pregnancy in women with no obvious cause for their infertility (unexplained), whilst the relationship may be more complex in women with minor endometriosis

Background The present study addresses the issue of biological ageing of the oocyte (as indicated by basal serum FSH levels) versus chronological ageing. Methods 1019 infertile but ovulating women were studied in their first cycle of IVF treatment. A series of logistic regression models were developed to assess statistical significance of effects of age and FSH on implantation rates and live babies born. Results The number of oocytes retrieved and embryos available for transfer declined with increasing age and basal serum FSH concentrations. Fertilizing ability of oocytes increased with advancing age but was not affected by FSH concentrations. Although the number of oocytes or embryos available for transfer had no independent effect on implantation rates, the implanting ability of fertilized oocytes (embryos) was inversely related to increasing age and independently to FSH. The chance of a baby being born, however, was determined more by age than by serum FSH. Conclusions Ovarian ageing affecting oocyte quality and fecundity can occur independently of chronological age. This has important practical implications whereby serum basal FSH measurement may be a valuable prognostic index, though chronological age remains important.

This study aims to determine the relative contribution of oocyte and/or sperm dysfunction to the reduction of fertilization rates in vitro in cases of minor endometriosis and prolonged unexplained infertility. The results of in-vitro fertilization (IVF) treatment with ovarian stimulation have been compared between couples with the above conditions and women with tubal infertility (as control for oocyte function) and the use of donor spermatozoa (as control for sperm function). Fertilization and cleavage rates using husband's spermatozoa were significantly reduced in endometriosis couples (56%, n = 194, P < 0.001) and further significantly reduced in couples with unexplained infertility (52%, n = 327, P < 0.001) compared with tubal infertility (60%, n = 509). Using donor spermatozoa the rates were the same as using husband's spermatozoa in tubal infertility (61%, n = 27) or endometriosis (55%, n = 21) but significantly though only partly improved with unexplained infertility (57%, n = 60, P < 0.02). In unexplained infertility, a significantly increased proportion of couples experienced complete failure of fertilization and cleavage in a cycle (5-6% versus 2-3%). However, complete failure was not usually repetitive, and the affected couples did not account for the overall reduction in fertilization and cleavage rates, which remained significantly lower in the rest of the unexplained and endometriosis groups. Implantation and pregnancy rates appeared similar in all groups. The benefit of IVF treatment in cases of minor endometriosis and prolonged unexplained infertility is due to superabundance of oocytes obtained by stimulation. The reduction in natural fertility associated with endometriosis appears to be at least partly due to a reduced fertilizing ability of the oocyte. In unexplained infertility, there is distinct impairment due to otherwise unsuspected sperm dysfunction but probably also oocyte dysfunction.

A pilot study was designed to examine whether the outcome of embryo transfer in women with a hydrosalpinx might be improved by surgical drainage of the hydrosalpinx at the time of oocyte collection for in-vitro fertilization treatment. A comparative, controlled but retrospective analysis of the results was performed of all women with infective tubal damage aged

Obesity and excessive weight gain during pregnancy are associated with poor outcomes for mother and baby. These include gestational diabetes, raised blood pressure (hypertension) in pregnancy, maternal venous blood clots (thromboembolism), delivery by caesarean section, high birthweight, stillbirth, maternal infection (sepsis), heavy maternal bleeding (haemorrhage) after delivery, and maternal death. As the number of women of childbearing age who are obese has increased so too has the number of women of childbearing age undergoing bariatric (weight-loss) surgery. This has resulted in an increased number of pregnant women with a history of weight-loss surgery. The most common bariatric procedure is gastric banding (laparoscopic adjustable gastric banding) in which a band containing a fluid-filled balloon is placed around the upper portion of the stomach creating a small upper pouch which limits transport of food into the lower pouch. This reduces a person's capacity to ingest food and so reduces nutritional intake. The volume of the balloon can be adjusted by addition to or removal of fluid from the balloon. At present there is no guidance on the best management of a gastric band during pregnancy and there is variation in care. Some clinicians advocate leaving the balloon filled (inflated) to limit food intake and limit weight gain during pregnancy. This strategy might reduce the likelihood of maternal high blood pressure or gestational diabetes and so improve the outcomes for mother and baby. There are concerns, however, that leaving the balloon inflated might reduce the intake of essential nutrients needed for normal fetal development and growth. In addition, it is possible that band complications, including nausea and vomiting, slippage or migration of the band because of the increased intra-abdominal pressure with pregnancy, might occur more frequently if the balloon is left inflated. As a result, some clinicians prefer to remove fluid to deflate the balloon when the woman becomes pregnant. This review aimed to compare outcomes for mothers and babies according to whether the balloon is deflated at the beginning of pregnancy compared to maintaining balloon inflation in pregnancy. No studies met the criteria for inclusion in the review. No conclusions can be drawn from randomised controlled trials regarding the best management of the gastric band in pregnancy. Further research is needed to define optimum management of the gastric band balloon during pregnancy.

To summarise the causes of decreased fecundity with age and review chronological vs biological ovarian ageing. To explore the clinician's means of assessing a woman's ovarian reserve. To review the recent literature on the effectiveness of different assisted reproductive technology (ART) techniques for women aged 40 and over and offer a single best treatment option.Pubmed and google scholar were searched for relevant articles using key words. Data were extracted based on authors, year, aims, sample and results.Success rates for women aged 40 or over with clomiphene, IUI, IUI with FSH are all extremely low, at less than 1% live birth per cycle. However, IVF offers a success rate of around 13.7% per cycle.An exploration of the effectiveness of available treatment options for older infertile women using their own gametes suggests that IVF offers the best prospects of success. Attempting treatments other than IVF will delay conception unnecessarily.

We report the safe use of levonorgestrel hormone releasing intra uterine system (Mirena®) as a contraceptive in egg donors during a treatment cycle. In the first case report, a 29-year-old egg donor using the Mirena coil for contraception and two egg recipients, aged 41 years and 32 years respectively underwent standard IVF treatment, oocyte retrieval in the egg donor and in vitro fertilization followed by embryo transfer in the recipient. The outcome of IVF cycle using donor eggs was satisfactory with successful pregnancy in the egg recipient. The second case involved a 34-year-old egg donor using the Mirena coil and a 44-year-old recipient. Our findings suggest that egg donors can safely use the (Mirena®) as a contraceptive device during treatment, without compromising follicular development and oocyte quality.

Purpose: Chronological age, or biological age as indicated by elevated FSH levels, are related to ovarian reserve. This study addresses the likelihood of cancellation of IVF treatment due to a poor ovarian response utilising both basal serum FSH and woman's age. Methods: A prospective cohort of 536 infertile but ovulating women were studied in their first cycle of IVF treatment. Standardised methods of pituitary desensitisation and ovarian stimulation prior to IVF treatment were employed. Treatment cycles cancelled due to a poor ovarian response to gonadotrophins were studied. A series of logistic regression models were used to explore the probabilities of cancellation in relation to age and FSH. Results: Both age and basal serum FSH levels were independently associated with the risk of treatment cancellation. A low risk of treatment cancellation was observed in women under the age of 35 irrespective of serum FSH, however in older women the risk of treatment cancellation was most likely in women with a high FSH. Conclusions: In combination both age and FSH may serve as a valuable indicator of poor ovarian response leading to treatment cancellation. However, among older women FSH has particular importance, while less so in younger women with regular menstrual cycles.

BACKGROUND: Insulin-like growth factor-1 (IGF-1) is known to play a role in ovarian follicular development augmenting the action of FSH. Low intrafollicular concentrations have been detected in women who respond poorly togonadotrophins. This study addresses the relationship between serum IGF-1 levels following pituitary desensitization and ovarian response to gonadotrophin stimulation. METHODS: This is a case-control study of 78 patients undergoing IVF-embryo transfer treatment. Thirty-nine strictly-defined poor responder patients requiring 50 or more ampoules (75 IU FSH) to reach oocyte retrieval were compared with 39 age-matched normal responders, requiring fewer than 50 ampoules. IGF-1 concentrations were determined by extraction radioimmunoassay on serum samples obtained after pituitary desensitization but prior to gonadotrophin stimulation. RESULTS: Despite highly significant differences in measures of ovarian response between groups, the mean serum IGF-1 concentration was not statistically significantly different between poor and normal responders {(31.5 nmol/l [95% confidence interval (CI) 28.5-34.5] versus 34.5 nmol/l (95% CI 31.8-37.2)} respectively. No correlation between oocyte number or total gonadotrophin used and serum IGF-1 concentration was observed. CONCLUSION: Whilst IGF-1 influences ovarian follicular development this study suggests that serum IGF-1 does not predict ovarian response and does not differentiate between critically-defined poor and normal responders.

Tubal pelvic damage is a common cause of infertility, and laparoscopy is the accepted gold standard for its diagnosis. However, laparoscopy is both costly and invasive. Chlamydia is now recognized as the most common cause of tubal pelvic damage. In contrast to laparoscopy, evidence of past chlamydial infection using serology is readily available, and the test is simple and quick to perform. As such, serology can be used as a screening test in infertile women. It is accepted that screening tests may have higher margins of error and may be less accurate than diagnostic tests. Screening is most valuable when detecting a disease for which the treatment is more effective when undertaken at the earliest opportunity. Because there are justified constraints to the indiscriminate use of laparoscopy, there is a need to minimize the number of patients who do not have disease (false positives) who are subjected to this diagnostic investigation. An appropriate Chlamydia antibody titre that would distinguish women at risk of tubal pelvic damage should be determined using diagnostic test analysis and clinical judgement. Identification by serology of women who are likely to have damage would enable these women to undergo a diagnostic test such as laparoscopy sooner, allowing treatment to be provided earlier. However, the severity of tubal pelvic damage varies, and the need to distinguish women with a favourable or unfavourable prognosis after treatment using a simple classification system is discussed.

Surveys in the United Kingdom have repeatedly discovered substandard care in significant proportions of maternal, fetal, and neonatal deaths. In the United Kingdom, training in obstetrical emergencies is carried out both nationally and locally in maternity units. This prospective, randomized controlled trial evaluated training in 6 hospitals in the United Kingdom. The 140 participants included 22 junior and 23 senior doctors as well as 47 junior and 48 senior midwives. They were randomized to one of 4 obstetrical emergency training interventions: a 1-day course at a local hospital, a 1-day course at a simulation center, a 2-day course with teamwork training at a local hospital, and a 2-day course with teamwork training at a simulation center. A 183-question multiple choice questionnaire (MCQ) was completed up to 3 weeks before the training intervention and again 3 weeks after the intervention. All but 7 of the 140 participants completed training and the posttraining assessment. Knowledge of obstetrical emergency management increased following training. The increase in the mean MCQ score was significant at the P < 0.001 level. All but 10 of 133 participants who completed both assessments had increased MCQ scores. Neither the location of training nor the inclusion of teamwork training significantly influenced posttraining scores. Changes in MCQ scores after training correlated negatively with pretraining scores. There were, however, no significant differences between staff groups in their relative responses to the 4 training interventions. With one exception-management of breech presentation-scores for individual components of the MCQ improved significantly. This is the first study demonstrating objective improvement in what doctors and midwives know following training in obstetrical emergency management. It remains to be determined whether this translates into lower maternal and neonatal morbidity and mortality rates. The investigators believe that all relevant staff should take part in this type of training on an annual basis.

A skeleton quality manual has been prepared by collaboration between the British Fertility Society, Association of Clinical Embryologists and the Human Fertilisation and Embryology Authority (HFEA). A quality manual is a fundamental part of the quality management system (QMS) and is designed to encompass the ethos of clinical governance including education and training, clinical audit, clinical effectiveness, research and development, openness and risk management. It is mandatory for fertility clinics licensed by the HFEA in the UK to have a QMS in place to enable continual improvement of service. This manual is a tool that Centres can adapt to reflect their own service provision. The aim is to provide a skeleton to compliment or develop a Centre’s QMS. The aims of each section describe what the outcome should be and practical examples have been given. The examples are not exhaustive, and Centres should develop their own standard operating procedures (SOPs) to support the quality manual. Where possible, the aims and examples within the manual have been mapped to the relevant HFEA standard licence conditions included in the 8th HFEA code of practice (CoP). Examples suggest where implementation of quality standards outlined in this manual might be mapped to compliance with some HFEA standard licence conditions. Users should be aware that not all requirements of standard licence conditions or of the 1990 Human Fertilisation and Embryology Act (as amended) or HFEA Directions are mapped to this manual. Implementing a QMS on the basis of this manual would not mean that a Centre would be fully compliant with all HFEA requirements. HFEA standard licence conditions in this template are denoted by the letter T and a number, and these references are linked to a list of HFEA standard licence conditions appended at the end of the document. A standard licence condition highlighted in bold indicates that it has been mapped to the quality manual template. This should help Centres comply with mandatory HFEA requirements. The manual and the activities undertaken in implementing the manual can form part of the evidence of compliance shared with the HFEA in the course of an inspection.