After Assisted Reproductive Techniques Research Articles

Obstetric perinatal and maternal outcomes of monochorionic diamniotic twins following assisted reproductive techniques. Retrospective observational study

IntroductionMultiple and specifically monochorionic diamniotic (MCDA) pregnancies are related to maternal and foetal complications. The aim of this study is to evaluate obstetric and perinatal outcomes of MCDA after assisted reproductive techniques (ART). MethodsThis is a case-control study comparing 23 MCDA twin pregnancies after ART (ART-MCDA) and 75 spontaneous MCDA (sMCDA). Maternal, obstetric, foetal, and perinatal outcomes variables including maternal age, prematurity, TTTS, sIUGR, TAPS, PROM, and neonatal weight were compared. Resultsmean maternal age is higher in the ART-MCDA pregnancies, 38.0±.6 (OR=1.32(1.13–1.53)). Neonates weighing between 1500 and 2500g are more frequent in the sMCDA group and those weighing >2500g in the ART group (OR=0.47(0.22–0.97)). Foetuses born at between 32 and 37 weeks are more frequent in sMCDA pregnancies and those born >37 in the TRA group (OR=0.27(0.09–0.80)). These differences are lost when we adjust the results by maternal age. There were no differences in maternal, obstetric, or foetal complications. ConclusionsART-MCDA are not associated with a higher number of maternal, obstetric or foetal complications if they are adjusted by maternal age. When they are not adjusted by maternal age, there would be better outcomes such as premature and neonatal weight in the ART group.

Vitamin D and Vitamin D Receptor in Female Infertility

Objective: To investigate the possible association of serum and follicular fluids(FF) Vitamin D levels with reproductive outcomes after assisted reproductive techniques (ART). Secondly, to detect Vitamin D Receptors (VDR) in serum and follicular fluid (FF) of ovarian follicle and explore its relationship with Vitamin D levels as well as reproductive outcomes.
 Methodology: This study was conducted on May 2019 in Aga Khan Hospital, Karachi, Pakistan. A total of 8 infertile female subjects were conveniently recruited. Serum was collected and follicular fluid(FF) was obtained by transvaginal-guided follicular puncture; 34 hours after intramuscular administration of Human Chorionic Gonadotrophin (HCG). Vitamin D and VDR was assessed in serum as well as in FF by Paired Sample t-test.
 Results: Females 2 out of 8 acquired clinical pregnancy, whereas 3 had pre-clinical abortion or no pregnancy. Vitamin D and VDR were detected highest in those female patients that acquired pregnancy in comparison to the pre-clinical abortion or non-pregnant ones (p value<0.007). Serum VDR did not show any significant results in all groups 
 Conclusion: Vitamin D in serum and FF and vitamin D receptor in serum and FF were associated with number of oocytes. High levels of VDR in FF observed in clinical pregnancy group proved our hypothesis that the presence of VDR in FF is a contributing factor for successful conception after ART success.
 

The risk of psychiatric disorders among Finnish ART and spontaneously conceived children: Finnish population-based register study

Evidence regarding the psychiatric morbidity of children born after Assisted Reproductive Techniques (ART) is inconsistent and limited. While normal mental well-being for ART children is usually reported, concerns are still being raised. Previous studies examine only some psychiatric disorders, but not all of them, ignore the impact of multiplicity, and limit the follow-up time to childhood. We examined all psychiatric diagnoses for singletons until their young adulthood. The aim was to study whether the risk of psychiatric disorders differs between ART and spontaneously conceived (SC) singletons until young adulthood. This retrospective Finnish population-based register study includes all ART and SC live-born children born in Finland during 1990–2013 and their hospital care in 1990–2014 (n = 1,425,975 of which 1,385,956, 97.2% were singletons). After excluding multiples, the final population included 17,610 ART and 1,368,346 SC singletons in 1990–2013 from the Finnish Medical Birth Registry. These data were linked to the Finnish Hospital Discharge Registry with the child’s and mother’s encrypted IDs. ART singletons had fewer psychiatric diagnoses (ART 10.2%, n = 1796, SC 12.0%, n = 164,408), but they received their diagnoses earlier (mean 8.3 years old, SD 5.0) than SC singletons (mean 10.5 years old, SD 5.7). After adjusting for confounding factors, ART singletons had an increased likelihood of getting a psychiatric diagnosis until young adulthood and the results were similar for boys (adjusted hazard ratios [aHR] = 1.16, 95% confidence interval (CI) 1.10–1.24) and girls (aHR = 1.25, 95% CI 1.16–1.35). We conclude that ART children receive their psychiatric diagnoses earlier than SC children, in particular during childhood and early adolescence. After adjusting for confounding factors ART children a slightly increased likelihood of any psychiatric diagnosis compared to SC controls.

The PLART study: incidence of preterm labor and adverse pregnancy outcomes after assisted reproductive techniques-a retrospective cohort study.

Even though assisted reproductive techniques represent one of the greatest achievements in modern medicine, the risk of preterm birth related to these pregnancies is about twice as high. This must be highlighted and further investigated to optimize the management of both mothers and newborns. The purpose of this study was to compare adverse pregnancy outcomes after assisted reproductive techniques (ART) and spontaneous conceptions, focusing on the incidence of preterm births (PTB) and distinguishing between iatrogenic and spontaneous events. This retrospective cohort study analyzed single births of one Italian hospital. The incidence of PTBs in ART pregnancies, divided into iatrogenic procedures, spontaneous preterm labors and preterm premature ruptures of the membranes (pPROMs), was compared with the non-ART control group. The incidence of other adverse pregnancy outcomes and the types of delivery were also reported and compared. Of the 11,769 single births included, 2.39% were conceived by ART. The incidence of PTBs was 4.74% for spontaneous pregnancies and 12.8% for ART pregnancies (aOR 1.93; 95% CI 1.29-2.88). The percentage of iatrogenic procedures was 27.78% in the ART-PTBs' group and 30.88% in the non-ART-PTBs' controls. ART pregnancies showed an increased incidence of pPROMs (6.40% versus 2.41%), preterm labors (2.85% versus 0.93%), hypertensive disorders of the pregnancy (8.19% versus 2.32%), placenta previa (3.20% versus 0.59%), cesarean sections(28.47% versus 16.27%) and vacuum extractions (10.32% versus 5.19%). Singleton ART pregnancies have a higher risk of PTB which is mostly linked to a higher incidence of pPROMs and spontaneous preterm labor. The concurrency of a demonstrated higher risk of hypertensive gestational disorders and placenta previa suggests that placental development plays an important role in the pathogenesis of PTB.

A population-based register study of infant and late child mortality in singletons born after assisted reproductive techniques (ART) vs natural conceptions

A population-based register study of infant and late child mortality in singletons born after assisted reproductive techniques (ART) vs natural conceptions

A view of maternal mortalities in women conceiving through assisted reproductive techniques: A nation-based study of Turkey

BackgroundOur aim was to evaluate maternal mortality causes among Turkish women giving birth after assisted reproductive techniques (ARTs). MethodsAll maternal deaths following conception with ART pregnancies were identified through the National Maternal Mortality Surveillance System. We analyzed the system data collected between 2007 and 2014. During this period, there were 10,369,064 live births and 1788 maternal deaths resulting from both direct and indirect causes. We identified 28 maternal death cases following ART procedures. The age, gestational age at birth, number of antenatal visits, delivery route, time of death, cause of death, and neonatal outcomes were recorded. Also, any existing delay (phase 1, 2, or 3) and preventability of maternal death were assessed. ResultsHypertensive disorders, pulmonary embolism, and cardiovascular disease were the leading causes of maternal death. Twelve (40%) women were over 35 years of age. Of the deaths, 15 (54%) were attributed to indirect causes. The number of unpreventable maternal deaths was 19 (67.9%), and 9 (36%) were classified as preventable after being assessed by the review commission of maternal mortality. ConclusionPregnancies conceived with ARTs should undergo a careful assessment of risk factors for hypertensive disorders, pulmonary embolism and cardiovascular diseases. Those women require closer antenatal surveillance because 1/3 of these deaths were preventable.

Heterotopic Quadruplet Pregnancy After ICSI Conception.

Heterotopic pregnancy (HP) is a condition characterized by the coexistence of multiple fetuses at two or more implantation sites. It occurs in 1% of pregnancies after assisted reproductive techniques (ART). Presence of triplet intrauterine pregnancy with ectopic gestational sac is one of the rarest forms of HP. Ectopic pregnancy is implanted in the ampullary segment of the fallopian tube in 80% of cases. Most of the patients present with acute abdominal symptoms due to rupture of the tube. This article reports a case of quadruplet heterotopic pregnancy after intracytoplasmic sperm injection (ICSI) with an ampullary ectopic pregnancy and intrauterine triplet pregnancies. The ruptured ampullary pregnancy was emergently managed by right salpingectomy. This was followed by embryo reduction at 12+6weeks and successful outcome of intrauterine twin pregnancy.

Twin pregnancies after assisted reproductive technologies: the role of maternal age on pregnancy outcome

ObjectivesOur aim was to investigate whether advanced maternal age (≥40years) still impairs the outcome of twin pregnancies after assisted reproductive techniques (ART). Study designThe retrospective observational study evaluated 430 nulliparous dichorionic diamniotic twin pregnancies conceived with ART. The population was divided into women <40 years old (Group A, n=265) and ≥40 years old (Group B, n=165). ResultsGestational diabetes mellitus and gestational hypertension/preeclampsia were significantly more frequent in nulliparous twin pregnancies after ART ≥40years compared to <40years (p=0.021 and p<0.001, respectively). In univariate analysis of twin pregnancies after ART, there was only a trend of higher incidence of total preterm birth (PB) rate within mother aged ≥40 years old (p=0.104). However, Group A showed higher rate of spontaneous preterm birth (SPB) <37 weeks, whereas Group B showed significantly higher rate of iatrogenic PB <37 weeks of gestation (p=0.023 and p=0.001, respectively). For delivery <32 weeks of gestation, the rate of SPB in Group A was significantly higher (p=0.002). A higher incidence of PB was observed in Group B after heterologous treatment (p<0.001). Despite this, the absolute prevalence of PB in the entire population is higher in Group A, both after autologous (22.5%) and heterologous (25%) ART treatment, than in Group B (10.1% vs 21.4%). ConclusionsOur data indicate that nulliparous twin pregnancies conceived with ART in mothers ≥40 years old did not show significantly higher incidence of PB, even if an increased rate of iatrogenic PB <37 weeks is showed.

Outcome of Multiple Pregnancy Conceived Spontaneously Versus by Assisted Reproductive Therapy (Comparative Study)

Background: There is a continuous controversy regarding the obstetric perinatal outcome of multiple pregnancies conceived after assisted reproductive techniques (ART). There is an ongoing discussion whether theses parameters may show poorer results as compared to spontaneous conception. Aims: of the present study wereto compare the perinatal outcome in spontaneous multiple pregnancies compared to those conceived by ART and to design a booklet to orient the parturient women included in the study about spontaneously conceived and ART conceived multiple pregnancies. Design: A prospectivecohort observational study was used. Setting: The study was conducted at the labor ward at labor and child hood hospital, Zagazig University hospital. Subjects: Group A consisted of 83 parturient women with spontaneously conceived multiple pregnancies and group B which consisted of 27 parturient women with multiple pregnancies conceived by ART who were admitted to the study setting within a period of one year from January to December, 2015. Tools: Data collection tool consisted of 3 parts, structured interview questionnaire, labor record and neonatal record. Results: Group B were significantly complicated with threatened abortion and placenta previa than group A (24.0%& 24.0% VS. 7.1% &2.4% respectively). Premature rupture of membrane and severe preeclampsia were statistically significant main indications of emergency cesarean delivery in group A compared to group B, while placenta previa was a statistically significant amin indication for emergency CS in group B compared to group A (P= 0.032). As regards neonatal outcome, there were a statistically significant increase in the neonatal intensive care unit admission and still birth in group B compared to group A (64.0% & 22.0% VS. 46.4% & 2.9% respectively). Conclusion: Based on the findings of the study, When compared to spontaneously conceived twins, ARTconceived twins are more or less similar to those conceived spontaneously. Recommendation: Multiple pregnancy in general whether conceived spontaneously or by ART techniques require proper antenatal, intra-natal and postnatal care as it poses several risks on both mother and fetus.

FSH treatment of male idiopathic infertility improves pregnancy rate: a meta-analysis.

IntroductionThe aim of this study is to comprehensively evaluate whether FSH administration to the male partner of infertile couples improves pregnancy rate, spontaneously and/or after assisted reproductive techniques (ART).MethodsMeta-analysis of controlled clinical trials in which FSH was administered for male idiopathic infertility, compared with placebo or no treatment. Randomization was not considered as an inclusion criterion.ResultsWe found 15 controlled clinical studies (614 men treated with FSH and 661 treated with placebo or untreated). Concerning the type of FSH, eight studies used recombinant FSH, whereas seven studies used purified FSH. Nine studies evaluated spontaneous pregnancy rate, resulting in an overall odds ratio (OR) of about 4.5 (CI: 2.17–9.33). Eight studies evaluated pregnancy rate after ART, showing a significant OR of 1.60 (CI: 1.08–2.37). Sub-dividing studies according to the FSH preparations (purified/recombinant), pregnancy rate improvement remained significant for each preparation. Eleven studies considered sperm quality after FSH treatment, finding a significant improvement of sperm concentration (2.66×106/ml, CI: 0.47–4.84), but not of concentration of sperm with progressive motility (1.22×106/ml, CI: −0.07 to 2.52). Three trials evaluated testicular volume, showing a non-significant increase in men treated (1.35 ml, CI: −0.44 to 3.14).ConclusionThe results of controlled clinical trials available in the literature indicate an improvement of pregnancy rate after FSH administration to the male partner of infertile couples, both spontaneously and after ART. However, the heterogeneity of studies, the high risk of bias and the lack of precise criteria to guide FSH administration limit the strength of these results. Future studies should be designed to identify the markers of FSH response which are helpful in the decision-making process. Meanwhile, the use of FSH in the treatment of male infertility should be cautious.

Does in vitro culture of human preimplantation embryos negatively affect perinatal outcomes?

Newborns after assisted reproductive techniques (ART) usually have poorer perinatal outcome when compared to newborns after spontaneous conception. Low birthweight, preterm birth and proportion of large for gestational age have been attributed to in vitro culture negative effects. The purpose of the study was to analyse if in vitro culture of embryos can influence perinatal outcome of infants born after intracytoplasmic sperm injection (ICSI) compared to infants born after timed intercourse or intrauterine insemination (IUI). A retrospective cohort of patients attending a fertility clinic in Germany between January 2011 and March 2013 were included in the study. Singletons and twins born after fresh ICSI cycles (n=206 and 87, respectively) were compared to singletons and twins born after IUI and timed intercourse (n=63 and 10, respectively). Patients having in vitro culture (5.5% CO2, 5% O2) were divided into two groups, SI (n=204) and TLI (EmbryoScopeTM, n=89). Perinatal outcomes were compared among newborns in the groups SI, TLI and ‘in vivo’ incubation (IVI). Continuous variables were tested by ANOVA and binary variables by Fischer′s exact test. We could not observe any significant difference in singletons among the groups IVI, TLI and SI, respectively, regarding gestational age at birth (GA) (37.89 weeks ± 0.21, 38.14 ± 0.16 and 37.66 ± 0.15), birthweight (3416 g ± 69.8, 3362 ± 65.3 and 3280 ± 46.3), size (51.6 cm ± 0.3, 51.1 ± 0.4 and 50.8 ± 0.3), gender (60.6%, 49% and 47% boys), Z-score (0.70 ± 0.13, 0.45 ± 0.11 and 0.52 ± 0.07) and malformations (0, 1 and 2 infants). Interestingly, there were less preterm birth (GA < 37 weeks) in the TLI group than in the SI group (4 versus 30, respectively, P=0.02, relative risk 2.959, CI 1.091 to 8.030) after singleton pregnancy. Data are presented as mean ± standard error. In vitro culture of embryos seems not to affect primary perinatal outcome of newborns after ICSI compared to infants after timed intercourse and IUI. However, use of time-lapse incubation (TLI) could significantly reduce number of preterm birth in singletons. Improving current culture system in ART laboratories may be a valuable step towards more physiological and embryo-friendly in vitro culture. Optimizing culture media and incubation systems is thus urgently needed in order to minimize poorer neonatal outcomes in ART newborns.

Prenatal testing among women pregnant after assisted reproductive techniques in Denmark 1995-2000: a national cohort study

Women pregnant after assisted reproductive techniques (ART) are generally older than women with spontaneously conceived pregnancies, and are consequently more likely to carry a child affected by a chromosomal disorder. Furthermore, a significantly increased rate of chromosomal abnormalities after intracytoplasmatic sperm injection (ICSI) has been reported. The aim of this study was to describe the use and results of prenatal invasive diagnostic testing in a national Danish cohort of in vitro fertilization (IVF)/ICSI pregnancies. Additionally, we examined to what extent second trimester serum screening was used. We used a register-based cohort study including all ongoing clinical pregnancies achieved by IVF/ICSI in 1995-2000 in Denmark. Data on fertility treatment, pregnancy and pregnancy outcome together with data on cytogenic testing and the use of triple test were retrieved from national statutory registers. Data on the invasive testing rate among the general Danish population were retrieved from the same national registers. In this 6 year period, 8531 ART pregnancies were recorded representing an unselected national ART population (6122 IVF, 2087 ICSI and 322 'IVFICSI'). The number of prenatal invasive procedures was relatively low, 16.3%, and the uptake of second trimester serum screening was very low, 7.4%. The invasive testing rate, corrected for advanced maternal age distribution, was lower in the study population than in the general population. The rate of karyotype aberrations detected by prenatal testing was 2.7% (43/1586), whereas the overall rate of pre- and post-natally detected aberrations was 0.6% (62/9625). Chromosome aberrations were more common in the ICSI-treated group compared with the IVF-treated group [1.3% (30/2297) versus 0.5% (32/6957), P < 0.0001]. This was also the case if only prenatally diagnosed chromosome aberrations were compared [4.3% (24/556) versus 1.9% (19/975), respectively, P < 0.01]. ART pregnancies represent a group of high-risk pregnancies with regard to chromosomal aberrations, but nevertheless their uptake of prenatal testing was low. ICSI pregnancies compared with IVF pregnancies had a higher rate of chromosomal abnormalities, even though the average maternal age was lower.

Outcome of twin pregnancies conceived after assisted reproductive techniques

There is a continuous controversy regarding the obstetric perinatal outcome of twin pregnancies conceived after assisted reproductive techniques (ART). There is an ongoing discussion whether theses parameters may show poorer results as compared to spontaneous conception. To evaluate the outcome of multifetal pregnancies and to compare maternal and neonatal complications between spontaneously conceived and assisted reproductive therapy. Prospective case-control study. In this prospective case-control study of 2-year duration, obstetric and perinatal outcomes were compared in 36 ART twin pregnancies (Group A) with 138 twins who conceived naturally (Group B). The outcomes were analyzed and used for a comparison between spontaneous and assisted multifetal pregnancies. The continuous variables were analyzed by Student's t-test and categorical variables were analyzed with Fisher's exact test. Pregnancy-related complications like pregnancy-induced hypertension, antepartum hemorrhage, were similar in both groups. Incidence of cesarean section, preterm delivery, and hospital stay was significantly more in Group A vs. Group B, P < 0.001. The newborns in the assisted group had more complications than the spontaneous group; most notable were respiratory distress syndrome, newborn intensive care admission, sepsis, and longer hospital stay (4.8 days vs. 1.6 days, P < 0.001). Increased rates of cesarean section and preterm delivery are the main reasons for increased obstetric risk in pregnancies conceived through ART. Preterm birth and neonatal prematurity-related complications were the main cause for longer stay in hospital in ART-conceived twins.

Monozygotic triplet pregnancy following egg donation and transfer of single frozen-thawed embryo

To describe a case of monozygotic triplet pregnancy following egg donation and the transfer of a single frozen-thawed embryo. Case report. District general hospital and regional department of fetal medicine in northeast England. A 38-year-old woman with a 2-year history of primary infertility due to severe endometriosis and poor ovarian reserve who conceived after egg donation and transfer of a single frozen-thawed embryo. Transfer of a single frozen-thawed embryo and delivery of three identical female infants by emergency caesarean section because of preterm labor at 32 weeks' gestation. Review of effect of assisted conception on monozygotic twinning rates. Healthy outcome for all three infants. Assisted reproductive treatments may lead to disturbances in zona pellucida architecture and an increase in monozygotic twinning rates. Couples need to be informed of this and the increased risks associated with these pregnancies before they begin with treatment.

Rapid Evaluation of Soluble HLA-G Levels in Supernatants of In Vitro Fertilized Embryos

Human leukocyte antigen G (HLA-G) molecules are crucial for the maternal tolerance against the fetus during pregnancy. Thus, the presence of soluble HLA-G (sHLA-G) in embryo cultures is thought to be correlated to a successful pregnancy after assisted reproductive techniques (ART). Here, we established a rapid detection assay based on Luminex technology, which can be integrated into ART proceedings, allowing sHLA-G quantification in sample volumes of only 10 μl within 1.5 hours. Using this method, sHLA-G levels of 526 single-embryo cultures, 47 two-embryo cultures, and 15 three-embryo cultures were analyzed corresponding to 313 ART cycles. In 117 embryo cultures, sHLA-G was detectable. In single-embryo cultures, the sHLA-G levels were positively correlated to embryo quality ( p = 0.048, r = 0.20, n = 100). The presence of sHLA-G in embryo cultures was significantly ( p < 0.0001) associated with clinical pregnancy after intracytoplasmatic sperm injections (ICSI), especially in couples with male factor infertility, but not after in vitro fertilization (IVF) or in couples with female infertility. Importantly, in sHLA-G negative embryos, the abortion rate was increased threefold ( p = 0.04). In conclusion, the results obtained by our novel method support strongly the diagnostic relevance of sHLA-G for predicting pregnancy outcome after ART. The ultimate conditions for this prediction have to be further investigated in a multicenter study.

P-54: Predictability of pregnancy viability after assisted reproductive techniques (ART) cycles by CA-125 and progesterone serum levels on the day of β-hCG testing

Ideally a marker of ART success should predict treatment outcome as early as possible. Serum progesterone levels have been found to be defective before an adverse pregnancy outcome. CA-125 is found in endometrial tissue and glands, although it may have an ovarian origin too. Higher levels in conception vs non conception ART cycles have been found, rising the question about a possible serum marker of endometrial receptivity. The objective of this study is to evaluate the prognostic value of pregnancy outcome of serum CA-125 and progesterone levels in ART cycles testing positive for β-hCG, with a fixed progesterone supplementation protocol.

Malformations after assisted reproductive medicine

New follow-up studies indicate a slightly increased risk of malformations after assisted reproductive techniques (ART). Even if study results vary a lot and the absolute risk for congenital malformations in ART children is small, couples must be properly informed. It is undisputed that parents after in vitro festilization (IVF) or intracytoplasmatic sperm injection (ICSI) have a greater risk to father a child with malformations because of underlying sociodemographic and anamnestic risk factors. Couples have also to be counseled that ICSI-children have a greater risk for chromosomal anomalies compared with naturally conceived children. This is due to transmitted chromosomal anomalies (1–4%), which are already existent in parents (predominantly fathers), or due to de-novo chromosomal anomalies, originating mostly of bad sperm quality (2.1% when the sperm count is <20 Mio./ml). The health of children after assisted reproductive medicine must be systematically documented in follow-up studies to draw clear conclusions regarding the safety of these techniques. The importance of the risk factor “sterility” itself and the significance of epigenetic changes are still unclear.

Outcome of twin pregnancies after assisted reproductive techniques—a comparative study

Objective: To compare obstetrical and perinatal outcome of twin pregnancies after assisted reproductive techniques (ART) with that of twins conceived spontaneously. Study design: Hospital based retrospective study. Results: There were 132 twin deliveries of which 36 were conceived after ART. Patients of the ART group were mostly nulliparous and slightly older. There was no statistically significant difference in the frequency of preterm delivery or mean gestational age at delivery. Elective Caesarean delivery was more frequent in twin pregnancies conceived after ART, and there were no other differences in maternal complications. There was also no difference in the mean birth weight or frequency of neonatal complication between the two groups. Conclusion: In this comparative study, the obstetric and neonatal outcomes between spontaneous twins and those conceived after ART are similar except for higher operative deliveries in the latter group of twins.

Optimal use of infertility diagnostic tests and treatments. The ESHRE Capri Workshop Group.

The general definition of infertility is a lesser capacity to conceive than the mean capacity of the general population and infertile couples can be characterized in two groups: those unable to conceive without therapy and those who are hypofertile, but conceive without therapy. The initial diagnostic tests for infertility should include a midluteal phase progesterone assay, a semen analysis and a test for tubal patency such as a hysterosalpingogram. Measuring progesterone is the best test for confirming ovulation. To predict ovulation, evaluating the luteinizing hormone (LH) surge is the best single assay while measurement of LH plus preovulatory oestrogen is the best prediction. Today primary investigation of the morphology of the uterus and tubes should be by hysterosalpingography. However, ultrasound, particularly with simple contrast media, is likely to gain in importance. Laparoscopy should be reserved as a further diagnostic procedure or in combination with endoscopic surgery. There are situations in which semen analysis is of utmost importance and of absolute predictive value, namely, in cases of azoospermia. In general semen analysis remains a substantial part of the fertility workup, but any consideration of its predictive value has to be cautious. Performing genetic tests before, during and after assisted reproductive techniques (ART) is an intrinsic part of good clinical practice. These tests allow one to reach a correct diagnosis, to give adequate genetic counselling to the couple and their families in cases such as (i) women with Turner syndrome; (ii) men with 47, XXY; (iii) men or women with structural chromosomal aberration; (iv) men with Yq11 deletion or (v) men with congenital bilateral absence of vas deferens. Patients should, of course, be made aware of the occurrence of de-novo mutations taking place in the testis and in the embryo. Treatment of some causes of infertility are of proven value. For example induction of ovulation. Others are more controversial. Among the many empirical treatments suggested for the treatment of the various form of subfertility, surgical treatment of varicocele in the male, treatment of pelvic endometriosis in the female and the efficacy of the ART strategies offered to the subfertile couple are considered. Many varicocele studies are of poor quality. A few are good, but small in size. They do not show an improvement in pregnancy rates. Therefore, at the moment, there is insufficient scientific evidence for recommending routinely surgical treatment in subfertile and/or oligozoospermic men with a varicocele. Randomized, double-blind controlled trials demonstrated the modest efficacy of endometriosis ablation in increasing the pregnancy rate in infertile women while drugs suppressing ovulation are of no benefit to infertile women with endometriosis. Although the largest body of evidence available suggests that IVF success declines in repeated ART cycles, an accurate estimate of the true success rate in the 'nth' cycle of IVF treatment is not possible. Similarly little is still known of the reasons for the overall low continuation rates with IVF treatment.

Outcome of triplet pregnancies after assisted reproductive techniques: How frequent are the vanishing embryos?

To assess the incidence of spontaneous embryo reduction as well as the obstetric and neonatal outcome of triplet gestations after assisted reproductive techniques (ART). We analyzed the spontaneous outcome of 38 pregnancies in which three gestational sacs were identified with vaginal ultrasound between 21 and 28 days after ART. Weekly follow-up visits were scheduled during the first trimester until referral to a high-risk obstetrician. After delivery, each patient was interviewed individually and, if necessary, the obstetrician was contacted. The triplets delivery rate was 47.4%, whereas 31.6% delivered twins, 18.4% delivered singletons, and only one patient miscarried all three cases (2.6%). Finding three fetal heart beats was associated with a triplet delivery rate of 69.2%, a twin incidence of 19.2%, and a singleton birth rate of 11.6%. Embryo resorptions were observed mainly during the first 7 weeks of gestation and did not occur beyond the 14th week. The mean gestational age at delivery and neonatal birth weight were significantly lower among triplets (32.8 weeks and 1,740 g versus 35.3 weeks and 2,352 g in twins and 39.1 weeks and 3,122 g for singletons). Triplets had a 100% prematurity and cesarean section rate compared with 67% and 75% in twins and 0% and 43% in singletons, respectively. Hospitalization at the Neonatal Intensive Care Unit was required in 83% of newborn triplets, 29% of twins, and 0% of singletons, with a mean stay of 34 and 21 days for triplets and twins, respectively. One stillbirth and no neonatal deaths were reported, with an overall perinatal mortality rate of 11.9 per 1,000. Spontaneously, approximately 50% of triplet pregnancies will experience at least one embryo resorption. The ongoing triplets demand a complex and more expensive perinatal management, a strong argument to consider limiting the number of oocytes-embryos transferred in ART.