P1: Effect of age, oestradiol levels and endometrial thickness on determining success of frozen embryo transfers

Fertility 2008 BFS Summer College 2008 OC1: Do patients receiving donor sperm need evaluation of their uterine cavity and fallopian tubes? Tulay Karasu, Ben Lavender, Anne Hemingway, Geoffrey Trew, & Stuart Lavery IVF Unit, Hammersmith Hospital, London, United Kingdom, and Imaging, Imperial College Healthcare, London, United Kingdom Introduction. In cases of infertility requiring the use of donor sperm, there is a debate about whether investigations for uterine and tubal pathology are routinely necessary, and if so which is the investigation of choice. We wanted to find out whether assessment of the uterine cavity and fallopian tubes with hysterosalpingogram (HSG) detects a significant amount of pathology which could affect treatment outcome. Material & Methods. This is a retrospective study in a London teaching hospital-assisted conception programme looking into the investigations of women prior to their treatment with Donor sperm. In the time period from January 2003 to November 2007, 162 women underwent assisted conception (IUI/IVF) Donor treatment in our unit. The patients were identified from the embryology database and data were collected from their case notes. Results. One hundred and forty-nine women (92%) had an HSG performed before starting their treatment. The HSG was normal in 92 women (56.8%) and showed abnormalities in 57 women (35.2%). Uterine pathology only was detected in 31 women (20.8%) and tubal pathology only was described in six patients (4%). Nineteen patients (12.8%) had uterine as well as tubal pathology on HSG examination. HSG was abandoned in one patient due to technical difficulties. Seventeen women (11.9%) underwent laparoscopic surgery, and 10 of these women had confirmed tubal pathology (7% in total), mainly hydrosalpinx. Hysteroscopy was performed in 35 women (24.5%) with 25 women showing uterine abnormalities (17.5% in total). The main findings were polyps in the uterine cavity. Conclusions. 17.5% of the patients had confirmed uterine abnormalities and 7% of the women demonstrated tubal pathology. The findings of the HSG did influence further management such as the decision to perform surgery or to proceed with IUI or IVF. We therefore believe that evaluation of the uterine cavity and tubes is justified in women before treatment with Donor sperm, and in our own practice we use the HSG. OC2: Correlation between number of eggs predicted and actual eggs collected during IVF/ICSI stimulated cycles: a prospective observational pilot study Koli Chandra Reddy, Arianna D’angelo, Grace Jose, Bebbie Jefferies, Lorraine Goucher, & Janet Evans IVF Wales University Hospital of Wales, Cardiff, United Kingdom Background. It is always difficult to predict accurately the number of eggs to collect during an ART cycle only looking at the follicular size and numbers on transvaginal scan on the day of hCG injection. The accurate prediction is extremely important for patients’ expectation and for the laboratory to prepare the culture dishes for the day of the egg collection. The aim is to assess the correlation between number and size of follicles reported by the scan and actual number of oocytes collected. Material & Method. Prospective observational data collection between December 2007 and February 2008 (6 weeks) at the IVF Wales Unit, University Hospital of Wales, Cardiff. On the day of the oocyte retrieval, patients’ details including demographic factors, stimulation regime, size and number of the follicles on day 11, and when appropriate, day 14 of monitoring were collected. The number of oocytes was predicted on the basis of follicular mean size of 16 mm around the time of the trigger injection. The actual number of eggs was collected on the day of the procedure for each patient. Any difficulties encountered during the procedure (i.e. high ovaries) were noted. Statistical analysis performed using Microsoft Excel software. Results. Twenty-six (26) women data were collected. Mean age was 34 years (25–42), mean BMI was 26 (19–40), 92.4% were nonsmokers, 65.3% were primary subfertile, 65.3% had no previous ART, 23% were PCO, 19.2% had endometriosis, 80.8% used urinary hMG. According to the number of follicles plotted during the scan, 57.6% had good response (6–14 follicles 16 mm), 30.7% had poor response (56 follicles 16 mm) and 11.5% had hyper response (415 follicles 16 mm). On day of hCG injection, 35 follicles were between 12 and 13 mm, 47 follicles were between 14 and 15 mm and 151 were 16 mm (total 233). The total number of eggs predicted was 231, and the actual total number of eggs collected was 217. 69.3% of the procedures were not difficult. Conclusions. The mean follicular size measured by ultrasound on the day of hCG of 12 mm over-estimates the number of eggs collected by 7.3% (þ16 eggs). However, considering only 14 mm on same day underestimates by 8.7% (719 eggs). This can be useful when counselling the patients and for the laboratory organization before the egg collection. OC3: Effect of pituitary desensitization on the early growing follicular cohort estimated using Anti-Mullerian Hormone Kannamannadiar Jayaprakasan, Bruce Campbell, James Hopkisson, Jeanette Clewes, Ian Johnson, & Nick Raine-Fenning NURTURE, School of Human Development, University of Nottingham, Nottingham, United Kingdom Background. Although the decrease in FSH secondary to shortterm administration of GnRH agonist during IVF does not affect the number of ultrasonographically detected antral follicles, its effect on the early growing follicle population, not evident on even highresolution ultrasound, is not known. The objective of this study was to evaluate the effect of pituitary desensitization on the early growing Human Fertility, August 2008; 11(S1): 3–13 ISSN 1464-7273 print/ISSN 1742-8149 online British Fertility Society DOI: 10.1080/14647270802336171 H um F er til ( C am b) D ow nl oa de d fr om in fo rm ah ea lth ca re .c om b y 41 .2 15 .7 0. 21 4 on 0 3/ 14 /1 1 Fo r pe rs on al u se o nl y. follicle population through assessment of serum anti-Mullerian Hormone (AMH) concentration. Other markers of ovarian reserve, basal FSH, LH, oestradiol, Inhibin-B and three-dimensional ultrasound ovarian parameters have also been assessed for comparison. Methods. One-hundred and two subjects aged5 40 years with FSH levels512 IU/l underwent venepuncture and transvaginal ultrasound in the early follicular phase of the menstrual cycle and after 14 days of downregulation using GnRH agonists. Serum levels of AMH and other markers of ovarian reserve measured during the early follicular phase and those measured following down-regulation were compared using a paired students’ t-test for normally distributed or Wilcoxon signed rank test and skewed data, respectively. The study was approved by the National Health Service research ethics committee, and written consent was obtained prior to the enrolment of each subject. Results. Although mean (+SD) AMH levels increased significantly (P5 0.01) by about 28% (1.3+ 0.7–1.6+0.9 ng/ml), there was a significant decline (P50.01) of about 40–50% in levels of Inhibin-B (47.9+26.5 to 15.0+16.0 pg/ml), FSH (7.1+1.9 to 4.2+1.5 IU/l), LH (5.3+3.0 to 2.6+ 1.6 IU/l) and oestradiol (156.5+ 66.3 to 64.3+45.3 pmol/l). Down-regulation treatment was also associated with a decrease (P50.01) in mean ovarian volume (6.5+ 2.0 to 5.6+ 2.2 cm) and in ovarian blood flow indices (vascularisation index: 7.5+ 4.3 to 6.1+5.0; flow index: 36.3+4.7 to 34.1+7.9 and vascular flow index: 2.9+ 1.8 to 2.3+1.8), but no difference was seen in the antral follicle count (14.9+ 4.4 to 14.6+ 6.0). Conclusion. Pituitary desensitization results in a significant increase in AMH levels, which implies that either the secretion of AMH by early growing follicles is enhanced or that the size of this follicle cohort is increased. The number of antral follicles visualised on ultrasound in the early follicular phase and at down-regulation appears unchanged suggesting any effect is restricted to the smaller ‘selectable’ follicles. OC4: Endometrial expression of follistatin and inhibin/ activin in women with implantation failure after IVF Alka Prakash, Elizabeth M. Tuckerman, Susan Laird, Bolarinde Ola, Tin C. Li, & William L. Ledger Addenbrookes Hospital, Cambridge, United Kingdom, Biomedical Research Unit, Sheffield, United Kingdom, BRMC, Sheffield Hallam University, Sheffield, United Kingdom, Academic Unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, United Kingdom, and Royal Hallamshire Hospital, Sheffield, United Kingdom Introduction. The aim of the study was to assess the expression of beta A and beta B subunit of inhibin/activin molecule and follistatin in the endometrium of women with history of implantation failure after IVF and compare it with a fertile control group. Methods. This was a case–control study. Eleven women with history of implantation failure were recruited from the implantation failure clinic whereas seven women with history of proven fertility were recruited as a control group. All women had daily measurements of luteinising hormone (LH) until an LH surge was identified. An endometrial biopsy sample was then taken at day LHþ 7. The tissue obtained was dated using Noyes criteria and immunocytochemistry using the ABC method was performed on paraffin embedded sections to assess expression of beta A subunit, beta B subunit and follistatin molecule expression in the endometrium. Results. There was a trend for lower beta A stromal score in women with implantation failure although this was not statistically significant. The mean H score for glandular epithelial follistatin expression was significantly lower in women with repeated IVF failure as compared with the control group (P1⁄40.03). Conclusion. The reduced expression of follistatin in the endometrial glandular compartment in women with implantation failure did not translate into increased activin expression from the endometrium. It may be hypothesized that other factors regulate the activin follistatin pathway than currently known, and follistatin appears to play a key role in implantation. OC5: Placental dysfunction after infertility treatment Jolly Joy, Lee Armstrong, Caroline Gannon, Joy Ardill, Neil McClure, & Inez Cooke School of Medicine, Obstetrics & Gynaecology, Queen’s University Belfast, Belfast, United Kingdom, and Royal Victoria Hospital, Belfast, United Kingdom Introduction. Artificial Reproductive Techniques (ART) and conception following a period of untreated infertility (41 year) are independently associated with increased pregnancy complications. Abnormal placentation identified by plasma markers, placental macroscopic and/or microscopic changes may explain some of these variances. The aim of this study was to compare the gestational profile of biochemical markers of placental function and placental histopathology of singleton pregnancies conceived with ART and those conceived spontaneously either with or without a period of infertility (41 year). Methods. Non-smoking, age-matched primiparous women with no significant medical history and with a singleton pregnancy were recruited in three groups: ART (n1⁄4 38); natural conception (n1⁄447); conception following untreated infertility (n1⁄421). Blood samples were collected at five time points during the pregnancy and tested for soluble fms like tyrosine kinase1 (sFlt1), Placental Growth Factor (PLGF) and Leptin. Placentae were collected and pathological examination was performed by one pathologist blinded to the groups. Results. ART group had significantly lower plasma levels of PLGF at all time points compared with infertility and control groups (P50.001). Infertility group had significantly higher levels of leptin than ART or control group at all time points (P50.001). This did not relate to their BMI. There were no significant differences in sFlt1 levels between groups at the various time points. The mean placental thickness was significantly higher in the ART group (P1⁄4 0.02) with significantly more placental haematomas (P1⁄4 0.03) compared with the control and infertility groups. There were no differences in the incidence of abnormal placental shapes or cord insertions. Lesions suggestive of a possible immunodysregulatory response were more prevalent in the infertility group compared with the other groups, but this did not achieve statistical significance. Conclusion. Low plasma PLGF levels, increased placental thickness and greater incidence of haematomas compared with the other groups suggest abnormal placentation and/or abnormal placental function in ART pregnancies. OC6: Outcome of cryopreservation of biopsied blastocysts after pre-implantation genetic diagnosis: a 2-year study Tarek El-Toukhy, Yacoub Khalaf, Jan Grace, Arri Coomarasamy, Eleanor Wharf, & Peter Braude Guy’s and St. Thomas’ Hospital NHS Foundation Trust, London, United Kingdom Background. The ability to cryopreserve surplus embryos found to be suitable for transfer after pre-implantation genetic diagnosis (PGD) for serious genetic disease is particularly valuable due to the complex nature and high cost of treatment. Methods. Between February 2006 and March 2008, we performed 21 PGD thaw cycles, in which 39 blastocysts resulting from embryos biopsied on day 3 were thawed. Outcomes were compared with 142 IVF/ICSI thaw cycles, in which 292 intact blastocysts were thawed, using similar slow freezing and rapid thawing laboratory protocols. 4 Fertility 2008 H um F er til ( C am b) D ow nl oa de d fr om in fo rm ah ea lth ca re .c om b y 41 .2 15 .7 0. 21 4 on 0 3/ 14 /1 1 Fo r pe rs on al u se o nl y. Results. The mean age at cryopreservation was similar in the two groups (32.4+4.7 vs. 33.5+3.7 years, P1⁄40.21). There were fewer cryopreserved embryos available for thawing in the PGD cycles (2.7+1.3 vs. 4.3+3 frozen embryos, P1⁄4 0.01). However, the survival rate (87% vs. 84%, P1⁄40.73), mean number of embryos replaced (1.5+0.5 vs. 1.6+0.48, P1⁄4 0.31), implantation rate (45% vs. 27%, P1⁄4 0.06) and clinical pregnancy rate (43% vs. 34%, P1⁄40.38) per thaw cycle were comparable in the PGD and IVF/ICSI cycles, respectively. In addition, the pregnancy loss rate in the first trimester was similar in the two groups (23.1% vs. 23.8%, P1⁄4 0.87). Conclusion. Day 3 blastomere biopsy does not compromise survival or implantation potential of cryopreserved blastocysts in PGD cycles. OC7: An exploration of the views and feelings of women prior to embarking on a cycle of in vitro fertilisation who have experienced a previous miscarriage Jill Bulmer Reproductive Medicine Unit, Leeds, United Kingdom Introduction. Miscarriage is an overwhelming experience for any woman, and a cruel blow for women who miscarry after years of infertility treatment. Couples undergoing infertility treatments experience many and varied emotions. This report is an exploration of the views and feelings of women prior to starting a cycle of in vitro fertilisation (IVF) who have experienced a previous miscarriage. The findings of this research will enable the care these women receive to be focussed on their needs and the development of the service by better understanding the women’s lived experience. Methods. To address this research problem a qualitative approach is used, and the study is based on phenomenological theory. Ethical approval was obtained. Non-probability, purposive sampling was employed to select the women to be interviewed. The transcribed interviews were analysed using the methods described by Burnard (1991). The categories are: treatment-related factors, psychological factors, pregnancy-related anxiety and suggested ways of improving care. Results. The women reported concerns about previous assisted conception treatments and shock, anxiety and stress following their miscarriage. They expressed high levels of stress and anxiety about starting treatment again because of the possibility of future loss and grief. Suggested developments in care included: improved patient information, better emotional support, incorporating a telephone help line, support group and counselling and the provision of miscarriage screening 2–3 weeks following their miscarriage. Conclusion. The data obtained during this project support the findings within the literature that both miscarriage and infertility treatments cause increased levels of stress and anxiety. It confirms previous findings that women experience high levels of stress, guilt, grief and fears about their future childbearing. The women were concerned about starting treatment again and needed support, reassurance and information about treatment and their risk of another miscarriage. They were extremely concerned about the possibility of miscarriage, even before their pregnancy test was positive.