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1.  Live Birth from Slow-Frozen Rabbit Oocytes after In Vivo Fertilisation 
PLoS ONE  2013;8(12):e83399.
In vivo fertilisation techniques such as intraoviductal oocyte transfer have been considered as alternatives to bypass the inadequacy of conventional in vitro fertilisation in rabbit. There is only one study in the literature, published in 1989, that reports live offspring from cryopreserved rabbit oocytes. The aim of the present study was to establish the in vivo fertilisation procedure to generate live offspring with frozen oocytes. First, the effect of two recipient models (i) ovariectomised or (ii) oviduct ligated immediately after transfer on the ability of fresh oocytes to fertilise were compared. Second, generation of live offspring from slow-frozen oocytes was carried out using the ligated oviduct recipient model. Throughout the experiment, recipients were artificially inseminated 9 hours prior to oocyte transfer. In the first experiment, two days after unilateral transfer of fresh oocytes, oviducts and uterine horns were flushed to assess embryo recovery rates. The embryo recovery rates were low compared to control in both ovariectomised and ligated oviduct groups. However, ligated oviduct recipient showed significantly (P<0.05) higher embryo recovery rates compared to ovariectomised and control-transferred. In the second experiment, using bilateral oviduct ligation model, all females that received slow-frozen oocytes became pregnant and delivered a total of 4 live young naturally. Thus, in vivo fertilisation is an effective technique to generate live offspring using slow-frozen oocytes in rabbits.
PMCID: PMC3866232  PMID: 24358281
2.  Ectopic Intrauterine Device in the Bladder of a Pregnant Woman 
Case Reports in Medicine  2010;2010:181032.
Background. Uterine perforation and transvesical migration of an intrauterine device are rare complications. Case. A 28-year-old woman who had an intrauterine device was admitted to our outpatient clinic with complaints of amenorrhea lasting 5 weeks and pelvic pain lasting a year. Transvaginal ultrasonography revealed embedding of the intrauterine device in the bladder. The misplaced device was removed by laparotomy. Conclusion. The followup of intrauterine device localization with transvaginal ultrasonography is essential for early detection of possible serious complications.
PMCID: PMC2929505  PMID: 20811600
3.  An oocyte score for use in assisted reproduction 
In this work, we describe a system for the morphological scoring of human oocytes prior to fertilisation and use this system to test whether oocyte morphology is an indicator of fertilisation, embryo development and implantation potential.
The study is a prospective trial of the use of oocyte morphological scores in 822 patients undergoing their first cycle of ICSI. Analyses of oocytes were performed prior to ICSI procedures and the scores compared with fertilisation rates, embryo quality and clinical results.
‘Top quality’ oocytes had a significantly higher level of fertilisation (96%) as compared to low scoring oocytes (25.6%). Where top quality oocytes formed top quality embryos, we noted a clinical success rate of 63.4%.
Clinical success rates were increased in cases where top quality oocytes formed top quality embryos after ICSI. The analysis of oocyte morphology may represent a positive selection feature during ICSI.
PMCID: PMC3454945  PMID: 17629723
Human oocyte; Morphological analysis; Intracytoplasmic sperm injection; Assisted reproduction; Pregnancy
4.  Predictive value of plasma human chorionic gonadotrophin beta subunit in diagnosing ectopic pregnancy after in vitro fertilisation and embryo transfer. 
A study was conducted aimed at establishing a range of plasma concentrations of the beta subunit of human chorionic gonadotrophin that might predict ectopic pregnancy after in vitro fertilisation and embryo transfer. From May 1984 to February 1986, 161 consecutive pregnancies at the Monash University in vitro fertilisation unit were analysed by determining plasma beta human chorionic gonadotrophin concentrations between two and 10 weeks after oocyte collection. Eighty eight ongoing singleton pregnancies, 25 multiple pregnancies, 27 first trimester spontaneous abortions, 12 anembryonic pregnancies, and nine ectopic pregnancies resulted from these conception cycles. When compared with values for ongoing singleton pregnancies two weeks after oocyte collection plasma beta human chorionic gonadotrophin concentrations in ectopic pregnancies were significantly lower (p less than 0.05; Wilcoxon rank sum test). Two weeks after oocyte collection all plasma beta human chorionic gonadotrophin concentrations in the set of ectopic pregnancies were below 30.6 IU/l, which corresponded to the lower quartile (25th percentile) of beta human chorionic gonadotrophin concentrations in ongoing singleton pregnancies. The beta human chorionic gonadotrophin concentration corresponding to the lower quartile of ongoing singleton pregnancies at each week of gestation was used to derive the predictive value of various statistics in detecting ectopic pregnancy in patients after in vitro fertilisation. The sensitivity, specificity, predictive value of a positive result, predictive value of a negative result, and efficiency of a single plasma beta human chorionic gonadotrophin concentration in predicting ectopic pregnancy were 100%, 68.1%, 16.7%, 100%, and 70%, respectively, two weeks after oocyte collection. These results suggest that a single determination of the plasma beta human chorionic gonadotrophin concentration beginning 14 days after oocyte collection is clinically useful in predicting the outcome of pregnancy achieved by in vitro fertilisation. Ectopic pregnancy after in vitro fertilisation is more likely when beta human chorionic gonadotrophin concentration is below the lower quartile of values in ongoing singleton pregnancies achieved by the technique.
PMCID: PMC1245730  PMID: 2436703
5.  Oocyte glutathione and fertilisation outcome of Macaca nemestrina and Macaca fascicularis in in vivo- and in vitro-matured oocytes 
Fertilisation and development of IVM non-human primate oocytes is limited compared with that of in vivo-matured (IVO) oocytes. The present study describes the IVM of macaque oocytes with reference to oocyte glutathione (GSH). Timing of maturation, comparison of IVM media and cysteamine (CYS) supplementation as a modulator of GSH were investigated. A significantly greater proportion of oocytes reached MII after 30 h compared with 24 h of IVM. Following insemination, IVM oocytes had a significantly lower incidence of normal fertilisation (i.e. 2PN = two pronuclei and at least one polar body) and a higher rate of abnormal fertilisation (1PN = one pronucleus and at least one polar body) compared with IVO oocytes. Immunofluorescence of 1PN zygotes identified incomplete sperm head decondensation and failure of male pronucleus formation as the principal cause of abnormal fertilisation in IVM oocytes. The IVO oocytes had significantly higher GSH content than IVM oocytes. Cumulus-denuded oocytes had significantly lower GSH following IVM compared with immature oocytes at collection. Cysteamine supplementation of the IVM medium significantly increased the GSH level of cumulus-intact oocytes and reduced the incidence of 1PN formation, but did not improve GSH levels of the denuded oocyte. Suboptimal GSH levels in macaque IVM oocytes may be related to reduced fertilisation outcomes.
PMCID: PMC2969167  PMID: 20591337
cumulus-denuded oocyte; cysteamine; male pronucleus formation
6.  Obstetric outcome in donor oocyte pregnancies: a matched-pair analysis 
To investigate the obstetrical and perinatal impact of oocyte donation, a cohort of women who conceived after OD was compared with a matched control group of women who became pregnant through in vitro fertilisation with autologous oocytes (AO).
A matched-pair analysis has been performed at the Centre for Reproductive Medicine of the UZ Brussel, Dutch speaking Free University of Brussel. A total of 410 pregnancies resulted in birth beyond 20 weeks of gestation occurring over a period of 10 years, including 205 oocyte donation pregnancies and 205 ICSI pregnancies with autologous oocytes (AO). Patients in the OD group were matched on a one-to-one basis with the AO group in terms of age, ethnicity, parity and plurality. Matched groups were compared using paired t-tests for continuous variables and McNemar test for categorical variables. A conditional logistic regression analyses was performed adjusting for paternal age, age of the oocyte donor, number of embryos transferred, and singleton/twin pregnancy.
Oocyte donation was associated with an increased risk of pregnancy induced hypertension (PIH) (matched OR: 1.502 CI: 1.024-2.204), and first trimester bleeding (matched OR: 1.493 CI: 1.036-2.15). No differences were observed between the two matched groups with regard to gestational age, mean birth weight and length, head circumference and Apgar scores.
Oocyte donation is associated with an increased risk for PIH and first trimester bleeding independent of the recipients’ age, parity and plurality, and independent of the age of the donor or the partner. However, oocyte donation has no impact on the overall perinatal outcome.
PMCID: PMC3488499  PMID: 22672289
Oocyte donation; Pregnancy outcome; Pregnancy-induced hypertension; First trimester bleeding
7.  Mouse oocytes fertilised by ICSI during in vitro maturation retain the ability to be activated after refertilisation in metaphase II and can generate Ca2+ oscillations 
At fertilisation, mammalian oocytes are activated by oscillations of intracellular Ca2+ ([Ca2+]i). Phospholipase Cζ, which is introduced by fertilising spermatozoon, triggers [Ca2+]i oscillations through the generation of inositol 1,4,5-triphosphate (IP3), which causes Ca2+ release by binding to IP3 receptors located on the endoplasmic reticulum (ER) of the oocyte. Ability to respond to this activating stimulus develops during meiotic maturation of the oocyte. Here we examine how the development of this ability is perturbed when a single spermatozoon is introduced into the oocyte prematurely, i.e. during oocyte maturation.
Mouse oocytes during maturation in vitro were fertilised by ICSI (intracytoplasmic sperm injection) 1 – 4 h after germinal vesicle break-down (GVBD) and were subsequently cultured until they reached metaphase II (MII) stage. At MII stage they were fertilised in vitro for the second time (refertilisation). We observed that refertilised oocytes underwent activation with similar frequency as control oocytes, which also went through maturation in vitro, but were fertilised only once at MII stage (87% and 93%, respectively). Refertilised MII oocytes were able to develop [Ca2+]i oscillations in response to penetration by spermatozoa. We found however, that they generated a lower number of transients than control oocytes. We also showed that the oocytes, which were fertilised during maturation had a similar level of MPF activity as control oocytes, which were not subjected to ICSI during maturation, but had reduced level of IP3 receptors.
Mouse oocytes, which were experimentally fertilised during maturation retain the ability to generate repetitive [Ca2+]i transients, and to be activated after completion of maturation.
PMCID: PMC1913504  PMID: 17584490
8.  Recent advances in oocyte and ovarian tissue cryopreservation and transplantation 
Options for preserving fertility in women include well-established methods such as fertility-sparing surgery, shielding to reduce radiation damage to reproductive organs, and emergency in-vitro fertilisation after controlled ovarian stimulation, with the aim of freezing embryos. The practice of transfering frozen or thawed embryos has been in place for over 25 years, and today is a routine clinical treatment in fertility clinics. Oocytes may also be frozen unfertilised for later thawing and fertilisation by intracytoplasmic sperm injection in vitro. In recent years, oocyte cryopreservation methods have further developed, reaching promising standards. More than 1000 children are born worldwide after fertilisation of frozen and thawed oocytes. Nevertheless, this technique is still considered experimental. In this chapter, we focus on options for fertility preservation still in development that can be offered to women. These include freezing of oocytes and ovarian cortex and the transplantation of ovarian tissue.
PMCID: PMC3554233  PMID: 22301053
fertility preservation; female; children; oocyte cryopreservation; egg freezing; ovarian tissue cryopreservation; ovarian tissue transplantation; reproductive health; cancer treatment; laparoscopy; gonadotoxicity; radiotherapy; chemotherapy; adolescents; prepubertal girls
9.  Experience of our surgery in iatrogenic vesicovaginal fistulas 
In this study, transvesical and transvaginal approaches used in our clinic for the treatment of gynecologic iatrogenic vesicovaginal fistulas are discussed.
Material and Methods
11 patients with vesicovaginal fistula admitted to the Department of Urogynecology, Zeynep Kamil Teaching- Research Hospital between 2005–2009 were enrolled in our study. Transvesical and transvaginal fistula repair were performed on all patients. All patients were treated by surgical repair, 4 cases by a classic transabdominal approach, 5 cases by an omental flap interposition and 2 cases by a martius flap interposition.
The most common cause of iatrogenic vesicovaginal fistula in our patients was total abdominal hysterectomy for benign conditions (n=10/11). The mean patient age was 43 years (34–53) and the mean time from the causative surgery to the operation was 7.5 months (3–12). The surgical techniques were successful in all patients. There were no intraoperative complications and no postoperative recurrences.
The mouth of the fistula should be determined clearly on preoperative evaluation and surgery procedure should be planned according to the fistula aperture. The point to be careful of is excision of all diseased tissue in the bladder and vagina, complete separation of the bladder from the vagina with a margin of healthy tissue, and watertight closure of both bladder and vagina without tension. The aim of the vascularized tissue interposition between the closed bladder and the vagina is to provide the improvement of vascularity. We believe that in the treatment of supratrigonal and large fistulas, the transvesical approach with use of omental flap interposition is more effective, while, in the treatment of small and trigonal fistula, the transvaginal approach with use of martius flap interposition is an effective tecnique.
PMCID: PMC3939220  PMID: 24591919
Iatrogenic vesicovaginal fistula; martius flap; omental flap
10.  Pregnancy established in an infertile patient after transfer of a donated embryo fertilised in vitro. 
In vitro fertilisation after stimulation of the ovulatory cycle has led to successful pregnancy. If more oocytes are recovered than are needed they may be left unfertilised, preserved, or donated to a recipient couple from whom oocytes cannot be obtained. A case of human pregnancy initiated by transfer of a donated embryo fertilised in vitro is reported. The donor was a 42 year old woman with primary infertility from whom six follicles were aspirated after stimulation of the ovulatory cycle. The recipient was a 38 year old infertile woman who had undergone several unsuccessful attempts for artificial insemination from a donor. Five oocytes were recovered from the donor's six follicles, four of which were inseminated with spermatozoa of the donor's husband and the fifth with a frozen sample of semen. Three of the four embryos fertilised by her husband were returned to the donor and the fifth was transferred to the recipient. No pregnancy was recorded in the donor, but pregnancy was confirmed in the recipient, though spontaneous abortion occurred after 10 weeks. This case will give useful information for further study of in vitro fertilisation, but also raises many ethical issues.
PMCID: PMC1547212  PMID: 6403104
11.  CLINICAL ASSISTED REPRODUCTION: Determination of the Efficiency of Controlled Ovarian Hyperstimulation in the Gonadotropin-Releasing Hormone Agonist-Suppression Cycle Using the Initial Follicle Count During Gonadotropin Stimulation 
Purpose: Our purpose was to evaluate the relationship between the initial follicle count during gonadotropin stimulation after gonadotropin-releasing hormone (GnRH) agonist suppression and the efficiency of controlled ovarian hyperstimulation (COH) in patients receiving treatment with assisted reproductive technologies (ARTs).
Methods: A total of 338 COH procedures in 291 couples was performed with cycles that reached the stage of oocyte retrieval. The ovarian antral follicle number was measured using transvaginal ultrasonography at the folliculometry during gonadotropin stimulation by GnRH agonist suppression in patients undergoing ARTs. Controlled ovarian hyperstimulation was accomplished using GnRH agonist down-regulation combined with FSH and menotropin stimulation. The characteristics of oocytes after retrieval and embryos after in vitro culture and the pregnancy rates were assessed.
Results: The procedures performed included 195 ET cycles, 129 TET cycles, and 14 incomplete cycles. The treatment cycles were divided into four categories according to the antral follicle number (i.e., ≤5, 6–10, 11–15, and ≥16) at the first folliculometry to evaluate the influence of various factors. The antral follicle count correlated significantly with the patient age, dosage of gonadotropins, serum estradiol concentration, number of antral follicles (≥13 mm) while receiving hCG injections, number of oocytes retrieved, and, later, number of embryos transferred. There was a trend toward an increasing number of pregnancies per cycle as the number of antral follicles increased (14.7, 26.5, 44, and 45%, respectively).
Conclusions: We were able to predict the efficiency of COH and outcome of ARTs based on the follicle count during the first folliculometry during gonadotropin stimulation after GnRH agonist suppression. The results of the folliculometry significantly predicted the ovarian response to COH and the outcome of ARTs in the current treatment cycle.
PMCID: PMC3455557  PMID: 11285987
Controlled ovarian hyperstimulation; gonadotropin-releasing hormone agonist suppression; initial follicle count; gonadotropin stimulation; folliculometry
12.  Oocyte activation and phospholipase C zeta (PLCζ): diagnostic and therapeutic implications for assisted reproductive technology 
Infertility affects one in seven couples globally and has recently been classified as a disease by the World Health Organisation (WHO). While in-vitro fertilisation (IVF) offers effective treatment for many infertile couples, cases exhibiting severe male infertility (19–57%) often remain difficult, if not impossible to treat. In such cases, intracytoplasmic sperm injection (ICSI), a technique in which a single sperm is microinjected into the oocyte, is implemented. However, 1–5% of ICSI cycles still fail to fertilise, affecting over 1000 couples per year in the UK alone. Pregnancy and delivery rates for IVF and ICSI rarely exceed 30% and 23% respectively. It is therefore imperative that Assisted Reproductive Technology (ART) protocols are constantly modified by associated research programmes, in order to provide patients with the best chances of conception. Prior to fertilisation, mature oocytes are arrested in the metaphase stage of the second meiotic division (MII), which must be alleviated to allow the cell cycle, and subsequent embryogenesis, to proceed. Alleviation occurs through a series of concurrent events, collectively termed ‘oocyte activation’. In mammals, oocytes are activated by a series of intracellular calcium (Ca2+) oscillations following gamete fusion. Recent evidence implicates a sperm-specific phospholipase C, PLCzeta (PLCζ), introduced into the oocyte following membrane fusion as the factor responsible. This review summarises our current understanding of oocyte activation failure in human males, and describes recent advances in our knowledge linking certain cases of male infertility with defects in PLCζ expression and activity. Systematic literature searches were performed using PubMed and the ISI-Web of Knowledge. Databases compiled by the United Nations and World Health Organisation databases (UNWHO), and the Human Fertilization and Embryology Authority (HFEA) were also scrutinised. It is clear that PLCζ plays a fundamental role in the activation of mammalian oocytes, and that genetic, molecular, or biochemical perturbation of this key enzyme is strongly linked to human infertility where oocyte activation is deficient. Consequently, there is significant scope for our understanding of PLCζ to be translated to the ART clinic, both as a novel therapeutic agent with which to rescue oocyte activation deficiency (OAD), or as a prognostic/diagnostic biomarker of oocyte activation ability in target sperm samples.
PMCID: PMC3393615  PMID: 22591604
Oocyte activation; Phospholipase c zeta (PLCzeta); Sperm; Male infertility; Assisted reproductive technology (ART); Therapeutic; Diagnostic; Biomarker
13.  Clinical Significance of Transvaginal Color Doppler Ultrasonography of the Ovarian Artery as a Predictor of Ovarian Response in Controlled Ovarian Hyperstimulation for In Vitro Fertilization and Embryo Transfer 
Purpose: Our purpose was to verify whether the blood flow impedance of the ovarian stromal artery in transvaginal color Doppler ultrasonography can predict the in vitro fertilization and embryo transfer (IVF–ET) outcomes.
Methods: Transvaginal color Doppler ultrasonographic examinations were performed in 99 patients undergoing controlled ovarian hyperstimulation (COH) for IVF–ET. The pulsatility index (PI) was evaluated in the bilateral ovarian stromal arteries on the starting day of COH (PI1) and the day of hCG administration (PI2). The patients were classified into three groups by the mean PI1, PI2, and ΔPI (PI1 − PI2), respectively, and the IVF–ET outcomes were analyzed and compared.
Results: There were no significant differences in the duration of COH, the total dosage of gonadotropins used for COH, the serum E2 concentration on day of hCG administration, the number of follicles on the day of hCG administration, the number of oocytes retrieved or fertilized in vitro, and the number of embryos transferred between their respective PI1, PI2, and ΔPI values. However, the pregnancy rate was significantly lower in the higher PI1 and PI2 groups than in the lower groups (p < 0.05, p < 0.05). Significant positive correlations were also found between PI1 and PI2 and the total dosage of gonadotropins for COH (Y = 0.483 X + 27.1, r = 0.052, p < 0.05; Y = 0.877 X + 26.6, r = 0.075, p < 0.05).
Conclusions: Our results showed that the lower PI in the ovarian stromal artery during COH is associated with the higher the pregnancy rate and the smaller amount of gonadotropins used for effective COH. This study suggests that the color Doppler ultrasonographic index (PI) of the ovarian stromal artery during COH may be useful for predicting the success of IVF–ET in infertile patients.
PMCID: PMC3468259  PMID: 12005303
Color Doppler ultrasonography; COH; IVF–ET; ovary; stromal artery
14.  The Utility of Serum Progesterone and Inhibin A for Monitoring Natural-Cycle IVF-ET 
Purpose:Our purpose was to assess the value of monitoring serum P and inhibin A to determine how values might improve the clinical monitoring of natural cycle in vitro fertilization (IVF)-embryo transfer (ET) patients.
Methods:All patients (n = 26) who underwent natural-cycle IVF-ET (n = 35) were analyzed. Groups were evaluated according to patients who had a spontaneous luteinizing hormone (LH) surge (group I) and women receiving human chorionic gonadotropin (hCG) who underwent subsequent oocyte aspiration (group II). Group II was further evaluated according to women who did (n = 10) and did not (n = 7) have an ET. All cycles were evaluated with serial transvaginal ultrasonography and serum estradiol, progesterone, and inhibin A. When follicle maturity was achieved, hCG, 10,000 IU, was administered intramuscularly if a LH surge was not detected. Transvaginal ultrasound-guided aspiration was performed 34–36 hr after hCG administration followed by a 48-hr transcervical ET.
Results:No differences were seen in cycles the day prior to (d-1) and the day of a spontaneous LH surge, (n = 18) or hCG (d-0)(n = 17) in group I or group II with respect to lead follicular diameter (d-1,15.3 ± 0.6 vs. 14.2 ± 0.9 mm; d-0, 17.4 ± 0.8 vs. 17.8 ± 0.6 mm) and serum estradiol (d-l, 148 ± 15 vs. 150 ± 15 pg/ml; d-0, 218 ± 15 vs. 199 ± 16 pg/ml), respectively. However, serum progesterone was significantly elevated in group I compared with group II on d-l (0.82 ± 0.6 vs. 0.48 ± 0.04 ng/ml; P < 0.05) and d-0 (1.1 ± 0.12 vs. 0.63 ± 0.08 ng/ml; P < 0.05). Inhibin A was significantly greater on d-l in group I (24 ± 2.5 vs. 15 ± 2.2 pg/ml; P < 0.05). In group II, cycles that resulted in an ET (n = 10) compared with group II cycles that did not (n = 7) revealed a significant difference in serum progesterone (0.51 ± 0.05 vs. 0.7 ± 0.07 ng/ml; P < 0.05) and inhibin A (15 ± 2.5 vs. 37.3±5 pg/ml; P < 0.05) the day of hCG.
Conclusions:The possible application of serum progesterone and inhibin A in managing natural-cycle IVF-ET is suggested. These assays may predict women who should be set up for egg retrieval, while canceling others in spite of the absence of an LH surge.
PMCID: PMC3454917  PMID: 9822981
progesterone; inhibin A; IVF-ET; predictive value
15.  Transvaginal Endoscopic Appendectomy 
Since Kalloo and colleagues first reported the feasibility and safety of a peroral transgastric approach in the porcine model in 2004, various groups have reported more complex natural orifice transluminal endoscopic surgery (NOTES) procedures, such as the cholecystectomy, splenectomy and liver biopsy, in the porcine model. Natural orifice access to the abdominal cavity, such as transgastric, transvesical, transcolonic, and transvaginal, has been described. Although a novel, minimally invasive approach to the abdominal cavity is a peroral endoscopic transgastric approach, there are still some challenging issues, such as the risk of infection and leakage, and the method of gastric closure. Hybrid-NOTES is an ideal first step in humans. Human hybrid transvaginal access has been used for years by many surgeons for diagnostic and therapeutic purposes. Here, we report a transvaginal flexible endoscopic appendectomy, with a 5-mm umbilical port using ultrasonic scissors in a 74-year-old woman with acute appendicitis.
PMCID: PMC3017980  PMID: 21221245
Endoscopy; Appendectomy; Hybrid NOTES
16.  The Effect of Endometrial Polyps on Outcomes of In Vitro Fertilization (IVF) Cycles 
Purpose:Our purpose was to investigate the effect of endometrial polyps on pregnancy outcome in an in vitro fertilization (IVF) program.
Methods:Endometrial polyps less than 2 cm in diameter were suspected by transvaginal ultrasound before oocyte recovery in 83 patients. Forty-nine women (Group I) had standard IVF–embryo transfer, while in 34 women (Group II) hysteroscopy and polypectomy were performed immediately following oocyte retrieval, the suitable embryos were all frozen, and the replacement cycle took place a few months later.
Results:Of the 32 hysteroscopies, a polyp was diagnosed in 24 cases (75%) and polypoid endometrium in another 5 patients (15.6%). An endometrial polyp was confirmed by histopathological examination in 14 women (58.3%). The pregnancy rate in group I was similar to the general pregnancy rate of our unit over the same period (22.4 vs 23.4%) but the miscarriage rate was higher (27.3 vs 10.7%, P = 0.08). In Group II, the pregnancy and miscarriage rates were similar to those of the frozen embryo cycles at Bourn Hall (30.4 and 14.3 vs 22.3 and 12.1%, respectively).
Conclusions:Small endometrial polyps, less than 2 cm, do not decrease the pregnancy rate, but there is a trend toward increased pregnancy loss. A policy of oocyte retrieval, polypectomy, freezing the embryos, and replacing them in the future might increase the “take-home baby” rate.
PMCID: PMC3455496  PMID: 10478319
endometrial polyp; frozen embryos; hysteroscopy; in vitro fertilization; vaginal ultrasound
17.  Detection of Soluble ST2 in Human Follicular Fluid and Luteinized Granulosa Cells 
PLoS ONE  2013;8(9):e74385.
Follicular fluid (FF) contains various cytokines that are involved with folliculogenesis, some of which have been shown to be associated with oocyte quality and the implantation potential of a resulting embryo. Several IL-1 family members have previously been identified in FF. This study investigates a newly identified member of the family, IL-33, and its receptor ST2, comparing values to those of FF Granulocyte-Colony Stimulating Factor (G-CSF) – a known predictor of Assisted Reproductive Technology (ART) success. FF was collected from patients undergoing in vitro fertilisation/intra-cytoplasmic sperm injection (IVF/ICSI) at oocyte retrieval to analyse IL-33 and sST2 expression in human follicles. sST2, but not IL-33, is highly increased in the FF compared to plasma levels (up to 7.9-fold), with higher levels in larger follicles (p<0.05). Furthermore, we identify that human luteinised granulosa cells are one possible source of the FF sST2, as these cells express and secrete sST2 when cultured ex vivo. FF associated with oocytes which when fertilised develop into good quality embryos have higher sST2 levels than those which are graded average (p<0.01). These embryos were transferred to the patient and levels of FF sST2 compared between successful and unsuccessful ICSI cycles. However unlike G-CSF, sST2 levels cannot be used to predict cycle outcome.
PMCID: PMC3769262  PMID: 24040238
18.  Transvaginal ultrasonography in first trimester of pregnancy and its comparison with transabdominal ultrasonography 
Examination of pregnant women in the first trimester with transvaginal ultrasonography with the aim to study various fetal development markers, e.g., gestation sac, yolk sac, fetal heart motion, CRL length, and fetal anatomy in both normal and abnormal pregnancies. Comparative evaluation of transvaginal ultrasonography vis-à-vis transabdominal scanning in the study of first trimester of pregnancy and its complications. To assess the relative merits and demerits of transvaginal ultrasonography in comparison with the transabdominal technique.
Materials and Methods:
The study will be conducted on 50 females patients during the first trimester of pregnancy. The study population will consist of both normal and abnormal pregnancies. These patients will be included on the basis of suspicion of or proven pregnancy of duration up to 12 weeks from LMP. The evaluation of the patients will include the following: Record of patients obstetrical history and clinical examination, record of pregnancy test and relevant investigations, ultrasonic examination of pregnancy. (a) Transabdominal ultrasound scanning will be done with moderately distended bladder by using real time scanners with low frequency probe (3/3.5 MHz); (b) transvaginal sonography will be done with the real-time sector scanner using high-frequency endovaginal probe (5/7.5 MHz), after the patient voids urine. Relevant images will be taken by using the multiformat automatic camera.
Results and Conclusions:
In the study of 46 normal intrauterine pregnancies, TVS showed additional information in 36 patients (78.3%) as compared to TAS, in detection of gestation sac, yolk sac, double bleb sign, or better visualization of embryonic anatomy. In the abnormal pregnancy (n=17), TVS provided more information in 11 cases (64.9%), which included detection of embryonic demise, yolk sac, double bleb sign, or subchorionic hemorrhage. Regarding ectopic gestations (n=7), TVS gave additional information in 5 cases (71.4%) which included detection of ectopic fetal pole, yolk sac, decidual cast, adnexal mass, and fluid in cul de sac. In two cases, both TAS and TVS gave equal information. However, in 2 cases TAS demonstrated the extent of intraabdominal fluid better than TVS. The other advantages of TVS over TAS are that there is no need for the patient to have uncomfortably full bladder and time is saved from having to wait for bladder to fill. Thus, the potential preoperative patient can be kept fasting. TVS is also superior in obese patients, in patients with retroverted uterus and it also bypasses obstacles such as bone, gas filled bowel, and extensive pelvic adhesions. The limitations encountered with TVS were limited manoveuribility of probe and because of the unorthodox position and angle of the transducer, correct orientation was difficult initially.
PMCID: PMC3178938  PMID: 21966152
Comparison; first trimester of pregnancy; transvaginal ultrasonography; various fetal development markers
19.  In vitro fertilisation in a small unit in the NHS 
In vitro fertilisation is one of the most effective new treatments for infertility, but financial restrictions have made it impossible for it to be widely carried out in the National Health Service. We report on the establishment of a small, largely self funded, unit that was set up with the help of the local health service management. All cycles are programmed so that most work is carried out during the working week; oocyte recoveries are performed as outpatient procedures without general anaesthesia and guided by ultrasound. Roughly a tenth of treatment cycles and roughly a fifth of embryo transfers resulted in a clinical pregnancy.
PMCID: PMC2545374  PMID: 3126964
20.  IVF for premature ovarian failure: first reported births using oocytes donated from a twin sister 
Premature ovarian failure (POF) remains a clinically challenging entity because in vitro fertilisation (IVF) with donor oocytes is currently the only treatment known to be effective.
A 33 year-old nulligravid patient with a normal karyotype was diagnosed with POF; she had a history of failed fertility treatments and had an elevated serum FSH (42 mIU/ml). Oocytes donated by her dizygotic twin sister were used for IVF. The donor had already completed a successful pregnancy herself and subsequently produced a total of 10 oocytes after a combined FSH/LH superovulation regime. These eggs were fertilised with sperm from the recipient's husband via intracytoplasmic injection and two fresh embryos were transferred to the recipient on day three.
A healthy twin pregnancy resulted from IVF; two boys were delivered by caesarean section at 39 weeks' gestation. Additionally, four embryos were cryopreserved for the recipient's future use. The sister-donor achieved another natural pregnancy six months after oocyte retrieval, resulting in a healthy singleton delivery.
POF is believed to affect approximately 1% of reproductive age females, and POF patients with a sister who can be an oocyte donor for IVF are rare. Most such IVF patients will conceive from treatment using oocytes from an anonymous oocyte donor. This is the first report of births following sister-donor oocyte IVF in Ireland. Indeed, while sister-donor IVF has been successfully undertaken by IVF units elsewhere, this is the only known case where oocyte donation involved twin sisters. As with all types of donor gamete therapy, pre-treatment counselling is important in the circumstance of sister oocyte donation.
PMCID: PMC2861671  PMID: 20334702
21.  Can dissenting findings regarding the comparative effectiveness of ICSI and IVF be explained by a learning curve? 
Purpose: To determine whether between-trial heterogeneity in relative risk of fertilisation for intracytoplasmic sperm injection (ICSI) compared to in vitro fertilisation (IVF) can be explained by learning or by between-trial variation in patient characteristics.
Methods: Systematic review and meta-analysis of trials comparing fertilisation outcomes for ICSI and IVF (without surgical sperm retrieval). Meta-regressions to identify associations between treatment effect and trial characteristics.
Results: Coefficients on individually significant covariates from the meta-regressions confirm that the ICSI versus IVF treatment effect is increased when patients are “unsuited for IVF” but reduced as semen quality improves and when IVF insemination concentrations are increased. However, the relative risk of fertilisation varies inversely with publication date; contrary to the hypothesised learning effect.
Conclusion: While it is recognised that publication date might proxy for unobserved covariates, the possibility of a learning effect in favour of ICSI is not supported by the meta-regression.
PMCID: PMC3455433  PMID: 16429320
Health technology assessment; ICSI; IVF; meta-regression.
22.  Correlation Between Human Follicular Diameter and Oocyte Outcomes in an ICSI Program 
Purpose: To determine the correlation between the follicular sizes and oocyte recovery, metaphase II oocyte recovery, fertilization rate and good embryo quality from mature and immature oocytes in an intracytoplasmic sperm injection (ICSI) program.
Methods: 991 follicles obtained from 72 ICSI cycles were classified into three groups according to their diameters as measured by transvaginal ultrasound including group A (<10 mm), group B (10–14 mm), and group C (>14 mm). All obtained oocytes were classified according to their nuclear maturation: germinal vesicle (GV), metaphase I (MI) and metaphase II (MII). Mature oocytes underwent ICSI while immature oocytes were further cultured until maturity before ICSI was performed. The rates of fertilization and good quality embryos at day 3 were evaluated.
Results: A progressive and significant increase in the rates of oocyte recovery and MII oocyte recovery were observed from group A follicles compared to the other groups (p < 0.001). The fertilization rate of mature and in vitro matured oocytes, as well as the rate of good quality embryos showed a tendency to increase from group A to group C follicles, but not significantly. The corresponding fertilization rates were 78 and 55.3% (p < 0.001) for mature and in vitro matured oocytes, respectively.
Conclusion: Collection of oocytes from small follicles, especially with a mean diameter less than 10 mm, and in vitro maturation of immature oocytes before fertilization may allow the total number of good quality and transferable embryos to be increased.
PMCID: PMC3455636  PMID: 12762412
Follicular sizes; in vitro maturation; metaphase II oocyte; oocyte recovery
23.  Disinfection of the Access Orifice in NOTES: Evaluation of the Evidence Base 
Introduction. Appropriate prevention of infection is a key area of research in natural orifice translumenal endoscopic surgery (NOTES), as identified by the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). Methods. A review of the literature was conducted evaluating the evidence base for access orifice preparation/treatment in NOTES procedures in the context of infectious complications. Recommendations based on the Oxford Centre for Evidence-Based Medicine guidelines were made. Results. The most robust evidence includes several experimental randomised controlled trials assessing infectious complications in the transgastric approach to NOTES. Transvaginal procedures are long established for accessing the peritoneal cavity following disinfection with antiseptic. Only experimental case series for transcolonic and transvesical approaches are described. Conclusion. Grade C recommendation requiring no preoperative preparation can be made for the transgastric approach. Antiseptic irrigation is recommended for transvaginal (grade C) NOTES access, as is current practice. Further human trials need to be conducted to corroborate the current evidence base for transgastric closure. It is important that future trials are conducted in a methodologically robust fashion, with emphasis on clinical outcomes and standardisation of enterotomy closure and postoperative therapy.
PMCID: PMC3138109  PMID: 21785559
24.  Natural orifice transluminal endoscopic surgery: New minimally invasive surgery come of age 
Although in the past two decades, laparoscopic surgery, considered as a great revolution in the minimally invasive surgery field, has undergone major development worldwide, another dramatic surgical revolution has quietly appeared in recent years. Ever since Kalloo’s first report on transgastric peritoneoscopy in a porcine model in 2004, interest in a new surgical procedure named natural orifice transluminal endoscopic surgery (NOTES) has blossomed worldwide. Considering that a NOTES procedure could theoretically avoid any abdominal incision, operation-related pain and scarring, many surgeons and endoscopists have been enthusiastic in their study of this new technique. In recent years, several NOTES studies have been carried out on porcine models and even on humans, including transvaginal cholecystectomy, transgastric appendectomy, transvaginal appendectomy, and transvesical peritoneoscopy. So what is the current situation of NOTES and how many challenges do we still face? This review discusses the current research progress in NOTES.
PMCID: PMC3218151  PMID: 22110263
Laparoscopic surgery; Natural orifice transluminal endoscopic surgery; Endoscopy
25.  Bilateral ovarian abscesses following transvaginal oocyte retrieval for IVF: a case report and review of literature 
Ultrasound-guided transvaginal oocyte retrieval (TVOR) is a relatively simple and atraumatic method with rare complications as well as the possibility of doing it under sedation. It has become the method of choice in most IVF centres, because it results in excellent oocyte yields, with increased speed and excellent follicle and major pelvic vessel visualization, thereby decreasing the probability of vessel puncture [1]. However, the technique is not without risk such as pelvic infection, bleeding secondary a blood vessel puncture or pelvic visceral trauma. Consumption coagulopathy is a serious complication of pelvic infection and sepsis which can be life threatening if not diagnosed and corrected early, especially if surgical intervention is required. We present a case of bilateral ovarian abscesses following transvaginal oocyte retrieval showing early signs of consumption coagulopathy.
PMCID: PMC3455067  PMID: 17450435
Infertility; IVF; Assisted reproduction; Oocyte retrieval; Ovarian abscess

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