Case reportA 37 year old woman presented in her fourth pregnancy eight weeks of gestation with recurrent episodes of vaginal bleeding for seven days. Her first delivery was by a lower segment transverse caesarean section at 33 weeks of gestation due to pre-eclampsia. Her second and third pregnancies ended by a normal vaginal delivery. On admission her pulse and blood pressure were normal. Pelvic examination revealed moderate bleeding from the cervical canal; the cervix was long and closed. The size of the uterus was consistent with her dates. Transvaginal ultrasound demonstrated a live fetus with a crown-rump length of 19 mm equivalent to her menstrual dates. The gestational sac was 25 mm diameter which was located in the anterior wall of the uterus, just above the internal 0s. Only 4 mm thickness separated the sac from the urinary bladder, and the sac was located between two normal segments of the anterior uterine wall (Fig. 1). Based upon the ultrasound findings, a diagnosis of pregnancy in a very thin uterine scar was made. Following discussion, it was decided to terminate her pregnancy with methotrexate.A single dose of 80 mg (50 mg/m2) intramuscular methotrexate was given. Daily ultrasonography revealed loss of fetal heart beats three days following the injection. No adverse side effects were observed. Three days after the injection, the plasma level of the p subunit of human chorionic gonadotropin (p hCG) was 12,100 mIU/mL; it decreased to 1270, 107 and 20 mIU/mL after two, four and eight weeks, respectively.Despite the declining values of plasma p hCG levels, the patient had prolonged mild vaginal bloody discharge. Ultrasonography showed the same gestational sac containing amorphous tissue debris. Nine weeks after the methotrexate injection 10 ml of straw-like fluid was aspirated from the gestational sac by a transvaginal ultrasound guided needle, without any complications. Three months later transvaginal ultrasound showed complete disappearance of the gestational sac and normal uterine anatomy. Eight months after the

The use of testicular spermatozoa for IVF/intracytoplasmic sperm injection (ICSI) is currently indicated exclusively for patients with azoospermia, since a favourable outcome is expected even when very few spermatozoa are present in the ejaculate. Here, a series of four couples with long-standing male factor infertility and multiple failed IVF/ICSI cycles are described. In all couples, the use of ejaculated spermatozoa for ICSI resulted in poor embryo quality and repeated implantation failure. Testicular sperm aspiration was performed in subsequent cycles, and testicular spermatozoa were used for ICSI. Embryo implantation and ongoing pregnancies/deliveries were achieved in all four couples. It is postulated that spermatozoa are subjected to post-testicular damage during sperm transport between the seminiferous tubules and epididymis, with the injection of damaged spermatozoa being the cause for repetitive IVF/ICSI failures. In selected patients, the use of testicular spermatozoa for IVF/ICSI should be considered, even when motile spermatozoa can be identified in the ejaculate.

Spontaneous ovulation during a natural menstrual cycle represents a simple and efficient method for synchronization between frozen embryos and the endometrium. The objective was to compare serial monitoring until documentation of ovulation, with human chorionic gonadotrophin (HCG) triggering, for timing frozen embryo transfer (FET) in natural cycles (NC). In a retrospective study, 112 women with regular menstrual cycles undergoing 132 NC-FET cycles were divided into two groups: group A (n = 61) patients had FET in an NC after ovulation triggering with HCG; group B (n = 71) patients had FET in an NC after spontaneous ovulation was detected. The main outcome measure was the number of monitoring visits at the clinic. Patients in both groups were similar in terms of demographic characteristics and reproductive history. Clinical and laboratory characteristics of fresh and frozen cycles were also found comparable for both groups, as were pregnancy and delivery rates. The number of monitoring visits in group A (3.46 +/- 1.8) was significantly lower than in group B (4.35 +/- 1.4) (P < 0.0001). In patients undergoing NC-FET, triggering ovulation by HCG can significantly reduce the number of visits necessary for cycle monitoring without an adverse effect on cycle outcome. Ovulation triggering can increase both patient convenience and cycle cost-effectiveness.

The study was designed to examine whether dynamic measurements of inhibin B and oestradiol following single administration of buserelin acetate were correlated with the ovarian response to stimulation in IVF. A total of 37 patients undergoing IVF treatment was studied when the long protocol was started in the early follicular phase. Blood samples were taken twice: on day 2 of the menstrual cycle, before the first s.c. administration of buserelin acetate 0.5 mg and on day 3, 24 h later. Inhibin B and oestradiol concentrations were compared with the ovarian response to stimulation. The ovarian response was defined in two ways: 'number of oocytes/total recombinant (r) follicle stimulating hormone (FSH) dose'; and 'square-root (number of follicles/total rFSH dose)'. The following measurements were highly correlated with the ovarian response to stimulation: increase in oestradiol (day 3-day 2 oestradiol concentration) [correlation coefficient (r) = 0.68, P: < 0.0001] and sum of inhibin B (day 2 + day 3 inhibin B concentrations) (r = 0.6, P: < 0.0001). Age and basal concentrations of FSH and inhibin B were inferior to the above measurements in terms of correlation with the ovarian response. In conclusion, dynamic measurements of inhibin B and oestradiol following single administration of buserelin acetate were highly correlated with the ovarian response to stimulation for IVF treatment.

In ovulatory patients, frozen-thawed embryo transfer (FET) is commonly performed during a natural cycle (NC). The objective was to compare serial monitoring until documentation of ovulation with human chorionic gonadotrophin (HCG) triggering, for timing NC-FET. Sixty women with regular menstrual cycles undergoing NC-FET were randomized into two groups: group A (n=30) had FET in a natural cycle after ovulation triggering with HCG; group B (n=30) had FET in a natural cycle after detection of spontaneous ovulation. The main outcome measure was the number of monitoring visits at the clinic per cycle. Secondary outcome measures included implantation rate, clinical pregnancy and live-birth rates. Both groups were similar in terms of demographic characteristics and reproductive history. Clinical and laboratory characteristics of fresh and frozen cycles and pregnancy and delivery rates were comparable for both groups. The number of monitoring visits in group A (3.2 ± 1.4) was significantly lower than in group B (4.7 ± 1.6) (P=0.002). In patients undergoing NC-FET, triggering ovulation by HCG can significantly reduce the number of visits necessary for cycle monitoring without an adverse effect on cycle outcome. Ovulation triggering can increase both patient convenience and cycle cost effectiveness.