To evaluate the role of endometrial thickness and pattern in in-vitro fertilization (IVF), these parameters were prospectively measured in 516 cycles of IVF with embryo transfer at our clinic. Pregnancy and embryo implantation rates were assessed for each mm of endometrial thickness and for each of three endometrial patterns. Embryo implantation, clinical and ongoing pregnancy rates were significantly higher in the patients with an endometrial thickness > 9 mm (24.4, 48.6 and 42.2% respectively) compared with those of < 9 mm (14.3, 16.0 and 11.7% respectively; P < 0.005). Endometrial thickness was negatively influenced by age and positively influenced by oestradiol concentration. The majority of patients (69.8%) exhibited a 'ring' endometrial pattern. Embryo implantation and clinical pregnancy (statistically significant), as well as ongoing pregnancy rates (not statistically significant), were lower in patients exhibiting the 'solid' pattern. Endometrial thickness is independent of pattern in its effect on pregnancy outcome. In conclusion, endometrial thickness > 9 mm as well as ring and intermediate endometrial patterns denoted a more favourable prognosis for pregnancy in IVF but thinner endometrium and those exhibiting a solid configuration had an acceptable pregnancy outcome.
Certain patients have a tendency for high response to gonadotrophin therapy which is often not ameliorated with prior gonadotrophin-releasing hormone agonist (GnRHa) suppression. As a result, these patients are frequently cancelled and often experience ovarian hyperstimulation syndrome (OHSS) episodes during in-vitro fertilization (IVF)-embryo transfer cycles. Patients with polycystic ovarian syndrome (PCOS) have been noted to be particularly sensitive to exogenous gonadotrophin therapy. We have developed a protocol which is effective in improving IVF outcome in high responder patients, including those with PCOS. Oral contraceptive pills (OCP) are taken for 25 days followed by s.c. leuprolide acetate, 1 mg/day, which is overlapped with the final 5 days of oral contraceptive administration. Low-dose gonadotrophin stimulation is then initiated on the third day of withdrawal bleeding in the form of either human menopausal gonadotrophins or purified urinary follicle-stimulating hormone at a dosage of 150 IU/day. Over a 5 year period, we reviewed our experience utilizing this dual method of suppression in 99 cycles obtained in 73 high responder patients. There were only 13 cancellations prior to embryo transfer (13.1%). The clinical and ongoing pregnancy rates per initiated cycle were 46.5 and 40.4% respectively. Only eight patients experienced mild-moderate OHSS following treatment. For those patients who had undergone previous IVF-embryo transfer cycles at our centre, significant improvements were noted in oocyte fertilization rates, embryo implantation rates and clinical/ongoing pregnancy rates with this protocol. Hormonal analyses revealed that the chief mechanism may be through an improved luteinizing hormone/follicle-stimulating hormone ratio following dual suppression. An additional feature of this dual method of suppression is significantly lower serum androgen concentrations, particularly dehydroepiandrosterone sulphate.
The improved outcome associated with GM-CSF values greater than 130 pg/ml may reflect: 1) a direct positive effect of GM-CSF; 2) an embryotrophic factor upregulated by GM-CSF; or, 3) that GM-CSF functions as a marker for the importance of the glandular component in endometrial co-culture systems.
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