Timing intra-Fallopian transfer procedures

RBMOnline - Vol 15 No 4. 2007 445-450 Reproductive BioMedicine Online; www.rbmonline.com/Article/2955 on web 3 August 2007

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!BSTRACT With the gradual decline in the use of zygote intra-Fallopian transfer (ZIFT), current practice is to offer ZIFT almost exclusively to patients with repeated implantation failure (RIF). For practical reasons, the procedure is sometimes deferred by 1 day and embryo intra-Fallopian transfer (EIFT) is performed. The aim of the present study was to compare the reproductive outcome of ZIFT versus EIFT. In a retrospective analysis, 176 patients who failed in 7.65 ± 3.7 previous IVF cycles underwent 200 ZIFT and 73 EIFT procedures. Implantation and live birth rates were compared for both groups. Patients in both groups were found comparable for demographic and clinical parameters. Similar numbers of oocytes were retrieved and fertilized in both groups, and 5.2 ± 1.2 zygotes/embryos were transferred. Implantation and live birth rates (10.5 and 26.5% versus 10.9 and 24.7% for ZIFT and EIFT respectively) were comparable. It is concluded that tubal transfer of zygotes and day-2 cleavage stage embryos are equally effective. Keywords: EIFT, IVF, repeated implantation failure, ZIFT

)NTRODUCTION The ability of tubal transfer of embryos to produce pregnancy and live birth was first demonstrated in a non-human primate model by Balmaceda et al. (1984). Soon thereafter, Devroey et al. described the first successful zygote intra-Fallopian transfer (ZIFT) in humans (Devroey et al., 1986). Early reports on ZIFT were encouraging, showing superior results over uterine embryo transfer (UET), mainly for the treatment of male factor and unexplained infertility. The hypothesis leading to the introduction of ZIFT was based on both theoretical and practical grounds. From the scientific point of view, it is well known that fertilization and the first days of embryonic life take place in the Fallopian tube. Gamete intra-Fallopian transfer (GIFT) and ZIFT were therefore aimed at imitating the most ‘natural’ environment for early embryonic development. From the practical point of view, suboptimal laboratory conditions developed in artificial culture media and incubators in the early days of IVF led to the assumption that

the tubal environment may be potentially superior (Tournaye et al., 1996). Since the embryo leaves the Fallopian tube in its journey to the uterine cavity only after it has reached the blastocyst stage, tubal transfer of cleavage stage embryos might also be considered. A variant in which day-2 embryos are replaced in the tubal lumen (tubal embryo transfer; TET) was subsequently introduced (Asch et al., 1988). Currently, both procedures are referred to as ZIFT. Whether the timing and embryonic stage at tubal transfer affect results has not been thoroughly evaluated. A recent meta-analysis summarizing studies in which ZIFT and transcervical embryo transfer in the general IVF population were compared has shown similar outcomes with both techniques (Habana and Palter, 2001). In the authors’ centre, ZIFT is almost exclusively reserved for patients with repeated implantation failure (RIF). Rarely, ZIFT is offered to patients

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Article - Timing intra-Fallopian transfer procedures - A Weissman et al.

who present with anatomical variants of the cervical canal that make standard transcervical embryo transfer procedures difficult and inefficient. ZIFT is normally performed in the pronuclear stage, 1 day after egg retrieval. For practical reasons, ZIFT is sometimes deferred by 1 day, and cleavage stage embryos are transferred 2 days after egg retrieval, a procedure previously termed ‘embryo intra-Fallopian transfer’, or EIFT (Levran et al., 2000). The aim of the present study was to compare tubal transfer of zygotes versus cleavage stage embryos in terms of implantation and live birth rates.

-ATERIALSANDMETHODS A total of 273 fresh intra-Fallopian transfer cycles, performed in 176 patients at the IVF unit of the Edith Wolfson Medical Centre between the years 1995–2005, were retrospectively analysed. Due to the retrospective nature of the study, institutional review board approval was not considered necessary and therefore not obtained.

0ATIENTS Patients included in the study had to fulfill all of the following criteria: (i) a minimum of three previous failed IVF−embryo transfer attempts, excluding frozen−thawed embryo transfers; (ii) a normal uterine cavity, as demonstrated by hysteroscopy; (iii) presence of at least one patent tube, as demonstrated by either hysterosalpinography (HSG) or by hysterosalpingo-contrast sonography (HyCoSy) (Echovist; Schering, Germany) under ultrasound guidance; (iv) normal response to ovarian stimulation in previous attempts, i.e. ≥5 eggs retrieved, ≥3 zygotes obtained; and (v) patients no older than 44 years of age. A total of 176 patients were included in the study. The mean age of the women was 34.2 ± 5.3 years, they had a mean of 7.65 ± 3.7 previous failed attempts, and a basal (day 3) FSH value of 7.1 ± 3.0 IU/l. Sixty-five women underwent more than one cycle, and 24 women underwent both ZIFT and EIFT. Only fresh transfers were included in the analysis.

3TIMULATIONPROTOCOLS For ovarian stimulation, either the long or the short gonadotrophin-releasing hormone agonist (GnRHa) protocol was used in the vast majority of cases (Levran et al., 2002). In 15 cycles, a GnRH antagonist protocol was used. Protocol selection and the starting dose of gonadotrophins were both based on information gained during previous treatment cycles. Cycle monitoring consisted of ovarian ultrasonography and serum oestradiol and progesterone measurements from stimulation day 6 onwards, with dose adjustments and monitoring frequency based on patient response.



Human chorionic gonadotrophin (HCG, 10,000 IU; Chorigon, Teva, Netanya, Israel) was administered i.m. when at least two follicles were ≥18 mm in diameter with serum oestradiol concentrations within the acceptable range for the number of mature follicles present. Oocyte retrieval was performed 32–36 h after HCG administration by transvaginal ultrasound-guided needle aspiration under general anaesthesia.

,ABORATORYPROCEDURES After retrieval, oocytes were fertilized by either conventional insemination or intracytoplasmic sperm injection (ICSI), as indicated and described in detail elsewhere (Levran et al., 1998). Fertilization was assessed 16–18 h following insemination, and was considered normal only when two clearly distinct pronuclei containing nuclei were present. The embryos were cultured in P1 medium (Irvine Scientific, Santa Ana, CA, USA) supplemented with 10% synthetic serum substitute (SSS; Irvine Scientific) at 37°C in 5% CO2.

4RANSFERPROCEDURESANDLUTEALSUPPORT ZIFT or EIFT were performed 24 or 48 h after egg retrieval, respectively. Cleavage-stage tubal transfers were only performed in order to avoid weekend procedures or based on physician availability. Zygotes or embryos were transferred into one tube via laparoscopy according to the previously described technique (Levran et al., 1998). In both groups, the luteal phase was supported by either transvaginal micronized progesterone 200 mg t.i.d. (Uterogestan; Besins Iscovesco, Paris, France) and progesterone in oil (Geston; Pains & Byrne Limited, Surrey, UK) 50 mg i.m. on alternate days when peak oestradiol concentrations exceeded 2500 pg/ml. When peak oestradiol concentrations were lower than 2500 pg/ml, vaginal progesterone was given as described above, and HCG 2500 IU given i.m. twice, 4 and 6 days after oocyte retrieval.

$ATAANALYSIS Data recorded for the analysis included age, infertility duration, number of previous failed IVF attempts, day-3 FSH concentrations, duration of stimulation, number of gonadotrophin ampoules required, serum oestradiol concentration on the day of HCG administration, number of oocytes retrieved and fertilized, number of zygotes or embryos replaced and number of cycles with freezing. Primary outcome measures included implantation rates and live birth rates. A clinical pregnancy was defined as ultrasonographic visualization of an intrauterine gestational sac with fetal heart beat. A spontaneous abortion was defined as a clinical pregnancy lost before 20 weeks’ gestation. Implantation rate was defined as the number of observed intrauterine gestational sacs divided by the number of embryos replaced. The statistical package Sigmastat (Jandel Corporation, San Raphael, CA, USA) was used for data analysis. Comparisons were made using the unpaired Student’s t-test, the Mann−Whitney rank sum test, chi-squared analysis and Fisher’s exact test, where appropriate. P < 0.05 was considered statistically significant. Results are expressed as means with SD.

2ESULTS Patients in both groups were comparable in terms of age, basal FSH concentrations, number of previous failed IVF cycles, gravidity, parity and duration of infertility (Table 1). Clinical and laboratory outcome parameters are presented in Table 2. The various protocols used for ovarian stimulation were used in a similar proportion in both groups. The duration of stimulation was about 1 day longer in the ZIFT group (13.1 ± 2.8 versus 12.0 RBMOnline®

Article - Timing intra-Fallopian transfer procedures - A Weissman et al.

± 2.7; P < 0.0001), which was also expressed in significantly increased gonadotrophin requirements in the ZIFT group (44.5 ± 18.8 versus 39.2 ± 18.2 ampoules for ZIFT and EIFT respectively; P = 0.03). Serum oestradiol and progesterone concentrations as well as endometrial thickness on HCG day, were comparable for both groups, as were the number of oocytes retrieved. ICSI was more frequently applied in the EIFT group (73.0 versus 89.0% for ZIFT and EIFT respectively; P = 0.008). The number of fertilized oocytes was comparable for both groups, but fertilization rate was significantly higher in the ZIFT group (73.5 ± 18 versus 69 ± 17; P = 0.048). A mean of 5.2 ± 1.2 zygotes or embryos were transferred in both groups. Clinical pregnancy rates in the ZIFT (66/200, 33.0%) and EIFT (23/73, 31.5%) groups were comparable, as were miscarriage rates (13/66, 19.7% versus 5/23, 21.7% for ZIFT and EIFT

respectively) and live birth rate (ZIFT 53/200, 26.5%; EIFT 18/73, 24.7%) (Table 3). There were four ectopic pregnancies in 200 (2.0%) ZIFT cycles and one in 73 (1.4%) EIFT cycles. A similar implantation rate was observed in the ZIFT (10.5%) and EIFT (10.9%) groups. The multiple pregnancy rates were comparably high in both groups: 28/66 (42.4%) and 10/23 (43.5%) in the ZIFT and EIFT groups respectively. These included twins (ZIFT 42.4%; EIFT 21.7%), triplets (ZIFT 6.1%; EIFT 13.0%), quadruplets (ZIFT 4.5%; EIFT 8.7%), and one set of quintuplets in the ZIFT group (1.5%). In six pregnancies of each group, embryo reduction was performed, leading to a multiple birth rate of 51.0% in the ZIFT group (including two sets of triplets) and 38.9% in the EIFT group (all twins).

Table 1. Characteristics of patients undergoing zygote intra-Fallopian transfer (ZIFT) or embryo intra-Fallopian transfer (EIFT).

n Age (years) Basal FSH (IU/l) Gravidity Parity Infertility duration (years) Previous IVF cycles

All patients

ZIFT

EIFT

176 34.2 ± 5.3 7.1 ± 3.0 1.0 ± 1.8 0.24 ± 0.6 6.4 ± 4.7 7.65 ± 3.7

137 34.5 ± 5.3 7.2 ± 3.2 1.1 ± 1.91 0.3 ± 0.6 6.6 ± 4.85 7.4 ± 3.4

63 33.5 ± 5.2 6.9 ± 3.7 0.8 ± 1.2 0.2 ± 0.4 5.9 ± 4.2 8.0 ± 4.4

Values are mean ± SD. There were no statistically significant differences between the two groups.

Table 2. Clinical and laboratory cycle characteristics for patients treated with zygote intra-Fallopian transfer (ZIFT) or embryo intra-Fallopian transfer (EIFT).

No. of cycles Long protocol (%) Short protocol (%) Antagonist protocol (%) Stimulation duration (days) No. of gonadotrophin ampoules used Oestradiol on HCG day (pg/ml) Progesterone on HCG day (ng/ml) Endometrial thickness on HCG day (mm) No. of oocytes retrieved No. of oocytes fertilized Cycles with ICSI (%) Fertilization rate (%) No. of zygotes/embryos transferred Cycles with embryo freezing (%)

ZIFT

EIFT

P-value

200 141 (70.5) 52 (26.0) 7 (3.5) 13.1 ± 2.8 44.5 ± 18.8 2389 ± 890 1.44 ± 1.3 10.1 ± 2.3 11.3 ± 6.5 8 ± 4.6 146/200 (73.0) 73.5 ± 18 5.2 ± 1.2 69/200 (34.5)

73 47 (64.4) 18 (24.6) 8 (11.0) 12.0 ± 2.7 39.2 ± 18.2 2379 ± 943 1.3 ± 0.7 10.1 ± 2.1 10.9 ± 4.9 7.3 ± 3.7 65/73 (89.0) 69 ± 17 5.2 ± 1.2 17/73 (23.3)