Ultrasound-Guided Peritoneal Oocyte and Sperm Transfer

VINAY SHARMA

Ultrasound-Guided Peritoneal Oocyte and Sperm Transfer

VINAY SHARMA

1988, Annals of the New York Academy of Sciences

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Peritoneal oocyte and sperm transfer (POST) was performed under ultrasound guidance and local anesthesia by the transabdominovesical route for a patient with unexplained infertility. This resulted in an intrauterine pregnancy confirmed by a raised f~-human chorionic gonadotropin (hCG) level and an ultrasound scan.

Journal of in Vitro Fertilization and Embryo Transfer, Vol. 4, No. 2, 1987 Ultrasound-Guided Peritoneal Oocyte and Sperm Transfer VINAY SHARMA, 1-3 BRIDGETT MASON, 2,3 GEORGE PINKER, 2,3 A N D R E W RIDDLE, 2,3 J U L I A N PAMPIGLIONE, 2,3 NICK FORD, 2,3 and STUART C A M P B E L L 2,3 Submitted: September 25, 1986 Accepted: December 22, 1986 (European Editorial Office) lating hormone (Metrodin, Serono, UK) intramuscularly daily from day 2 to day 6 of the menstrual cycle (MC). From the eighth day 300 IU of human menopausal gonadotropin (hMG; Pergonal, Serono, UK) was administered daily for 4 days. An ultrasound scan was performed on the second day of the MC which confirmed that both ovaries were of normal morphology. Daily ultrasound scans were performed from the eighth day, and follicles were scanned in the sagittal and transverse planes; the horizontal and vertical diameters were measured and the arithmetic mean of these four diameters was recorded. The patient was also asked to collect 24-hr urine samples on days 2 to 3 and daily from day 7 for total estrogen excretion. The couple were advised to abstain from intercourse for 3 days before and 3 days after the procedure. The results of total urinary estrogen excretion are shown in Table I. On the eleventh day the patient had one preovulatory follicle (mean diameter, 17 mm) and two small follicles (each having a mean diameter of 10 mm); 5000 IU of human chorionic gonadotropin (hCG; Profasi, Serono, UK) was administered intramuscularly. Thirty-five hours later three unruptured follicles of similar size were visualized on ultrasound scan. The semen was prepared in Earle's Peritoneal oocyte and sperm transfer (POST) was perf o r m e d under ultrasound guidance and local anesthesia by the transabdominovesical route f o r a patient with unexplained infertility. This resulted in an intrauterine pregnancy confirmed by a raised f~-human chorionic gonadotropin (hCG) level and an ultrasound scan. KEY WORDS: ultrasound; in vitro fertilization; peritoneal oocyte and sperm transfer. INTRODUCTION Successful pregnancies following translaparoscopic intrafallopian sperm and oocyte transfer (GIFT) in patients with unexplained infertility or infertility due to cervical or male factor have been reported (1,2). More recently, in a similar group of patients, three pregnancies have resulted from direct intraperitoneal insemination by culdocentesis (3). We report the first successful pregnancy achieved after sperm and oocyte transfer into the peritoneal cavity by the transabdominovesical route under ultrasound guidance and local anesthesia, in a 41-yearold patient with unexplained infertility. METHODS TableL Total UrinaryEstrogen Excretion During the Follicular Phase The female partner was given 100 mg of clomiphene citrate orally and 300 IU of follicle-stimui To whom correspondence should be addressed at The IVF Clinic, Hallam Medical Centre, 77 Hallam Street, London WIN 5LR, United Kingdom. 2 The IVF Clinic, Hallam Medical Centre, London, United Kingdom. 3 Academic Department of Obstetrics and Gynaecology, Kings College School of Medicine and Dentistry, London, United Kingdom. 89 Day of the cycle Total urinary estrogens (nmol/24 hr) 3 7 8 9 10 11 12 39 48 58 103 205 232 396 0740-7769/87/0400-0089505.00/0 9 1987 Plenum Publishing Corporation 90 SHARMA ET AL Table II. Semen Data Sperm density Motility Progression Before preparation After preparation 62 million/ml 71% Good 400,000/ml 89% Good medium by layering and a swim-up technique. Details of the semen before and after preparation are shown in Table II. The prepared sample was then placed in the incubator at 37~ gassed with 5% CO2 in air until use. Oocyte recovery under ultrasound guidance and local analgesia was performed by the transabdominovesical route (6). One oocyte from the preovulatory follicle on the right ovary and another from a small follicle on the left ovary were recovered. The third small follicle was also punctured and flushed but there were no granulosa cells and no oocyte was collected. After identification both oocytes were placed in microdroplets of Earle's medium under sterile paraffin at 37~ and in an atmosphere of 5% CO2 and air. After oocyte recovery was complete the aspiration needle (16 gauge, I. 1-mm i.d., Hallam Medical Centre Needle, Rocket, London, UK) was advanced further into the pouch of Douglas as shown diagrammatically in Fig. 1. A Rocket R57.536 embryo transfer cannula with a tuberculin syringe was then rinsed with Earle's m e d i u m twice u n d e r sterile c o n d i t i o n s . Four hundred thousand spermatozoa in 1 ml of Earle's medium and the two oocytes were then aspirated into the catheter. The catheter was then introduced into the pouch of Douglas through the needle and the contents were injected (Fig. 2); catheter and needle were then withdrawn simultaneously. The duration of the procedure was 15 rain. The patient was discharged home an hour later. She was given luteal support using hCG (2000 IU after 2 and 5 days). Midluteal progesterone was 193 nmol/liter. The plasma 13-hCG level was measured 20 days Luer Loc~ ....'Abdominal Hallam Needle Bladder Ovary Ovary Rocket Catheter Fig. 1. Diagrammatic representation of the method of introduction of the needle and the catheter into the follicle and into the pouch of Douglas. Journal o f in Vitro Fertilization and Embryo Transfer, Vol. 4, No. 2, 1987 ULTRASOUND-GUIDED OOCYTE AND SPERM TRANSFER 91 Fig. 2. Ultrasound scan in the transverse plane showing the needle in the pouch of Douglas after aspiration of the follicle. after the procedure and 15 days after the last hCG injection. It was greater than 25 IU/liter. An ultrasound scan was performed 25 days after the procedure and this confirmed the presence of a gestational sac with an embryo with fetal heart activity. DISCUSSION This is the first reported pregnancy after peritoneal transfer of both sperm and the oocyte. We have recovered oocytes after spontaneous ovulation from the cul-de-sac in patients undergoing in vitro fertilization (unpublished observations). Similarly, sperm have also been retrieved laparoscopically from peritoneal fluid and fimbrial washings (4,5). Sperm transport to the site of fertilization may be defective in patients with cervical hostility, male or female antisperm antibodies, and unexplained infertility or oocytes may not be released from luteinized unruptured follicles. In these patients, gamete transfer into the peritoneal cavity or into the ampulla of the fallopian tube may bypass the unexplained obstruction to normal fertility. This technique of peritoneal transfer needs to be evaluated in a larger and randomized series and compared with GIFT. If equally successful, it offers several advantages over the previously reported procedure (1,2). This technique can be performed as an outpatient procedure under local analgesia. The duration of the procedure is very short and it does not require hospitalization, general anesthesia, or laparoscopy. A single entry into the abdomen with a 16-gauge needle is all that is necessary, compared with multiple and larger entries for the laparoscopic procedure, thus reducing postoperative morbidity. Peritoneal transfer under local anesthesia is considerably cheaper and therefore likely to be much more cost effective than GIFT. It is also possible that this technique will be superior Journal of in Vitro Fertilization and Embryo Transfer, Vol. 4, No. 2, 1987 92 SRARMA ET AL to i n t r a p e r i t o n e a l i n s e m i n a t i o n , as it a v o i d s p r o b lems inherent in predicting the time of ovulation. REFERENCES 1. Asch RH, Ellsworth LR, Baimaceda JP, Wong PC: Pregnancy' following translaparoscopic gamete intrafallopian transfer (GIFT). Lancet 1984;2:1034 2. MoUoy D, Speirs A, Du Plessis Y, Gellert S, Bourne H, Johnston WIH: Gamete intrafailopian transfer. Med J Aust 1985;143:428 3. Forrler A, Dallenbach P, Nisand I, Moreau L, Crauz CL, Clavert A, Rumpler Y: Direct intraperitoneal insemination in unexplained and cervical infertility. Lancet 1986;1:916 4. Ahlgren M: Sperm transport to and survival in the human fallopian tube. Gynaecol Invest 1975;6:206 5. Asch RH: Laparoscopic recovery of sperm from peritoneal fluid, in patients with negative or poor Sims-Huhner test. Fertil Steril 1976;27:1111 6. Lenz S, Lauritsen JG: Ultrasonically guided percutaneous aspiration of human follicles under local anaesthesia: A new method of collecting oocytes for in-vitro fertilisation. Fertil Steril 1982;38:673-677 Journal o f in Vitro Fertilization and Embryo Transfer, Vol. 4, No. 2, 1987

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