Outcome of pregnancies complicated by severe ovarian hyperstimulation syndrome (OHSS): a follow-up beyond the second trimester

The main aim of this study was to assess the obstetric complications for those pregnancies that are complicated by ovarian hyperstimulation syndrome (OHSS) and continue beyond the first trimester. We checked also for other related serious events that occurred during the first trimester.

METHODS

We included only patients whose pregnancies continued beyond the first trimester and compared them with IVF-treated patients displaying moderate ovarian response.

RESULTS

We studied 165 patients with OHSS (101 singletons and 64 twins) and 156 IVF control patients (85 singletons and 71 twins). Two serious complications, gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH), were noted in both groups. However, the incidence of these two complications did not differ significantly between the groups. In the OHSS group, GDM presented with an incidence of 9.9% for singletons and 9.4% for twins, and 12.9% and 7.0%, respectively, for the control group. PIH presented as 6.9% for singletons and 10.9% for twins in the OHSS group, and 8.2% and 7.0%, respectively, for the control groups. During the first trimester laparoscopies for suspected ovarian torsion were performed in 13 patients, and in 10 patients the diagnosis were confirmed.

CONCLUSIONS

Although patients with OHSS-complicated pregnancies previously reported a relatively high risk of GDM and PIH, the occurrence rates do not differ from a matched control group of normally responding patients who conceived after IVF.

Descending auditory system/cerebellum/tinnitus

The cerebellum and the descending auditory system (DAS) are considered clinically significant for influencing the development of the clinical course of tinnitus of the severe disabling type. It is hypothesized that the SPECT of Brain perfusion asymmetries in cerebellum, demonstrated since 1993, reflect clinically the influence of an aberrant auditory stimulus i.e. tinnitus, on the activity and function of the descending auditory system highlighted by the cerebellum and the acousticomotor systems. SPECT of Brain perfusion asymmetries in the cerebellum have been demonstrated in 60-70% of tinnitus patients of the central type. Electrophysiologic support for this finding includes interference in ocular fixation suppression of the vestibulocular (VOR) with rotation and position testing. Abnormalities in cerebellar function are considered to reflect the psychomotor component of tinnitus. Support for the hypothesis is demonstrated with one patient with a predominantly central type tinnitus of the severe disabling type with cerebellar perfusion asymmetries and associated electrophysiologic evidence of interference in the VOR with rotation testing.

The progestative effect of the levonorgestrel-releasing intrauterine system--when does it manifest?

The objective of the study was to evaluate, clinically and sonographically, the time required for the progestative effect of the levonorgestrel-releasing intrauterine system (IUS, Mirena) to be manifested. Doppler flow of the cervical branch and spiral artery of the uterine artery, as well as the endometrial width (up to day 10 of the cycle), were evaluated in 36 women carrying levonorgestrel-releasing IUS 1-2 months after insertion of the device compared to 4-6 months after insertion. The rate of intermenstrual bleeding was reduced from 44% during the first 2 months, to only 8% of women after 4-6 months of use. Complete cessation of menstrual bleeding occurred in 5% after 2 months and in 66% after 4-6 months following insertion. While there was no change in the Doppler flow in the cervical branch of the uterine artery between both groups, there was a significant reduction in the subendometrial flow in the spiral artery. This observation was reinforced by the demonstration of significant reduction in endometrial thickness in the following 4 months of use. The present study has demonstrated that the local progestative effect of the levonorgestrel-releasing IUS on the endometrium is already manifested within a period of 3 months and over after insertion.

The local progestational effect of the levonorgestrel-releasing intrauterine system: a sonographic and Doppler flow study

BACKGROUND

We aimed to evaluate the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) on the uterine vasculature and the endometrium.

METHODS

The study was a prospective controlled study evaluating the local effects of LNG-IUS compared with the copper intrauterine device (IUD). Forty-seven women carrying LNG-IUS (group A) were compared with 35 women carrying copper IUD in a control group (group B). Clinical measures of menstrual bleeding, endometrial thickness and Doppler flow of the cervical branch of the uterine artery and spiral artery were evaluated and compared between the two groups.

RESULTS

Doppler flow in the cervical branch of the uterine artery did not reveal any changes between the groups (resistance index = 0.6 +/- 0.01 in both groups). Endometrial width was significantly thinner in group A (4.1 +/- 0.2 mm) compared with group B (7.3 +/- 0.2 mm) (P < 0.0001). Subendometrial flow in the spiral artery was significantly reduced in 35 women of group A (75%) and in none of group B (P < 0.0001).

CONCLUSIONS

The present study offers an explanation for the oligomenorrhoea in LNG-IUS users, i.e. a local progestational effect on the endometrium with no change in the blood flow in the uterine artery. This should be presented to the women in the pre-contraceptive counselling in order to lessen the discontinuation rate.

Serial first- and second-trimester Down's syndrome screening tests among IVF-versus naturally-conceived singletons

BACKGROUND

It has been reported that second-trimester serum markers may be affected by assisted reproduction, leading to a higher false-positive rate.

METHODS

A total of 285 naturally and 71 IVF-conceived singletons which underwent a serial disclosure Down's syndrome screening programme were compared. The study protocol included first-trimester combined [nuchal translucency (NT), free beta-HCG and pregnancy-associated plasma protein-A (PAPP-A)] testing. The second-trimester triple serum screening included alpha-fetoprotein (AFP), intact HCG and unconjugated estriol (uE3). After excluding aneuploidies, miscarriages, anatomical anomalies and cases with incomplete follow-up, the serum samples of normal cases were assessed and correlated.

RESULTS

NT measurement was not significantly changed in either group. However, the IVF group had lower PAPP-A [0.96 versus 1.05 multiples of normal median (MoM)] and higher AFP (1.13 versus 1.07 median MoM). Both groups had similar rates of first-trimester false-positive results (FPR; 7 and 9% respectively), but the IVF group had a significantly higher mid-gestation FPR rate (10 versus 5%; Pearson chi2, P = 0.029). This has contributed to amniocentesis uptake rates of 15 and 13% for the IVF and natural conception pregnancies respectively.

CONCLUSIONS

The IVF group tended to have a significantly higher second-trimester FPR rate. To counterbalance this phenomenon, integrated first- and second-trimester screening tests or the use of NT alone might be a reasonable option that deserves further investigation.

In vitro fertilization following natural cycles in poor responders

This prospective study was designed to examine the feasibility of natural cycle in vitro fertilization (IVF) in poor responders, and the clinical factors that may predict successful outcome. Twenty-two poor responders underwent IVF treatment with 44 unstimulated cycles. The results of the natural cycles were compared with those of the 55 low-response stimulated cycles of these patients during the 12 months prior to the study. Eighteen (82%) patients had at least one oocyte retrieved, while nine (41%) had at least one cycle with embryo transfer. Two (9%) patients each gave birth to a healthy term baby. These results are comparable with those of the stimulated cycles. Serum early follicular follicle stimulating hormone (FSH) level was found to be the only reliable predictor of oocyte recovery and overall outcome in each specific natural cycle. However, because of great variability in basal FSH levels among different cycles of the same patient, this is not a reliable predictor of outcome in future cycles. We conclude that poor responders are a unique group of patients who may benefit from natural-cycle IVF treatment.

A comparative study of multifetal pregnancy reduction from triplets to twins in the first versus early second trimesters after detailed fetal screening

OBJECTIVES

To compare the outcome of multifetal pregnancy reduction from triplets to twins performed either early (at 11-12 weeks' gestation) or late (at 13-14 weeks).

METHODS

Ninety-five high-order pregnancies following assisted conception were studied. Transabdominal sonographically guided multifetal pregnancy reduction was performed early in 46 women, while 49 women first underwent a sonographic fetal anomaly scan before undergoing selective reduction.

RESULTS

Sonographic screening led to selective termination of a specific fetus in nine cases due to increased nuchal translucency and relative intrauterine growth restriction in three cases each, and meningomyelocele, abdominal cyst and cystic hygroma in one case each. In the early reduction group a diagnosis of hypoplastic left heart in the two remaining twins was subsequently made, and one pair of twins suffers from cerebral palsy. The rate of pregnancy loss was not statistically different between the early (4.3%; 2/46) and late (4.0%; 2/49) termination groups. The birth weight and gestational age at birth were not statistically different between the early ( n = 85) and late ( n = 94) groups (2110 +/- 580 vs. 2140 +/- 490 g, and 35.8 +/- 3.0 vs. 35.7 +/- 3.5 weeks). Similarly there was no statistically significant difference between early and late groups in the incidence of very premature (24-32 weeks; 9.3 vs. 8.3%) and premature (33-36 weeks; 46.5 vs. 47.9%) births.

CONCLUSIONS

Early second-trimester multifetal pregnancy reduction from triplets to twins may allow more selective termination of abnormal fetuses without an adverse effect on the outcome of pregnancy. However, further studies are needed in order to confirm our observations in a larger series.

A randomized, double-blind clinical trial using fixed daily doses of 100 or 200 IU of recombinant FSH in ICSI cycles

The effect of 100 and 200 IU per day recombinant FSH (rFSH) on numbers of oocytes retrieved and the total dose used in ovarian stimulation before intracytoplasmic sperm injection was investigated in a double-blind, randomized multicentre trial. A total of 91 women was treated with a low-dose protocol and 88 with a high-dose regimen at five centres. For each started cycle, significantly more oocytes were retrieved in the 200 IU group than in 100 IU group (12.0 versus 5.7, P < 0.001); total rFSH consumption was 1121 and 1875 IU in the low- and high-dose groups respectively. Significant variations were noted between centres with regard to numbers of oocytes collected per started cycle, ranging from 2.8 to 7.2 in the 100 IU group and from 9.0 to 19.1 in the high-dose group. Exploratory analyses of secondary outcomes suggested there were no differences in vital pregnancy rates per started cycle (19.2 versus 16.9%) and per embryo transfer (26.2 versus 19.3%) in the low- and high dose groups respectively. There were four hospitalizations due to ovarian hyperstimulation syndrome, all in the 200 IU group.

Laser-induced noninvasive vascular injury models in mice generate platelet- and coagulation-dependent thrombi

A minimally invasive laser-induced injury model is described to study thrombus development in mice in vivo. The protocol involves focusing the beam of an argon-ion laser through a compound microscope on the vasculature of a mouse ear that is sufficiently thin such that blood flow can be visualized by intravital microscopy. Two distinct injury models have been established. The first involves direct laser illumination with a short, high-intensity pulse. In this case, thrombus formation is inhibited by the GPIIb/IIIa antagonist, G4120. However, the anticoagulants, hirulog, PPACK, and NapC2 have minimal effect. This indicates that thrombus development induced by this model mainly involves platelet interactions. The second model involves low-intensity laser illumination of mice injected with Rose Bengal dye to induce photochemical injury in the region of laser illumination. Thrombi generated by this latter procedure have a slower development and are inhibited by both anticoagulant and anti-platelet compounds.

Comparison of triple serum screening and pregnancy outcome in oocyte donation versus IVF pregnancies

The current study compared triple serum screening results and outcomes in 37 oocyte donation (OD) and 46 self oocyte IVF-conceived singletons of similarly aged women (28.8 +/- 4.4 years and 30.7 +/- 4.5 years respectively). Both groups were followed from their embryo transfer and throughout pregnancy. Although the daily pattern of first-trimester serum beta-human chorionic gonadotrophin (HCG) was similar in both groups, higher mid-gestation HCG serum concentrations were found, i.e. 1.38 and 1.32 multiples of the median (median MoM) for IVF and OD respectively, in comparison with 0.99 median MoM from the same reference laboratory. Only the OD group had significantly increased alpha fetoprotein (AFP) concentrations (1.45 median MoM) (P = 0.002) compared with the reference laboratory. A total of 11% of the IVF and 13% of the OD women were found to be screen positive. In neither group were chromosomal abnormalities detected and no fetal or neonatal deaths were recorded. Seven (15%) of the OD and seven (19%) of the IVF women had an adverse obstetric outcome. Of those cases, six IVF and four OD women had serum HCG > or = 1.2 MoM and five OD women had AFP >1.2 MoM. Therefore, in those pregnancies the high serum HCG concentrations may alert for adverse obstetric outcome rather than indicating a high risk for Down's syndrome fetuses.

Long-term inhibition of tinnitus by UltraQuiet therapy: preliminary report

Masking of tinnitus by noise can produce residual inhibition, a persistence in the reduction in tinnitus after the noise is removed. Typically, this relief is very short-lived, on the order of minutes. This report highlights long-term inhibition of tinnitus by UltraQuiet therapy, a new technique that employs patterned sound in the 10- to 20-kHz range, presented through bone conduction. Nine subjects participated in a study of the efficacy of this tinnitus suppression technique. Eight reported improvement in tinnitus symptoms; one did not complete the study. The duration of the improvement ranged from days to weeks. This long-term inhibition may involve a truly plastic change in the brain at the central level.

The effects of leupeptin on cochlear blood flow, auditory sensitivity, and histology

The purpose of this study was to evaluate the long-term safety of administering leupeptin (1 mg/ml in Hank's Balanced Salt Solution) to the round window membrane by investigating its effects on cochlear blood flow, auditory sensitivity (i.e., auditory brainstem response), and cochlear histology. A comparison of baseline and posttreatment measurements of cochlear blood flow and mean arterial blood pressure in guinea pigs revealed no significant changes. Auditory brainstem response measurements revealed no significant changes in auditory threshold shifts when compared to controls at the 2-, 4-, 6-, and 8-week time points. Furthermore, poststudy surface preparations of the organs of Corti and cytocochleograms from leupeptin-treated ears and controls revealed no significant hair cell losses. These data suggest that the prolonged administration of leupeptin (1 mg/ml at a rate of 0.5 microliter/hr for 8 weeks) to the round window membrane is not ototoxic. This study may serve as a basis for future clinical trials of leupeptin administration for the prevention or treatment of noise-induced hearing loss and the management of tinnitus.

Central auditory speech test findings in individuals with subjective idiopathic tinnitus

This study reports central auditory speech test performance of 25 consecutive patients with subjective idiopathic tinnitus of the severe disabling type. A preliminary study of 14 individuals who had subjective idiopathic tinnitus and complained of difficulty in hearing and understanding revealed a high incidence of abnormal central auditory speech test performance (71%), despite satisfactory peripheral hearing. The results (1) identify objectively for the first time that tinnitus affects specific components of the auditory pathway; (2) provide a basis for monitoring methods of tinnitus control; and (3) provide a basis for understanding "the interference effect" and problem of communication difficulties in patients with tinnitus of the severe disabling type.

Effects of gonadotrophin-releasing hormone agonists on human ovarian steroid secretion in vivo and in vitro-results of a prospective, randomized in-vitro fertilization study

The aim of this prospective randomized study was to compare the effects of two gonadotrophin-releasing hormone (GnRH) agonists, buserelin and triptorelin, on human ovarian follicular steroidogenesis, oocyte fertilization and IVF treatment outcome. Ovulatory, healthy women undergoing IVF were treated either with human menopausal gonadotrophin (HMG) alone or with HMG and one of the two GnRH agonists. Serum and follicular fluid hormonal concentrations and cultures of luteinizing granulosa cells obtained during follicular aspiration were analysed. GnRH agonist treatment significantly affected steroidogenesis both in serum and follicular fluid. In follicular fluid, progesterone and oestradiol concentrations were significantly elevated while testosterone concentrations were significantly lower in the triptorelin group. The ratios of testosterone/progesterone, oestradiol/progesterone but not oestradiol/testosterone concentrations were significantly affected by GnRH agonist administration. Similarly, the steroidogenic activity of luteinizing granulosa cells in vitro was significantly decreased in women treated with GnRH agonists. Women treated with GnRH agonists had significantly more fertilized oocytes and cleaving embryos. The results indicate a marked effect of GnRH agonists on the pattern of ovarian follicular steroidogenesis that cannot be explained solely by changes in gonadotrophin concentrations.

[Use of civilian emergency departments by the Israel Defense Force for emergency care for soldiers]

Many physicians, civilian as well as in military, feel that some referrals of soldiers to civilian emergency departments are inappropriate and that soldiers should receive medical attention within their military units. We therefore evaluated referrals of soldiers to our emergency department. 707 referral letters from military physicians and the corresponding emergency room discharge letters were evaluated. Most soldiers were referred for mild trauma (45.0%) or miscellaneous diseases (52.9%); 22 (3.1%) were hospitalized. It appears that some military physicians use the civilian hospital emergency department as a surrogate for an outpatient specialty clinic and for x-ray and laboratory services. This is in contrast to the designated functions of the emergency department which are to provide emergency and trauma services and to evaluate the need for hospitalization of referred patients.

Gingko biloba (Rökan) therapy in tinnitus patients and measurable interactions between tinnitus and vestibular disturbances

Tinnitus is one of the most important symptoms in neurootology after vertigo, nausea, and hearing loss. In most cases, the origin of the tinnitus remains inexplicable. Well-known, however, is that tinnitus may arise in any part of the hearing pathway (i.e., both within the cochlea receptor and in the temporal lobe and projections). Tinnitus also is associated frequently with vertigo, nausea and hearing loss. An age predominance exists, with tinnitus more common among those older than 40 years. From this starting point, a great demand exists today for new ideas and developments in the diagnosis and treatment of tinnitus.

Intratympanic drug therapy with steroids for tinnitus control: a preliminary report

Intratympanic drug therapy (ITDT) is a surgical technique of instilling medication into the middle ear to perfuse the inner ear in treating hearing loss, tinnitus, vertigo, and ear blockage, alone or in combination, in patients with a predominantly inner-ear site of lesion. This preliminary report of ITDT focuses on attempts at tinnitus control (TC). Between November 1997 and February 1999, 10 patients with severe tinnitus were treated with steroid medication and were last seen in February 2000. TC was established in 7 of these 10 patients (70%). The clinical diagnosis of a predominantly cochlear-type tinnitus was established in each patient by a correlation of the clinical history with a medical-audiological tinnitus patient protocol that included cochleovestibular testing. An additional single patient with sudden hearing loss experienced no hearing improvement on ITDT steroid therapy. Vertigo as an associated complaint was reported by 6 of 10 patients with subjective idiopathic tinnitus. Significant control of the associated vertigo complaint was reported by 5 of 10 patients. Duration of tinnitus relief in 7 of 10 patients was hours in 1 of the 7; days in another of the 7; and 1 year or more in 5 of the 7. One of the seven patients reported TC 3 months after the procedure. Complications included tympanic membrane perforation that persisted for more than 6 months in two patients and an increase in the complaint of ear blockage and tinnitus intensity in one patient. In our preliminary study, ITDT with steroid has resulted in both short- and long-term tinnitus relief in 7 of 10 patients (70%) identified to have a predominantly cochlear-type tinnitus.

Benzodiazepine receptor deficiency and tinnitus

As regards the symptom of a predominantly central tinnitus of the severe, disabling type, it has been hypothesized that a deficiency in the benzodiazepine receptor exists in the medial temporal lobe system of brain and is directly related to affect impairments including anxiety, stress, depression, and fear. This hypothesis has been investigated with single-photon emission computed tomography using the benzodiazepine radioligand 123I Iomazenil. Visual analysis revealed preliminary results of diminished benzodiazepine-binding sites in the medial temporal cortex of all patients with severe tinnitus (N = 6), a finding that is consistent with the hypothesis implicating GABAergic mechanisms in the pathophysiology of the disorder. An abnormal gamma-aminobutyric acid--A benzodiazepine receptor density may be an objective neurochemical measure of the severity of a central-type tinnitus and a rationale for treatment. Clinical correlation with the history, clinical course of the patient, and stress questionnaire are presented.