The significance of an early (premature) rise of plasma progesterone in in vitro fertilization cycles induced by a "long protocol" of gonadotropin releasing hormone analogue and human menopausal gonadotropins

OBJECTIVE

Our purpose was to assess and clarify the mechanism of whether an early progesterone rise in cycles with gonadotropin-releasing hormone agonist (GnRH-a) is associated with an impairment of IVF outcome.

METHODS

Seven hundred eighty-six cycles were induced with GnRH-a and human menopausal gonodotropin (hMG) ("long protocol"). Plasma progesterone (PP) levels on the day of human chorionic gonadotropin (hCG) administration were divided into three groups: < 0.9 ng/ml (Group A), 1-2 ng/ml (Group B), and > 2 ng/ml (Group C). We also analyzed the pregnancies achieved in our egg donation protocol in relation to the PP levels of each donor on the day of hCG administration.

RESULTS

Group A involved 525 cycles, Group B had 223, and Group C had 38. The overall pregnancy rate per egg transfer was 19.2%, with the highest for Group A (22.3%), declining for Groups B (14.3%) and C (7.9%) (A = B = C; P < 0.005). The embryo implantation rate was found to be negatively correlated with the PP levels on the day of hCG administration. In contrast, there was an opposite trend between PP levels and the chance of conception in 30 pregnancies achieved by egg donation.

CONCLUSION

Since premature luteinization is very unlikely to occur under the conditions of this study, our findings suggest that an early PP rise has a negative impact on endometrial receptivity but not on egg and embryo quality.

Serial color Doppler flow of uterine vasculature combined with serum beta-hCG measurements for improved monitoring of patients with gestational trophoblastic disease. A preliminary report

Weekly serum beta-hCG measurements and transvaginal ultrasound scans coupled with color Doppler flow were performed on 8 patients with hydatidiform mole. Two patients later developed persistent trophoblastic disease, necessitating chemotherapy. The correlation coefficients between Doppler flow indices, systolic-diastolic (S/D) ratio and pulsatility index (PI) with log beta-hCG were -0.96 and -0.97, respectively. The weekly S/D and PI indices were plotted on an individual curve. Only the 2 patients who developed persistent gestational trophoblastic disease had PI index levels of < or = 1.5 as early as 2 weeks after molar evacuation. At that stage their serum beta-hCG levels were not different from some of the other patients. In this preliminary report, the regression of the disease could be reliably assessed by observing the changes in low resistance flow which paralleled the gradual decrements in serial beta-hCG levels. Thus, the contribution of this noninvasive imaging technique encourages the authors to further investigate Doppler flow monitoring among a larger sample of patients suffering from various gestational trophoblastic diseases.

Relationship between the threshold of ovarian sensitivity to human menopausal gonadotrophin stimulation and in-vitro fertilization treatment outcome

In a retrospective study of 813 oocyte retrieval-embryo transfer cycles in women with normal follicle stimulating hormone and luteinizing hormone concentrations, we sought to investigate the relationship between the amount of human menopausal gonadotrophin (HMG) used for ovarian stimulation and treatment outcome. Patients were divided into three groups: group A patients (495 cycles) required < 40 ampoules of HMG and had a predicted probability for pregnancy of 25% per embryo transfer; group B patients (165 cycles) required 41-77 ampoules per cycle, with a predicted probability rate for pregnancy of 5-25% per embryo transfer; and group C patients (153 cycles) required > 77 ampoules of HMG and the predicted probability for pregnancy was < 5% per embryo transfer. Groups C and A differed significantly (P < 0.005). The mean oestradiol concentration on the day of HCG administration in group C was 6412 pmol/l, and the mean number of eggs retrieved was seven. The highest success rates were found when up to 2.5 ampoules of HMG were required for each egg or 4.4 ampoules for each embryo. The lowest rates were obtained when > 4.8 ampoules of HMG were necessary for each oocyte or > 9.6 ampoules for each embryo (P < 0.005). We identified a group of infertile patients who required excessive amounts of HMG to achieve a fair degree of steroidogenesis, number of eggs and number of embryos but who had very low pregnancy rates. Although all other relevant parameters were normal, this may highlight the beginning of ovarian-gamete insufficiency before the basic hormonal status is affected. In cases of repeated failure, oocyte donation should be considered.

The impact of different types of anesthesia on in vitro fertilization-embryo transfer treatment outcome

OBJECTIVE

Our objective was to evaluate retrospectively the influence of different types of anesthesia on the outcome of ovum retrieval.

METHODS

Sedation combined with local anesthesia was used on 120 occasions (Group I), epidural block in 139 ovum retrievals (Group II), and general anesthesia in 173 cycles (Group III).

RESULTS

No differences were found in embryo yield or number or the quality of the embryo transferred. Of 99 pregnancies achieved, 66 live deliveries were recorded. Significantly lower clinical pregnancy rates were found in Group III (14.5%) compared with Group II (23.7%; P = 0.018) or Group I (25.8%; P = 0.0074). Highly significant differences were found in the delivery rates between Group III (8.7%), Group II (20.11%; P = 0.0017), and Group I (19.2%; P = 0.0043).

CONCLUSION

The use of general anesthesia, especially nitrous oxide, for oocyte retrieval has an adverse effect on IVF outcome. This deleterious effect manifests itself only after embryo transfer and leads to lower pregnancy and delivery rates.

Induction of artificial endometrial cycles with oestradiol implants and injectable progesterone: establishment of a viable pregnancy in a woman with 17-alpha-hydroxylase deficiency

Repeated attempts with oral oestrogens and injectable progesterone failed to induce secretory endometrium in a woman with 17-alpha-hydroxylase deficiency. The insertion of s.c. 17-beta-oestradiol implants dramatically improved the endometrial response and enabled the establishment of endometrial maturation. A viable pregnancy was achieved after the uterine transfer of in-vitro fertilized donated eggs.

Ectopic pregnancy and laparoscopy: review of 1197 patients treated by salpingectomy or salpingotomy

The past few decades have witnessed such a rapid rise in the incidence of ectopic pregnancy that it verges on the point of an 'epidemic disease'. Its early detection, with the aid of serum beta-hCG, high resolution ultrasound and the more liberal use of laparoscopy, has dramatically altered the clinical presentation of this disease and permits the use of more conservative methods of management directed towards preserving fertility and reducing morbidity. In this review of 1197 patients, compiled from the English literature, various conservative or tubectomy operative laparoscopic procedures have been employed, with 93% and 98% respectively, being able to avoid further surgery. Among the group treated by the conservative approach, a 6% post-operative complication rate was reported, of which 4% were persistent ectopic, 48% intra-uterine, and 18% repeated ectopic pregnancies. Among the radically treated patients, 2 intra- and 1 post-operative complications necessitated laparotomies. The fertility work-up and performance outcome are less obvious among this group. The benefits, safety and efficacy of each of the laparoscopic options, with appropriate recommendations for their use, are discussed. However, despite the aforementioned dramatic progress, women with previous ectopic pregnancies still have reduced fertility potential. Preventive measures aimed at reducing its overall occurrence therefore seem to be the major factor towards preserving a patient's future fertility potential.

First trimester embryo reduction: a medical solution to an iatrogenic problem

The incidence of multiple pregnancies is increasing, mainly as a consequence of the widespread use of various infertility protocols. Since such gestations present a high risk of feto-maternal morbidity and mortality, selective first trimester fetocide remains one of the few reasonable options. We reviewed the literature dealing with the outcome of 804 multiple pregnancies following the use of transcervical, transvaginal or transabdominal approaches. Questions relating to dealing with technical failure, method of fetocide and procedural improvements are examined. In a comparison of the variables: miscarriage, preterm delivery, perinatal and neonatal loss rates, the transvaginal approach fares better, but statistical significance (P < 0.001) is achieved only for preterm delivery. We speculated that this might be attributable to the very early gestational age at which the procedure is usually performed. However, the transabdominal approach offers better results when post-manipulation maternal morbidity is considered, i.e. infection and vaginal bleeding. Since each option offers different advantages and disadvantages, additional experience and larger population samples are required to further clarify this important issue.

Penile condylomata: a gynecological epidemic disease: a review of the current approach and management aspects

Viral venereal infection caused by human Papillomavirus has reached epidemic state. The proper management of this infection in men is of great benefit, because it may possibly decrease the reservoir of disease in both sexes from which genital condylomata and associated lesions may arise. We report a selection of current knowledge about the epidemiology, etiology, diagnosis, and treatment of male condyloma, occurring predominantly among male consorts of women with genital human Papillomavirus infection. In a review of 1455 affected women, compiled from the literature, 1019 (70 per cent) of their sexual partners were diagnosed as having been infected with the same viral disease. The current diagnostic and treatment modalities and their outcomes are discussed with appropriate recommendations for their use.

Ovarian cyst formation in two pre-menopausal patients treated with tamoxifen for breast cancer

Pre-menopausal tamoxifen treatment causes hyperoestrogen production and ovarian cyst formation. Two pre-menopausal breast cancer patients who were treated with tamoxifen developed both permanent supraphysiological oestrogen concentration and ovarian cysts. Serum oestrogen decreased to post-menopausal concentrations and ovarian cysts completely resolved during and following simultaneous treatment with tamoxifen and gonadotrophin-releasing hormone agonist (GnRHa). In pre-menopausal breast cancer patients, GnRHa may prevent possible side-effects of tamoxifen, such as ovarian cysts and supraphysiological oestrogen production.

The significance of plasma progesterone levels during early pregnancies achieved after in vitro fertilization (IVF) treatment

OBJECTIVE

Corpus luteum steroidogenesis is lower for in vivo ectopic pregnancy than for intrauterine pregnancy. There is a progesterone hallmark level distinguishing between viable intrauterine pregnancy and nonviable or ectopic pregnancy. This study attempts to answer whether this is also true for in vitro fertilization-treated patients.

STUDY DESIGN

Using information retrieved from a computerized database, we compared the plasma 17 beta-estradiol (E2) and progesterone during the luteal phase and for every 2 to 3 days for several weeks during early pregnancy between those patients with proven ectopic pregnancies and those with singleton and multiple intrauterine pregnancies. Vaginal ultrasonography to detect an intrauterine gestational sac was performed from day 19. A total of 73 pregnancies resulted from the replacement of fresh embryos in our in vitro fertilization-embryo transfer program.

RESULTS

Only at day 10 post embryo transfer did those patients with ectopic pregnancy show statistically lower mean (SD) serum levels of E2 [2257 (SD, 2351) pmol/L] and plasma progesterone [PP; 221 (SD, 283) nmol/L] compared with patients with intrauterine pregnancy, whose mean E2 was 8846 (SD, 5871) pmol/L and mean PP was 805 (SD, 582) nmol/L (P = 0.008). For the rest of the follow-up until surgery was performed in ectopic pregnancy, there were no differences of statistical significance between extrauterine pregnancy and the intrauterine pregnancy groups. Furthermore, only on day 10 post embryo transfer, did we find a discriminatory zone (confidence interval, 95%) for E2 levels (903 to 3502 pmol/L for EP vs 6116 to 9493 pmol/L for a singleton and 4875 to 9493 pmol/L for multiple pregnancies). PP levels were 26 to 283 nmol/L for ectopic pregnancy versus 496 to 1096 nmol/L for both singleton and multiple pregnancies. An intrauterine gestational sac was visualized at a mean of 23.2 (SD, 4) days after embryo transfer. On this day, the mean P levels were 982.6 (SD, 286.2) nmol/L for intrauterine and 804.5 (SD, 502.4) nmol/L for ectopic pregnancies (P = NS).

CONCLUSIONS

Except for day 10 post embryo transfer, the steroidogenesis in ectopic pregnancy after in vitro fertilization treatment does not differ from successful intrauterine pregnancy. This observation negates an impaired steroidogenesis for ectopic pregnancy after in vitro fertilization and makes the PP level irrelevant in the diagnosis of pregnancy implantation.

Estrogen and progesterone receptor expression of decidual endometrium in a postmenopausal woman treated with tamoxifen and megestrol acetate

To the best of our knowledge, this is the first report of in vivo endometrial estrogen and progesterone receptor induction as a result of tamoxifen exposure in a postmenopausal breast cancer patient. The following observations, that the postmenopausal endometrium is sensitive to tamoxifen, that this agent can act as an estrogen-like substance, and that it may cause proliferation of the endometrium in the absence of progestin, may explain the endometrial decidual changes described herein as a protective mechanism against possible neoplastic endometrial changes.

The role of color Doppler flow in the management of nonmetastatic gestational trophoblastic disease

Three patients with findings suggestive of invasive gestational trophoblastic neoplasm and lung metastasis were assessed by color Doppler transvaginal ultrasound, before and during chemotherapy. The sonographic findings were correlated with beta-hCG levels measured at various stages of treatment. Results were compared with blood flow indices found during normal first trimester pregnancies, and those following elective termination of pregnancy. The mean resistance indices were significantly lower in the patients treated with chemotherapy (0.410 +/- 0.04) than in the early pregnancy control group (5-8 weeks gestation; n = 20, resistance index = 0.494 +/- 0.06). The difference between the groups was statistically significant (chi 2; p < 0.05). No pathological flow patterns could be discerned in 10 patients, who after termination of pregnancy had beta-hCG levels below 5 IU/ml. The response of gestational trophoblastic neoplasms to chemotherapy could be reliably assessed by observing the changes in flow resistance, which paralleled the gradual decrements in serial measurements of beta-hCG levels. Thus, the statistically significant results of our study are very encouraging and may indicate that color Doppler flow is a noninvasive, reproducible, useful and highly reliable new diagnostic approach for the diagnosis and management of patients suffering from uterine malignant gestational trophoblastic disease.

Infertility due to diseased pelvic peritoneum: laparoscopic treatment

Thirty-one patients complaining of unexplained infertility for at least 36 months and diagnosed elsewhere were reassessed laparoscopically. After staining their pelvic peritoneum with concentrated methylene blue, they presented with extensive areas of dark blue discoloration, and were diagnosed as suffering from 'diseased pelvic peritoneum'. The levels of peritoneal CA 125 were assessed. At the end of the diagnostic procedure, bipolar electrocoagulation or defocalized laser beam therapy was performed to destroy the affected peritoneal areas, and to allow peritoneal regeneration. Twenty-five pregnancies were obtained following this treatment. A detailed description is given of the diagnosis and treatment procedures.

The inability of preovulatory ovarian scan to predict multifetal pregnancy occurrence in a follow-up of induction of ovulation with menotropins

OBJECTIVE

To establish the predictive role of preovulatory ovarian ultrasonography in the occurrence of multiple pregnancy after hMG and hCG treatment for anovulatory infertility.

DESIGN

Prospective.

SETTING

Outpatient Infertility Clinic.

PATIENTS

Ninety-five anovulatory women who conceived after gonadotropin therapy.

INTERVENTION

Induction of ovulation by hMG and hCG monitored by plasma E2 measurements and ovarian ultrasonography.

MAIN OUTCOME MEASURES

All follicles visualized on the day of hCG administration were recorded and divided into the following four groups: group I, 10 to 12 mm; group II, 13 to 15 mm; group III, 16 to 18 mm; and group IV, 19 mm and larger. The sonographic findings were statistically evaluated to 80 singletons and 45 multiple pregnancies.

RESULTS

No statistical correlation was found to exist between the number of follicles from the different groups and the number of fetuses.

CONCLUSIONS

The number and sizes of follicles visualized on the day of hCG administration have no predictive value regarding the occurrence of a multiple pregnancy.

Growth hormone--non multum sed multa (quality, not quantity)

In view of the recent availability of recombinant human growth hormone (GH) and reports of its ability to augment ovulation induction by exogenous gonadotropins, we have surveyed the reproductive physiological role of GH and the family of polypeptides that mediate its action. The clinical studies using GH to improve ovulation induction, although achieving a significant reduction in exogenous gonadotropin administration, show only minor benefits in terms of attainment of pregnancy. An explanation for this phenomenon is suggested, and we provide guidelines for whom GH should be recommended.

Relationship between embryo morphology and implantation rate after in vitro fertilization treatment in conception cycles

OBJECTIVE

To investigate the relationship between the embryo number and morphology in conception cycles and the incidence of multiple pregnancies.

DESIGN

The study is based on information received from a computerized data base.

SETTING

In Vitro Fertilization Unit, Sapir Medical Center, Kfar Saba, Israel.

PATIENTS

A total of 117 consecutive pregnancies resulted from replacement of fresh embryos in our IVF-ET program.

MAIN OUTCOME MEASURES

The impact of embryo quality, as assessed by morphological parameters, on the multiple pregnancy rate (PR).

RESULTS

Implantation rates positively correlated with the number and the quality of transferred embryos. However, no multiple pregnancies occurred when only two embryos were replaced. There were no multiple pregnancies when only embryos of low quality (grades 1 and 2) were transferred. Furthermore, there was no correlation between the number of replaced embryos of poor quality and the rate of implantation. The multiple PR increased from 10% when a mixture of high and low quality embryos were transferred to 30.76% when only embryos of highest quality were transferred.

CONCLUSION

The implantation rate of transferred embryos is directly correlated with the morphological scoring. The results of the study suggest that the number of embryos transferred should be balanced against their morphological quality to reduce the rate of multiple pregnancies.

Percutaneous catheter drainage of tubo-ovarian abscesses

We present the successful treatment of tubo-ovarian abscesses in three young patients by continuous percutaneous drainage, inserted under the guidance of real-time ultrasonography using only local anesthesia. Each patient had been diagnosed laparoscopically as suffering from acute pelvic inflammatory disease, but had formed abscesses despite extensive broad-spectrum antibiotic therapy. One case involved a complication of the ovum pick-up procedure; the woman had tubo-ovarian abscesses with infected hematomas. Because the abscesses were localized anteriorly in the lower abdomen and did not reach the pouch of Douglas, they could not be drained through a posterior colpotomy. Ultrasound guidance allowed us to drain all the areas of the multioculated abscesses. We suggest that percutaneous abscess drainage be the initial treatment of choice for tubo-ovarian abscesses before laparotomy is considered.

Mumps orchitis among soldiers: frequency, effect on sperm quality, and sperm antibodies

This study reports on 72 young soldiers who suffered from a recent epidemic of acute mumps, with special emphasis on 19 who suffered from mumps orchitis and whose spermograms were in the fertility range. The immunological work-up for antibodies in sera or seminal plasma gave normal results for the patients diagnosed with orchitis, as well as the controls. The only remarkable finding was an increased risk of borderline significance for orchitis in smokers. The present study has proven that the presence of antisperm antibodies does not play a role in the etiology of mumps orchitis.

Third-trimester uterine rupture after prostaglandin E2 use for labor induction

Prostaglandin E2 is a powerful oxytoxic agent that reliably initiates labor, even in the presence of an unripened cervix. The very low incidence of obstetric and neonatal side effects contributes to its universal use. Only nine cases of uterine rupture during the third trimester of pregnancy after application of various prostaglandin E2 preparations have been reported in English. Although uterine rupture after prostaglandin administration is a very rare complication, no prostaglandin compound seems to be exempt from it.

Ectopic pregnancy, the new gynecological epidemic disease: review of the modern work-up and the nonsurgical treatment option

Over the past few decades, the incidence of ectopic pregnancy has increased almost to the extent of an "epidemic disease." Early diagnosis of tubal pregnancy, with the aid of serum human chorionic gonadotropin, high-resolution ultrasound, and the more liberal use of laparoscopy, has dramatically reduced both maternal mortality and the need for radical surgery. Despite this, women with previous ectopic pregnancies still have reduced fertility potential. We report on some current aspects of the epidemiology, etiology, and work-up of ectopic pregnancy. In a review of 328 patients, gleaned from the literature, who were treated with various nonsurgical options, 283 (86%) were able to avoid surgery. The benefits, safety, and efficacy of the various treatment options are discussed, with appropriate recommendations for their use.

Lack of correlation between hormonal blood levels and endometrial maturation in agonadal women with repeat implantation failure following embryo transfer from donated eggs

Five women with ovarian failure who repeatedly failed to conceive following embryo transfer from donated eggs underwent endometrial development investigation. One endometrial biopsy was obtained on cycle days 19, 21, and 23 during three consecutive artificially induced cycles. All five patients had only early secretory changes on days 19 and 21. Histological evaluation on cycle day 23 revealed various developmental stages: two women had "in-phase" endometrium, two patients had adequately developed stroma but significantly retarded glandular maturation, and one women showed no progress. The histological findings were conclusive for a significant maturation delay and an impaired endometrial receptivity. There was a lack of correlation between the peripheral hormonal blood levels and the endometrial maturation.