Impact of whole systems traditional Chinese medicine on in-vitro fertilization outcomes

Patients undergoing IVF may receive either acupuncture or whole-systems traditional Chinese medicine (WS-TCM) as an adjuvant IVF treatment. WS-TCM is a complex intervention that can include acupuncture, Chinese herbal medicine, dietary, lifestyle recommendations. In this retrospective cohort study, 1231 IVF patient records were reviewed to assess the effect of adjuvant WS-TCM on IVF outcomes compared among three groups: IVF with no additional treatment; IVF and elective acupuncture on day of embryo transfer; or IVF and elective WS-TCM. The primary outcome was live birth. Of 1069 non-donor cycles, WS-TCM was associated with greater odds of live birth compared with IVF alone (adjusted odds ratio [AOR] 2.09; 95% confidence interval [CI] 1.36 to 3.21), or embryo transfer with acupuncture only (AOR 1.62; 95% CI 1.04 to 2.52). Of 162 donor cycles, WS-TCM was associated with increased live births compared with all groups (odds Ratio [OR] 3.72; 95% CI 1.05 to 13.24, unadjusted) or embryo transfer with acupuncture only (OR 4.09; 95% CI: 1.02 to 16.38, unadjusted). Overall, IVF with adjuvant WS-TCM was associated with greater odds of live birth in donor and non-donor cycles. These results should be taken cautiously as more rigorous research is needed.

Acupuncture and in vitro fertilization: a retrospective chart review

OBJECTIVES

In 2007, Craig et al. reported the results of a randomized controlled trial in which a standardized acupuncture protocol performed on the day of embryo transfer (ET) resulted in lower pregnancy rates after in vitro fertilization (IVF). Between 2005 and 2007, the Craig protocol was used by one of the authors (LHR) at an infertility clinic unaffiliated with the Craig et al. trial. The objective was to retrospectively review clinic records to evaluate the effect of the Craig protocol in both donor and nondonor IVF cycles on four outcomes: (1) live births; (2) biochemical pregnancies; (3) adverse outcomes; and (4) live births in nondonor cycles across age groups established by the Society for Assisted Reproductive Technology.

DESIGN

The study design was a retrospective chart review.

SETTING

The study was conducted at a private infertility clinic.

PATIENT(S)

Patients underwent fresh, donor (N=70) or nondonor (N=402) IVF-ET.

INTERVENTION(S)

The Craig protocol included the following points before ET: GV-20, CV-6, ST-29, SP-8, PC-6, LV-3; Shenmen and Brain on the left ear; and Uterus and Endocrine on the right ear. After transfer the points were LI-4, SP-10, ST-36, SP-6, KI-3; Uterus and Endocrine on the left ear; and Shenmen and Brain on the right ear.

MAIN OUTCOME MEASURE(S)

Live births (LB) beyond 24 weeks' gestation was the main outcome measure.

RESULT(S)

In nondonor IVF cycles, there were no differences in LB across age groups (odds ratio [OR]=1.04, 95% confidence interval [CI] 0.68-1.57), biochemical pregnancies (OR=0.60, 95% CI 0.27-1.33), or adverse outcomes (OR=0.63, 95% CI 0.31-1.26). In donor cycles, LB were higher in the acupuncture group (relative risk=1.31, 95% CI 1.02-1.71).

CONCLUSIONS

In this observational study, the Craig protocol was not found to lower IVF LB. In fact, the Craig protocol was associated with higher LB in donor cycles. These findings should be considered cautiously because more adequately powered, randomized research is needed.

Aggressive outpatient treatment of ovarian hyperstimulation syndrome with ascites using transvaginal culdocentesis and intravenous albumin minimizes hospitalization

PURPOSE

To assess the effectiveness of outpatient treatment of Ovarian Hyperstimulation Syndrome associated with ascites.

METHODS

Forty-eight patients diagnosed with ovarian hyperstimulation and ascites from 2,246 consecutive in vitro fertilization cycles were retrospectively studied. Patients were treated with outpatient transvaginal culdocentesis and rehydration with intravenous crystalloids and albumin every 1-3 days until resolution of symptoms or hospitalization was required. Outcomes measured included incidences of hospitalization, pregnancy outcomes, cycle characteristics, and oocyte donors versus nondonors comparisons.

RESULTS

No complications occurred from outpatient treatments, and 91.6% of patients avoided hospitalization. The pregnancy rate in patients undergoing transfer was 84.7%, and the spontaneous loss rate was 16%. Overall, the estradiol on day of hCG was 4331 pg/mL (range 2,211-8,167), ascites removed was 1910 cm3 (122-4,000), and number of outpatient treatments was 3.4 (1-14). Nondonors averaged more outpatient treatments than donors (3.97 vs. 1.85), but similar rates of hospitalization (3/35 vs. 1/13).

CONCLUSIONS

Outpatient treatment consisting of culdocentesis, intravenous rehydration, and albumin minimized the need for hospitalization in hyperstimulated patients.

Donor oocyte cytoplasmic transfer did not enhance implantation of embryos of women with poor ovarian reserve

PURPOSE

To determine whether donor oocyte cytoplasm transferred into the oocytes of women < or = 40 years or with diminished ovarian reserve would enhance embryo quality, implantation, or pregnancy rates.

METHODS

Study subjects included women > or = 40 years (15) or with abnormal FSH levels (3). Healthy volunteers (18) produced oocytes for cryopreservation. Donor oocytes were thawed and cytoplasm from surviving oocytes was injected with a single sperm into the cytoplasm of recipient oocytes. Outcome measures included embryo quality scores, implantation, and pregnancy rates.

RESULTS

Eighteen donors produced 213 oocytes for cryopreservation and 39/171 (22.8%) survived thawing. Eighteen recipients initiated 25 IVF cycles with embryo transfer in 20 cycles after cytoplasmic transfer (CT). Four cycles resulted in three biochemical losses and one aneuploid clinical loss. Embryo quality did not improve with CT compared to pre-CT IVF cycles in six recipients.

CONCLUSIONS

CT with cryopreserved donor oocyte cytoplasm did not enhance success in women with advanced reproductive age or low ovarian reserve.

The number of embryos available for transfer predicts successful pregnancy outcome in women over 39 years with normal ovarian hormonal reserve testing

PURPOSE

The purpose was to determine whether the number of embryos available for transfer following IVF in women over age 39 predicted a successful pregnancy outcome.

METHODS

Retrospective analysis of 455 consecutive IVF cycles in women > or = 40 years of age.

RESULTS

Few cycles were canceled (29/455, 6.4%) or produced no embryos (5/455, 1.1%). Women 40-43 years of age with normal ovarian reserve had a significantly greater delivery rate when > or = 4 embryos were available for transfer than when < 4 embryos were available (17.8% versus 2.4%, P = 0.002). Subsequent IVF cycles, from women with normal FSH whose first cycle produced < 4 embryos, produced delivery rates of 13.0% when > or = 4 embryos were available. Women with abnormal ovarian reserve or age > or = 44 years had very low delivery rates (1.2% and 1.4% respectively).

CONCLUSIONS

The number of embryos available for transfer significantly predicts delivery from IVF-ET among reproductively older women. Many women age 40-43 with normal ovarian reserve can achieve pregnancy through IVF.

Pregnancy rates in sequential in vitro fertilization cycles by oocyte donors(1)

OBJECTIVE

To evaluate the clinical outcome of in vitro fertilization (IVF) treatment cycles from individual oocyte donors who underwent multiple sequential donations.

METHODS

We reviewed clinical outcome data from sequential anonymous oocyte donation cycles using donors who underwent multiple IVF stimulations. Donors were grouped by the interval between cycles and the cycle number (rank). The primary outcome measure was delivery rate by individual donor per retrieval from the combined derivative fresh and frozen embryo transfers.

RESULTS

Duration and amount of gonadotropin therapy and the fertilization rates did not correlate significantly with the interval between cycles or cycle rank. Cumulative delivered pregnancy rates for cycles 1-6 were 51.5%, 54.6%, 50.5%, 51.5%, 51.1%, and 57.6%, respectively. Delivered pregnancy rates did not vary by interval between cycles.

CONCLUSION

Young healthy presumed or proven fertile women can reliably donate oocytes for at least six cycles with the expectation of consistently high pregnancy rates.

Serum concentrations of enclomiphene and zuclomiphene across consecutive cycles of clomiphene citrate therapy in anovulatory infertile women

OBJECTIVE

To determine the serum concentrations of enclomiphene and zuclomiphene across consecutive cycles of clomiphene citrate treatment in anovulatory infertile women.

DESIGN

Prospective cohort.

SETTING

Tertiary institutional infertility clinic.

PATIENT(S)

Fourteen consenting anovulatory infertile women receiving standardized, cyclic, incremental treatment with clomiphene citrate for ovulation induction.

INTERVENTION(S)

Clomiphene citrate treatment (50-150 mg/d, cycle days 5-9), titrated to the minimum effective ovulation-inducing dose, was administered for three to six total cycles. Blood samples were obtained on cycle days 3 and 10 in each treatment cycle.

MAIN OUTCOME MEASURE(S)

Serum concentrations of enclomiphene and zuclomiphene.

RESULT(S)

Cycle day 3 zuclomiphene levels were below assay limits in all initial cycles, increased progressively across three consecutive cycles, and thereafter plateaued. Cycle day 3 enclomiphene concentrations were uniformly undetectable. Cycle day 10 enclomiphene levels increased with dose administered, but these observations were not statistically significant.

CONCLUSION(S)

Clomiphene citrate induction of ovulation results in an isomer-specific systemic accumulation of zuclomiphene across consecutive cycles of treatment. The combined maximum concentration of enclomiphene and zuclomiphene attained in practice approximates 100 nmol/L and is generally well below levels previously demonstrated to have adverse effects in vitro.

Preservation of reproductive function before therapy for cancer: new options involving sperm and ovary cryopreservation

In summary, sperm cryopreservation for future ICSI and ovarian tissue cryopreservation for future autotransplantation are new opportunities to preserve reproductive options of great importance to patients with newly diagnosed cancer. Since patients must utilize these strategies before cancer therapy is initiated, and these patients will not have a future chance to benefit once therapy has damaged gonadal function, awareness of these technologies among oncologists, radiation therapists, and other colleagues who interface with the victims of cancer is a high priority.

Characteristics of gonadotropin response, follicular development, and endometrial growth and maturation across consecutive cycles of clomiphene citrate treatment

OBJECTIVE

To examine the patterns of gonadotropin response, follicular development, and endometrial growth and maturation across consecutive cycles of clomiphene citrate (CC) treatment.

DESIGN

Prospective analysis of cycle characteristics.

SETTING

Academic tertiary medical center.

PATIENTS

Nineteen consenting anovulatory infertile women receiving standardized, cyclic, incremental treatment with CC (50 to 150 mg/d, cycle days 5 to 9) for ovulation induction.

INTERVENTIONS

In each of up to six consecutive treatment cycles, urinary LH was monitored twice daily from cycle day 10 until detection of the LH surge or day 21; blood samples and transvaginal ultrasound (US) examination were obtained on cycle days 3, 10, and every 1 to 3 days thereafter until collapse of the dominant follicle. Endometrial biopsy was performed 11 to 13 days after the LH surge in the first, third, and sixth ovulatory cycle.

RESULTS

Follicular phase duration, peak follicular diameter, the number of preovulatory follicles, and peak endometrial thickness and echo pattern remained consistent across consecutive ovulatory (n = 55) and anovulatory (n = 23) treatment cycles. Endometrial dating was > or = 3 days out of phase in 2 of 31 (6%) cycles sampled. Peak serum E2 and P concentrations did not vary with cycle number or correlate with endometrial thickness or echo pattern. Cycle day 10 FSH levels were significantly higher in ovulatory subjects than in anovulatory subjects.

CONCLUSIONS

Patterns of gonadotropin response, follicular development, and endometrial growth and maturation remain consistent across consecutive cycles of CC treatment.

Comparisons of pregnancy loss patterns after intracytoplasmic sperm injection and other assisted reproductive technologies

OBJECTIVE

To compare outcome of pregnancies after intracytoplasmic sperm injection (ICSI) with those of other assisted reproductive technologies.

DESIGN

Pregnancy outcomes after ICSI were followed prospectively and compared with pregnancy outcomes after IVF with fresh and frozen ETs and donor oocyte cycles.

SETTING

A private tertiary referral center for genetics and infertility in Fairfax, Virginia.

PATIENTS

One hundred thirty-six couples achieving pregnancy after undergoing ICSI, 71 after IVF, 35 donor oocyte recipients, and 19 after transfer of frozen-thawed embryos.

INTERVENTIONS

In vitro fertilization and/or ET for all couples. Dilatation and curettage to obtain products of conception for chromosome analysis in 28 women experiencing spontaneous abortion.

MAIN OUTCOME MEASURES

Pregnancy outcomes were classified as preclinical loss, clinical loss, and ongoing pregnancy.

RESULTS

The mean frequency of preclinical pregnancy loss was 26% after ICSI, 28% after IVF, 3% after ET using donor oocytes, and 11% after frozen ET. The rate of clinical loss after ICSI (21%) was compared with IVF (18%), donor oocyte cycles (11%), and frozen ETs (21%).

CONCLUSIONS

Intracytoplasmic sperm injection is not associated with an increase in pregnancy losses, clinical or preclinical, compared with conventional IVF.

Effects of enclomiphene and zuclomiphene on basal and gonadotrophin-stimulated progesterone secretion by isolated subpopulations of small and large ovine luteal cells

We examined the effects of enclomiphene and zuclomiphene, alone and in combination with oestradiol, on basal and gonadotrophin-stimulated progesterone secretion by isolated subpopulations of both large (granulosa-lutein) and small (theca-lutein) ovine luteal cells. Isolated large and small luteal cells derived from intact, enucleated ovine corpora lutea were incubated for 48-120 h with or without 22R-hydroxycholesterol or pregnenolone (2.5 microM) and a range of enclomiphene, zuclomiphene, and/or oestradiol concentrations (3-100 microM), both with and without ovine luteinizing hormone (100 ng/ml). Spent media were assayed in duplicate for progesterone content by radioimmunoassay. Enclomiphene, zuclomiphene, and oestradiol exhibited equivalent dose-dependent inhibitory effects on basal and gonadotrophin-stimulated small and large ovine luteal cell progesterone secretion under all substrate conditions. Both cell types became more sensitive to clomiphene inhibition with increasing time in culture. In combined treatments, the effects of oestradiol and either enclomiphene or zuclomiphene became additive in longer-term cultures and were never antagonistic. In this model system, (i) clomiphene, like oestradiol, appears to inhibit 3beta-hydroxysteroid dehydrogenase activity, (ii) both stereoisomers act as oestrogen agonists, (iii) neither demonstrates any anti-oestrogenic properties, and (iv) both large and small luteal cells become more sensitive to clomiphene inhibition with increasing duration of exposure.

Single vs. multiple semen specimens in screening for male infertility factors. A comparison

OBJECTIVE

To reevaluate the number of semen analyses necessary to establish whether further male infertility testing is necessary.

STUDY DESIGN

The results of three consecutive semen analyses for infertility evaluations were retrospectively reviewed. A male factor was defined by an abnormal semen analysis if either the first specimen of three (single-sample screening) or two of the three specimens (multiple-sample screening) met World Health Organization criteria. Males considered abnormal by multiple-sample screening underwent sophisticated andrologic evaluation.

RESULTS

A single-sample conventional semen analysis obtained from 209 males demonstrated a diagnostic accuracy of 10.4% false negatives and a sensitivity of 89.6% when compared to that of multiple-sample analysis. Andrologic evaluation of abnormal males by multiple-sample screening confirmed that 9 of the 11 men with normal first specimens were abnormal; all others were confirmed as abnormal.

CONCLUSION

Analysis of multiple semen specimens provides a reliable screen in the evaluation of male factor infertility when the goal is to minimize the false negative rate of screening tests.

Ultrasonographic characteristics of first-trimester gestations in recurrent spontaneous aborters

OBJECTIVE

To compile, for the first time, serial ultrasonographic findings during the first trimester of pregnancy in women with a history of primary recurrent spontaneous abortion so as to define the dynamics of early normal and abnormal gestations in this category of gravidas.

STUDY DESIGN

Transvaginal ultrasonograms were obtained weekly from 5 to 12 weeks' gestational age in 40 women, 10 each of four groups: recurrent spontaneous aborters and primiparas (controls), with both successful and failed gestations.

RESULTS

Embryonic heart motion was detected in 40-50% of successful pregnancies during the fifth week of gestation and in the balance by the sixth week, while heart motion was detected in no more than 50% of pregnancies that later failed. Of the failed pregnancies, all were evident by the eighth week of gestation, including those with previously documented viability. The gestational sac size and crown-rump length were smaller than expected in both failed groups, with the sac size difference evident as early as week 5 and the crown-rump length difference apparent by week 7.

CONCLUSION

Appropriate timing of the initial ultrasonogram in recurrent aborters (i.e., 8 weeks' gestational age) can identify, by means of heart motion and gestational sac features, all pregnancies that will ultimately fail.

Life table analysis of pregnancy rates in a general infertility population relative to ovarian reserve and patient age

This study evaluated the impact of age and ovarian reserve status on cumulative pregnancy rates. Approximately 1200 women from a general infertile population underwent ovarian reserve screening with the clomiphene citrate challenge test in the first few months of their initial evaluation. All patients then underwent a thorough infertility evaluation with therapy appropriate for their specific diagnoses. Patients with evidence of tubal disease, peritoneal adhesive disease, or male factor were eliminated. The 588 remaining patients were evaluated based on their age and ovarian reserve status, and their long-term pregnancy rates were compared using life table analyses. There was a dramatic decrease in pregnancy rates associated with an abnormal clomiphene citrate challenge test which was uniformly poor independent of age. Patients with normal ovarian reserve had much higher pregnancy rates, but a significant age-related decline in pregnancy rates was clearly identified. We conclude that women with evidence of diminished ovarian reserve have uniformly poor pregnancy rates independent of their age, but that age remains an important prognostic factor among those with a normal ovarian reserve. The combined use of maternal age and ovarian reserve screening should be used when counselling individual patients regarding their long-term prognoses for conception.

Activation of complement in humans with a first-trimester pregnancy loss

Serum complement (C') activity in recurrent spontaneous aborters and primiparous controls with successful and unsuccessful pregnancies was quantified so as to define the dynamics of C' activation in early pregnancy loss. C' hemolytic activity was shown to be stable throughout the first trimester of pregnancy and did not differ from preconception levels in all of the successful pregnancies of recurrent aborters and controls and in the majority of pregnancy losses. However, 30% of recurrent aborters and 20% of controls with a pregnancy loss demonstrated activation of C' by the alternate pathway as early as the 7th week with a progressive decline in C' activity until abortion was clinically completed. Circulating levels of C3 dropped from 1.34 to 0.53 mg/dl, and factor B levels declined from 0.34 to 0.14 mg/dl in these hypocomplementemic women. Pregnancy loss is therefore associated with C' activation in a subset of both recurrent and nonrecurrent aborters and this occurs largely before loss of fetal viability.

The effect of a surgical lubricant on in vivo sperm penetration of cervical mucus

The implications of these data is that coital lubricants may impair fertility of some couples. Unfortunately, conception was not an end point on this study, and our conclusions must be considered inferential. Nevertheless, the results from this study lead us to recommend avoidance of surgical lubricants by couples attempting pregnancy.

Outcome of pregnancy after laparoscopy and chromotubation during cycles of conception: a report of three cases

BACKGROUND

Diagnostic tubal patency procedures may displace an early pregnancy. Hysterosalpingography performed in the presence of an unrecognized pregnancy has been reported to result in an ectopic pregnancy. No such information on laparoscopy performed during a cycle of conception has been reported.

CASES

Three cases of laparoscopy were performed during the luteal phase of an unrecognized pregnancy cycle. The three patients were counseled to avoid conception before surgery. All had an undetectable serum hCG level within 3 days of surgery and an undetectable urine hCG level on the day of surgery. The three pregnancies had an uneventful prenatal course, with delivery at term.

CONCLUSION

Although follicular phase scheduling of tubal patency tests would avoid potential pregnancy complications, the risk from luteal phase laparoscopy and chromotubation to an unrecognized pregnancy may be less than expected.

Characterization of peripheral blood and peritoneal fluid mononuclear cell subsets in fertile and infertile women

Mononuclear cell subpopulations from the peripheral blood (PB) and peritoneal fluid (PF) of fertile and infertile women were quantified by flow cytometry using a double-staining monoclonal antibody technique. No differences in the percentage distribution of mononuclear cells between fertile and infertile women were demonstrated when either the PB constituents or the PF components were compared to one another. When the mononuclear cell composition in the PB was compared with that in the PF however, the percentage of PF-activated T cells and monocytes was increased in both fertile and infertile women as opposed to that in the PB, while there was a decrease in T helper cells (fertile and infertile women) and natural killer cells (fertile women and infertile women with endometriosis). Even though shifts do exist in the immunocytes of PF from fertile and infertile women, evidence is lacking that the PF is an immunologic mediator of infertility.

First trimester sonographic characteristics of patients with recurrent spontaneous abortion

First trimester ultrasonographic evidence of FHM infers a good prognosis for normal pregnancies, although similar data in RSA is scarce. Abortion before 20 weeks' gestation occurred in 12 of 167 control patients (7.2%) and five of 23 patients with RSA (21.7%) after detection of fetal heart motion (P = 0.0382). The abortion rate decreased with a MSS-CRL difference of > 8 mm in controls but not in patients with RSA. We conclude that the probability of pregnancy success is not improved with FHM identification in patients with RSA.

The predictive value of hysterosalpingography for tubal and peritoneal infertility factors

OBJECTIVE

To investigate a practical classification system of hysterosalpingogram (HSG) results that accurately identifies patients with severe pelvic disease or a normal pelvis to allow appropriate patient counseling of therapeutic options.

DESIGN

Retrospective chart review from university teaching hospital. Hysterosalpingography results were classified as normal, abnormal (bilateral distal tubal obstruction), or suspicious (all others). At surgery, chromopertubation was performed, and pelvic disease was documented.

RESULTS

From a total of 756 patients, HSGs were confirmed surgically in 96.6% of normals, 63.1% of suspicious, and 95.7% of abnormal. Associated moderate-severe pelvic disease was found in 16.2% of normals, 53.9% of suspicious, and 81.7% of abnormal.

CONCLUSION

Abnormal HSGs are highly predictive of severe pelvic disease, and counseling of treatment options does not require diagnostic laparoscopy. Patients with suspicious HSGs frequently have normal tubes but also have a significant likelihood of tubal or associated pelvic disease, and they are responsible for the poor predictive value of the HSG. This group of patients requires confirmatory laparoscopy preferably by a physician qualified in pelviscopic surgery. Normal HSGs have a high negative predictive value. Nevertheless, the incidence of associated pelvic disease in the normal HSG group is high enough to warrant diagnostic laparoscopy if nonsurgical treatment is unsuccessful.

Natural killer cell activity from pregnant subjects is modulated by RU 486

Natural killer cells form an integral component of the body's innate immune system. Natural killer cell activity is reduced during pregnancy, especially in the latter half. To investigate the role progesterone may play in immunomodulating natural killer cell activity during pregnancy, we evaluated the effect of RU 486 on natural killer cells isolated from pregnant subjects. Natural killer cell activity was measured with an 18-hour, Chromium 51 release, microcytotoxicity assay with K-562 cells as target cells. We demonstrated that RU 486, in a concentration range from 5 to 40 mumol/L, augmented natural killer activity threefold to fivefold over baseline. This augmentation of activity was suppressed to baseline by the addition of excess progesterone. The addition of hydrocortisone resulted in an insignificant reduction in this augmented activity. This study suggests that progesterone may play a role as an immunomodulating factor in maternal acceptance of the fetal allograft.

Tubal and peritoneal factors in the infertile woman: use of patient history in selection of diagnostic and therapeutic surgical procedures

For facilities with both ambulatory and inpatient surgical capabilities, we have attempted to develop an efficient strategy for the evaluation of infertile women. The strategy was intended to (1) avoid inpatient laparoscopy, (2) minimize the number of patients having laparoscopy who subsequently required laparotomy, and (3) minimize hysterosalpingography (HSG). Patients were selected for ambulatory laparoscopy or inpatient laparotomy by means of an algorithm based on their history and the selective use of HSG. Laparoscopy was avoided in 18.1% of patients and HSG in 41.6% of patients. We conclude that, when both inpatient and outpatient surgical facilities are available, the evaluation of female infertility may not always require HSG or laparoscopy.

Natural killer cell activity and serum autoantibodies in women with postpartum thyroiditis

Postpartum thyroiditis (PPT) is a form of painless lymphocytic thyroiditis which is thought to be caused by an exacerbation of underlying subclinical autoimmune thyroid disease during a postpartum period of immune rebound. The purposes of this study were to analyze natural killer cell (NK) functional activity and antibody-dependent cell-mediated cytotoxicity (ADCC) of peripheral blood mononuclear cells in patients with PPT compared to those in normal nonpostpartum and postpartum women. NK activity and ADCC were determined by specific lysis of 51Cr-labeled K562 human erythroleukemia tumor cells at varying effector (mononuclear cell) to target cell ratios. Nineteen PPT patients between 4-9 months [mean, 6.5 +/- 0.4 (+/- SE)] postpartum were compared to 20 nonpostpartum women, 31 healthy women between 4-9 months (6.7 +/- 0.3) postpartum, and 14 women 2 days after delivery. There were significant differences in the NK functional activities of the 4 groups (F = 7.95; P = 0.0002). The mean NK activities, as measured by percent specific lysis at an effector to target cell ratio of 10:1, were 31.1 +/- 3.3%, 20.9 +/- 2.3%, 22.5 +/- 2.8%, and 11.5 +/- 2.0% in the nonpostpartum, PPT, postpartum, and 2-day postpartum groups, respectively. Specific lysis by ADCC was not significantly different from lysis by NK activity in any group. The PPT, postpartum, and 2-day postpartum groups had significantly lower NK activity compared to that in nonpostpartum women (P less than 0.05). Both the PPT and postpartum women had higher NK activities than the 2-day postpartum women (P less than 0.05). However, there were no significant differences in the NK activities of the PPT patients compared to those of the healthy postpartum women. Patients with PPT were also found to have associated autoimmune dysfunction. The PPT group had significantly higher serum antinuclear antibody titers; 8 of 24 patients (33%) had titers of 1:160 or greater compared to only 2 of 29 healthy postpartum women (7.4%; P less than 0.05). Seven of the PPT patients had serum immune complexes, and 3 had TSH receptor antibodies. We conclude that functional NK activity and ADCC in peripheral lymphocytes of PPT patients are not different from those in healthy postpartum women; however, the postpartum women had significantly decreased activity compared to that in nonpostpartum women. These data emphasize the importance of studying healthy postpartum women in investigations of PPT, since the immunological changes in pregnancy and the postpartum period remain largely undefined.

The role of laparoscopy in the evaluation of candidates for sterilization reversal

An algorithm that avoids preliminary laparoscopy for sterilization reversal (SR) candidates with previous Pomeroy, loop, Hulka clip, Irving, and single-burn cautery tubal ligation techniques was used. Anastomosis was attempted only when it could be anticipated that the final length of at least one tube would be 3 cm or more. Of 259 SR candidates evaluated according to the algorithm, 235 had SR procedures. Seven of 185 patients (3.8%) who did not undergo laparoscopy were found to have inoperable tubes at laparotomy. Four of these patients had histories of a prior unilateral salpingectomy. The authors conclude that, given their criteria for proceeding with tubal anastomosis, laparoscopy can be avoided in properly selected SR candidates. The results also indicate that patients with a history of unilateral salpingectomy should undergo preliminary laparoscopy.

Systemic nocardiosis in pregnancy. A case report

Pregnancy in women with significant medical complications has become a part of modern obstetrics. We report a case of systemic nocardiosis in a gravida with sarcoidosis. The importance of aggressive management and the influence of pregnancy on antibiotic treatment are discussed.