The dosage of human chorionic gonadotropins influences the relationship between progesterone and cycle outcome during in vitro fertilization-embryo transfer.

OBJECTIVE: To determine if the dose of hCG affects the initial rise in progesterone seen in patients undergoing IVF-ET and therefore affects it usefulness as a predictor of cycle outcome. DESIGN: Comparison of the rise in progesterone with cycle outcomes for IVF patients receiving 5,000 or 10,000 mIU hCG to stimulate oocyte maturation. SETTING: University-based infertility program. Patients-One hundred six patients undergoing IVF-ET on a long protocol of down-regulation with GnRH, hMG stimulation, and hCG to stimulate oocyte maturation. Stimulation protocol varied only in dose of hCG [5,000 mIU (N = 72) vs. 10,000 mIU (N = 34)]. MAIN OUTCOME MEASURE(S): Rise in progesterone from 12 hours before to 12 hours after hCG administration and its relationship with cycle outcome. RESULTS: All 106 women exhibited a rise in progesterone following the administration of hCG. As seen in earlier studies, there appeared to be a relationship between minimal progesterone increases (<3-fold) and cycle failure in patients receiving 5,000 mIU (P < .02). However, using the criteria of the previous study, there appears to be no relationship between progesterone and cycle outcome in patients receiving 10,000 mIU (P = .30). Further, the higher dose of hCG appeared to induce greater increases in progesterone over the 24-hour period examined (P < .02). After readjustment of the critical value to 3.5-fold, there was an increased tendency toward cycle failure in women exhibiting a minimal progesterone increase. Unlike the relationship associated with 5,000 mIU hCG, though, the relationship between 10,000 mIU hCG and progesterone levels was not statistically different (P = .10). CONCLUSIONS: Increasing the dose of hCG used to stimulate oocyte maturity shifts the previously described relationship between progesterone and IVF-ET-cycle outcome. However, while it remains unclear if progesterone can be used as a predictor of outcome at the higher hCG dose, it appears clear that a relationship exists between minimal progesterone response to hCG and cycle failure.

Update: cancer screening in women.

Current cancer screening recommendations for women have been reviewed. Controversies have been identified. Many additional references are available upon request.

Hormone release from cultured luteinized-granulosa cells mimics differences seen in vivo in patients undergoing IVF-ET.

OBJECTIVES: Previous research from this laboratory has suggested that a relationship exists between the increase in circulating progesterone concentrations at the time of hCG administration and cycle outcome in patients undergoing IVF. Progesterone (P) increases of threefold or better within the 24-h period surrounding hCG administration appeared to be associated with a higher pregnancy rate. These data suggest a functional difference in the luteinized-granulosa of patients undergoing IVF. To test this hypothesis: DESIGN: A split-split plot arrangement of treatments with two cell sources under five hormonal stimulations at four time points. METHODS: Luteinized-granulosa cells (LGC) were collected from patients with either a normal increase (> or = threefold = NC) in circulating P (n = 4) or those with lower P increases (AC; n = 4). The cells were isolated by Ficoll gradient centrifugation and then cultured in 24-well culture plates using a modified media 199 containing 100 mIU/ml of hMG, FSH, LH, hCG, or a nonhormonal control to stimulate steroid-hormone production. At time points 2, 4, 6, and 8 days, media from each well was frozen for later hormone assay and replaced with fresh media containing the same stimulating factor. After all the media had been collected, P and estradiol (E2) released into the media were measured using radioimmunoassay. RESULTS: Results indicate a higher media concentration of P (P < 0.001), but not E2 (P = 0.254), from NC, regardless of hormone stimulation or time in culture, when compared to the media from AC. Media concentrations of E2 were affected by a cell source by hormone stimulation by time interaction (P < 0.001) with varying effects. Media from NC maintained a constant E2 of between 1000-3000 pg/ml over the 8-day period (P = 0.163). However, media from AC demonstrated a stimuli-dependent E2 release (P < 0.001) ranging from < 1000 to over 11,000 pg/ml. CONCLUSIONS: These data appear to support the existence of functionally different populations of luteinized-granulosa cells from patients undergoing IVF-ET.

Adhesion-promoting properties of dyes routinely used during fertility surgeries.

PURPOSE: With the link between peritoneal adhesions and infertility well established, it is critical that materials used in pelvic surgery be tested for their adhesion-forming properties. The current study examined the adhesion-inducing properties of two dyes routinely used for visualization during pelvic surgery. DESIGN: In vivo and in vitro examination of the effects of the dyes methylene blue and indigo carmine on adhesion formation in a mouse model. METHOD: A series of three experiments was conducted. In the first, dyes were injected directly into the peritoneal cavity. The mice were then sacrificed at one of two time points and the peritoneal cavity examined for adhesion formation. In addition, because of their purposed role in adhesion formation, macrophages from the cavity were examined for signs of dye-induced activation. Further studies of macrophage activation were then conducted in vitro to determine the effects of dye concentration and exposure time on the activation process. RESULTS: Both methylene blue and indigo carmine appeared to induce adhesion formation as well as macrophage activation in vivo. Further, long-term exposure to visual concentrations of both dyes appeared to induce macrophage activation. However, only those macrophages exposed to methylene blue exhibited signs of activation when the exposure time was limited to times equivalent to those which might be expected during surgery. CONCLUSION: Of the two dyes tested, indigo carmine might be the dye of choice in surgeries where fertility is to be maintained.

Increases in progesterone after human chorionic gonadotropin administration may predict cycle outcome in patients undergoing in vitro fertilization-embryo transfer.

In this study, both IVF-ET cycle and pregnancy outcome were compared with increases seen in P concentration during the 24-hour period from 12 hours before to 12 hours after hCG administration. A significantly higher PR (P < 0.001) was seen in women who had at least a threefold increase in P during this time period. Further, no pregnancies were reported from women with a less than twofold increase in P.

The fourth-year medical school curriculum: recommendations of the Association of Professors of Gynecology and Obstetrics and the Council on Resident Education in Obstetrics and Gynecology.

OBJECTIVES: The Association of Professors of Gynecology and Obstetrics and the Council on Resident Education in Obstetrics and Gynecology have proposed a fourth-year medical school curriculum for a student interested in pursuing a residency in obstetrics and gynecology. STUDY DESIGN: Faculty members and residents in North Carolina, Illinois, and Michigan were surveyed as to the ideal curriculum that they would recommend for fourth-year students. The committee members representing the Council on Resident Education in Obstetrics and Gynecology and the Association of Professors of Gynecology and Obstetrics then reviewed these surveys and proposed a final curriculum. RESULTS: A core curriculum of general medicine as an acting internship, an intensive care unit rotation, neonatology, and emergency medicine was recommended. Additional courses strongly considered were ambulatory obstetrics-gynecology, acting internship in obstetrics-gynecology, endocrinology, and general surgery. CONCLUSION: The committee recommends a curriculum that is broad and balanced in general medical education.

Chronic pelvic pain.

Chronic pelvic pain is a common and important gynecologic problem. The causes are diverse but can usually be categorized by the astute clinician. Gynecologic causes can often, although not always, be pinpointed for specific management protocols. Highlights of helpful areas are described in terms of history, physical examination, and laboratory and endoscopic diagnosis. Therapy may be medical, surgical, psychologic, or supportive. If specific, treatment is likely to be effective in some patients whereby a cause cannot be found, yet the patient may be helped. Some patients improve without treatment.

Resident attrition in obstetrics and gynecology.

OBJECTIVE: Our goal was to determine the rate of attrition from obstetrics and gynecology residency programs. STUDY DESIGN: The Council on Resident Education in Obstetrics and Gynecology sent questionnaires to all 295 obstetrics and gynecology residency program directors in the United States and Canada. These programs represent 4306 postgraduate-year 1 through 4 (or 5) resident positions each year. The program directors were asked the number of residents who left voluntarily or were dismissed in a 2-year period and the reasons they left. RESULTS: In a 2-year period 299 residents left or were dismissed (6.94% over 2 years, or 3.47% per year). Only 88 (1% per year) left specifically because they decided they preferred a different discipline. CONCLUSION: The rate of attrition from obstetrics and gynecology residency programs is not excessively high.

Seminal concentssrations of total and ionized calcium from men with normal and decreased motility.

In this study, sperm motility, velocity, and progression were compared with the total and Ca++ concentrations in the SF from men with normal and decreased motility (less than 60%). No significant difference in SF total calcium content was observed in men with normal and hypomotility. However, a statistically significant decrease in seminal Ca++ was observed in those men with decreased motility, when compared with that of men with normal motility.

Antepartum testing for vasa previa: current standard of care.

Vasa previa is a rare accident in obstetrics with high fetal mortality. There are simple tests available to distinguish fetal from maternal blood. Recently it has been called into medicolegal question whether patients with third-trimester bleeding need to be tested for fetal bleeding. We surveyed 100 community hospitals and all the medical schools in the United States in an attempt to answer the question. It appears that the standard of care in the United States does not require such testing.

A survey of pregnancies complicated by decreased amniotic fluid.

Four hundred seventy-one patients undergoing diagnostic ultrasonography were identified as having moderately decreased amniotic fluid or oligohydramnios, and 339 of these cases were reviewed. Ninety-two of the patients were excluded from further statistical analysis because their decreased fluid was attributed to rupture of the membranes only. Of the remaining patients there was a 7% neonatal malformation rate. Decreased amniotic fluid before 27 weeks of gestation was associated with a significantly poor outcome. Of all the live births, infants of patients with oligohydramnios had lower Apgar scores at 1 minute and 5 minutes than did infants of patients with moderately decreased amniotic fluid. Of cases of patients with decreased fluid, 10% involved fetal distress during labor and in 17% meconium was present. Decreased levels of fluid were associated with an increased rate of abdominal deliveries. Preeclampsia was present in 24.7% of patients with decreased fluid. There was no correlation between the quantitative fluid amounts and the severity of the disease. In view of normative data and clinical experience, these observations suggest that the diagnosis of decreased amniotic fluid on routine ultrasonography requires a fetal scan to rule out anomalies, close antepartum observation to detect complications that may arise in the pregnancy, and delivery under conditions that allow appropriate support and intervention on behalf of the fetus.

Embryonic/fetal growth following suckling-induced delay of implantation.

In rats fertilized during the first or second day post partum (second consecutive pregnancy), suckling induces delay of implantation for 8 to 22 days. However, pregnancy is prolonged for only 3 to 17 days because accelerated embryonic and early fetal growth makes up 4 to 5 days of the implantation delay. After implantation, embryonic/fetal growth is accomplished within 11 to 12 days for a second consecutive pregnancy, whereas 16 days are required for first or second-spaced pregnancies. After weaning, increased function of the intestinal tract and liver is not needed anymore for mammary milk synthesis, and abundant nutrients can be shifted to the uteroplacental unit for rapid embryonic/fetal growth. Because the exponential curves for fetal growth are similar for first, second consecutive, and second-spaced pregnancies, it seems that, besides an increased supply of nutrients, an as yet unidentified maternal or a placentofetal factor(s) may play a role for embryonic/fetal growth.

Antimicrobial effect of chlorhexidine and povidone-iodine on vaginal bacteria.

The antimicrobial potency of 4 per cent chlorhexidine gluconate was compared with that of 10 per cent povidone-iodine (1 per cent free iodine) on the vaginal bacteria of 150 premenopausal, non-pregnant women. From 30 of the women blood samples were taken before and at either 15, 30 or 60 minutes after vaginal cleansing with chlorhexidine for chlorhexidine analysis. Five minutes after applying either chlorhexidine or povidone-iodine almost 99 per cent of bacteria present on the lateral wall of the vagina were killed. Chlorhexidine was significantly more effective than povidone-iodine. Serosanguineous , mucoid or white-yellowish vaginal discharge did not alter the effectiveness of either antimicrobial agent. In contrast to povidone-iodine, vaginally applied chlorhexidine was not absorbed in measurable amounts (sensitivity of detection method: 0 X 1 mg/l) into the bloodstream. Chlorhexidine may therefore prove of value for treating vaginitis especially during pregnancy and also for combating microbes such as Group B streptococci which are potentially harmful to the newly-born child.

Thymoma in pregnancy.

The natural history of slow, localized progression usually seen with thymomas seems to be transformed by pregnancy into one of rapid growth and distant metastatic spread. Five of the six previously reported cases had died of the malignancy within 6 months postpartum. The one previous long-term survivor died of treatment-induced complications. Two important questions remain unresolved: What is the risk of recurrence in the patient who has no residual disease at the time of conception? Approximately 50 per cent of female patients can anticipate having complete resection of their thymoma, and their recurrence risk is about 2 per cent. Potentially, there are many patients who have conceived and delivered after surgical therapy. Documentation of these case histories is needed for an accurate prediction of the true risk. Two of the cases within the present review fall within this category. The clinical course in these two patients is consistent with the natural history of the disease. One exhibited local recurrence and progression. The other patient died from sepsis, probably related to immunosuppression. Whether there is a cause and effect relationship between pregnancy and their recurrences is unknown. What is the risk to the patient who is first diagnosed while pregnant? The only survivor in this category was presented by Goldman. This patient underwent immediate therapeutic abortion following diagnosis. She had radiation therapy for invasive unresectable disease and subsequently delivered two term pregnancies, but died of postcesarean cardiac arrest. She had no evidence of recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Vaginal absorption of povidone-iodine.

In 12 nonpregnant women, total iodine, protein-bound iodine, inorganic iodine, and thyroxine values were measured in serum before and 15, 30, 45 or 60 minutes after a two-minute vaginal disinfection with povidone-iodine (Betadine). Only 15 minutes after application, serum iodine levels were raised and remained significantly elevated 30, 45 and 60 minutes after disinfection. Serum concentrations of total iodine and inorganic iodine were increased up to fivefold to 15-fold, respectively; during the relative short period of observation, thyroxine levels were not altered. An overload of iodine can suppress thyroid hormonogenesis, and the fetal and neonatal thyroid glands are especially sensitive. In pregnant women, vaginitis should not be treated with povidone-iodine because of the possible development of iodine-induced goiter and hypothyroidism in the fetus and newborn. The risk is especially high when povidone-iodine is used repeatedly.