Corpus luteum activity in tubal pregnancy.

Corpus luteum activity was monitored in 20 women undergoing nonsurgical management of ectopic pregnancy with methotrexate and citrovorum factor (N = 15) or observation (N = 5). The functional integrity of the corpus luteum was assessed by measuring progesterone and 17-hydroxyprogesterone. Trophoblastic viability was assessed by measuring the immunoreactive beta subunit of human chorionic gonadotropin. Ten of 15 methotrexate-treated patients demonstrated initial progesterone levels above 1.0 ng/mL, declining to levels below 1.0 ng/mL after treatment. Five of 15 methotrexate-treated patients and all five managed by observation alone demonstrated progesterone and 17-hydroxyprogesterone values below 1.0 ng/mL both initially and throughout the surveillance period, leading to resolution, indicating previous death of the corpus luteum. We conclude the following regarding ectopic pregnancy: 1) Corpus luteum function declines early in the biologic history of some gestations while persisting in others, and 2) corpus luteum function varies from active to inactive independent of serum levels of immunoreactive beta-human chorionic gonadotropin.

Survey of attitudes regarding the use of siblings for gamete donation.

We conclude that the acceptability of using a sister for gamete donation is high among couples desiring ovum donation. On the contrary, couples undergoing AID generally rejected the concept of using the husband's brother as a known donor. Thus, although similar in concept, disparity exists regarding the use of siblings for gamete donation. Though the use of sibling gamete donation may provide a short-term solution to the dwindling supply of acceptable gamete donors, the long-term acceptability of such practice remains unknown.

Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial.

Unruptured tubal pregnancies diagnosed at laparoscopy were treated with either methotrexate/citrovorum factor (MTX/CF) (n = 21) or observation (n = 5). Entry criteria required that the ectopic pregnancy be visualized, less than or equal to 3 cm in diameter, with intact serosa and no active bleeding. Treatment selection was based upon preoperative levels of beta-human chorionic gonadotropin (beta-hCG), with MTX/CF given to subjects exhibiting a plateaued or rising pattern and observation alone given to those with falling levels. Twenty-five of 26 ectopic pregnancies resolved without need of laparotomy. Two subjects received blood transfusions and one required a second operation for intra-abdominal bleeding. In both cases, fetal cardiac activity was noted pretreatment on ultrasound. The authors conclude the following: (1) MTX/CF may be safely used to treat selected unruptured ectopic pregnancy; (2) many ectopic pregnancies resolve spontaneously; and (3) ectopic pregnancies that form fetal elements, as evidenced on ultrasound, should not be managed medically.

Timely diagnosis of early ectopic pregnancy using a single blood progesterone measurement.

We obtained a single serum P measurement in 70 subjects at risk for an EP. Retrospectively, a P less than 15 ng/ml was 100% predictive of either an EP or otherwise nonviable IUP, while P greater than 15 ng/ml would have ruled out an EP in all cases. Because of this high degree of diagnostic accuracy, we speculated on the clinical utility of an outpatient D and C for those patients in our series having a P less than 15 ng/ml. Laparoscopy would be reserved for those cases without identifiable chorionic villi on frozen section of curettings. Following this course of management could have potentially diagnosed all EPs at the first ER visit without disruption of a single normal IUP in our series. This sequence could have expedited the diagnosis of EP by up to 14 days compared with a standard hCG/US protocol. This report describes a promising new test for the early detection of EP. The findings, however, require confirmation in a prospective trial before widespread clinical implementation.

The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience.

Seven women with unruptured tubal pregnancies diagnosed on laparoscopy were treated with methotrexate and citrovorum rescue. Criteria for inclusion in the study were that the level of human chorionic gonadotropin (hCG) be plateaued or rising, that the ectopic pregnancy not exceed 3 X 3 cm, that the tubal serosa be intact, and that there be no active bleeding. The women were followed with serial measurements of hCG, complete blood counts, and liver function tests. All women responded to a single course of therapy. The median time to resolution (from the first day of treatment to when the hCG was undetectable) was 31 days (range, 5 to 50 days). Follow-up hysterosalpingograms were available for five women. Four women demonstrated tubal patency, and one showed a unilateral occlusion on the side of the ectopic. One woman was found to have an intrauterine pregnancy prior to the scheduled time of hysterosalpingogram.

Polysiloxane vaginal rings and cylinders for physiologic endometrial priming in functionally agonadal women.

17 beta-estradiol (E2)-and/or crystalline progesterone (P)-impregnated polysiloxane vaginal rings and cylinders were tested as a system for endometrial priming in functionally agonadal women awaiting donor embryo transfer. Endometrial tissue was obtained by a transcervical biopsy procedure on simulated cycle day 26. The adequacy of the replacement regimen was judged by endometrial histologic dating, scanning electron micrographs, receptor content, and circulating E2 and P serum concentrations. Endometrial dating was consistent with cycle day 26. Electron micrographs showed normal surface characteristics. E2 and P receptor concentrations were within the normal range. Serum E2 levels were midfollicular, 105 +/- 12.8 pg/ml (mean +/- SEM), and midcycle, 254 +/- 28.6 pg/ml. P levels during the simulated follicular phase were undetectable (less than 0.2 ng/ml) but rose to a mean peak level of 17.3 +/- 1.8 ng/ml. The steroid-impregnated polysiloxane vaginal ring and cylinder system provided continuous and sustained hormone release, morphologically and endocrinologically normal endometrium, serum levels of E2 and P within the normal range for the entire menstrual cycle, and a convenient and physiologic therapeutic alternative to oral, vaginal, or intramuscular steroid replacement.

Utility of an algorithm to diagnose ectopic pregnancy.

In recent years, algorithms have been proposed to evaluate ectopic gestations. To determine the usefulness of an algorithm for a large county hospital, a surveillance project was initiated. During 2 years, 4045 women were screened in the emergency room for pregnancy. Of these, 1648 (41%) were noted to be pregnant, initially detected by rapid enzyme immunoassay for urinary human chorionic gonadotropin, and later confirmed using quantitative radioimmunoassay for serum human chorionic gonadotropin. Within this group, 249 women were diagnosed with ectopic pregnancies. Hemoperitoneum was discovered by culdocentesis in 128 of 249 cases of ectopic gestations, all operated upon acutely. A discriminatory zone for ultrasound was diagnostic of ectopic pregnancy in only 33 cases, as the majority of women presented with human chorionic gonadotropin levels below 6500 mIU/ml. Uterine curettage performed when abnormal serial levels of chorionic gonadotropin were observed detected an additional 46 cases. Early diagnosis permitted treatment prior to tubal rupture in 147 instances with conservation of the fallopian tube in 125 (50%). We conclude: (1) even in a busy county emergency room, algorithms are useful for expediting the diagnosis of ectopic pregnancy; (2) when ectopics are diagnosed early, conservative tubal surgery is possible in many patients.

Scanning electron microscopy of the endometrium in functionally agonadal women receiving steroid replacement therapy with polysiloxane vaginal rings and cylinders.

We prepared a group of five agonadal women to receive donated embryos by delivering physiologic concentrations of 17 beta-estradiol (E2) and progesterone (P4) through a polysiloxane vaginal ring and cylinder delivery system. In order to detect endometrial surface ultrastructural asynchrony that might reduce prospects for successful embryo transfer, we performed scanning electron microscopy (SEM) on biopsies obtained from these five women and compared them against those from four normal, spontaneously ovulating controls. Light microscopy revealed all nine women to be in the late luteal phase (day 26 +/- 2) and with glandular-stromal synchrony. Further concordance was seen with SEM, with no discernible difference in the development of cilia, microcilia or apical secretory protrusions between the two groups. SEM, a technique that permits visual assessment of endometrial surface topography, demonstrated that this regimen of native E2 and P4 restored the surface ultrastructure of the prematurely menopausal human endometrium to correspond to that in the normal menstrual cycle.

Reliability of ultrasound in predicting uterine leiomyoma volume.

Recently ultrasound has been used to size and track individual myoma volumes for patients undergoing medical therapy. However, little is known about the specific performance characteristics and limitations of this technique with respect to volume measurements. We performed and prospectively interpreted serial ultrasound examinations on myoma patients and confirmed the location, size and number of myomas in the surgical specimens. The smallest detectable tumor was 2.7 cm in diameter. The specificity was 94%; reproducibility had a 14% coefficient of variation for tumors with diameters greater than 6 cm. We conclude that ultrasound is suitable for imaging and sizing myomas provided that the diagnosis is otherwise certain and the tumors tracked are large.

Patient selection for laparoscopic myomectomy.

STUDY OBJECTIVE: To determine if preoperative criteria could select patients who were likely to be managed successfully by laparoscopic myomectomy. DESIGN: Prospective. SETTING: Two community hospitals. PATIENTS: Premenopausal women who had symptomatic uterine myomata and met the following criteria underwent laparoscopic myomectomy: uterine size less than or equal to 14 weeks after 12 weeks of gonadotropin-releasing hormone (GnRH) agonist therapy; no individual myoma larger than 7 cm; no leiomyoma near the uterine artery, or near the tubal cornua if fertility was desired; and at least 50% of the leiomyoma subserosal, to be accessible and to allow adequate repair of the myometrium through the laparoscope. INTERVENTIONS: Laparoscopic assessment of the pelvis and laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Forty-one patients entered the study: 23 met the selection criteria and were accepted for laparoscopic myomectomy, but 4 were excluded during laparoscopic assessment of the pelvis. Clinical examination or initial sonogram correctly predicted successful laparoscopic myomectomy in 13 of 19 women. After 3 months of GnRH agonist therapy, clinical examination or sonogram identified four additional candidates. In six patients in whom the optimum approach was still uncertain, laparoscopic assessment found two additional appropriate candidates for laparoscopic myomectomy. Nineteen patients underwent the procedure without the need to convert to laparotomy. None experienced any complications. CONCLUSIONS: Careful patient selection can decrease the likelihood of inappropriate performance of laparoscopic myomectomy and avoid the need to convert to laparotomy.