Cardiovascular reflex tests detect autonomic dysfunction in symptomatic and pre-symptomatic subjects with hereditary transthyretin amyloidosis.

PURPOSE: Autonomic dysfunction is a distinctive but undervalued feature of hereditary transthyretin amyloidosis (ATTRv). It may predate the onset of polyneuropathy and cardiomyopathy, thereby providing crucial prognostic and therapeutic information. The objective of this study was to assess autonomic function by means of the standardized cardiovascular autonomic reflex tests (CRTs) in a cohort of subjects with genetically proven ATTRv from non-endemic areas who were in the symptomatic and pre-symptomatic stages. METHODS: All subjects enrolled in this cross-sectional study had genetically proven ATTRv. They underwent the head-up tilt test, Valsalva manoeuvre, deep breathing test, cold face test and handgrip test while under continuous blood pressure and heart rate monitoring. Based on the results of the nerve conduction study, the subjects were divided into two groups: those with polyneuropathy (ATTRv-wPN) and those without polyneuropathy (ATTRv-woPN). Age- and sex-matched healthy controls (HC) were used for comparison. RESULTS: Thirty-seven ATTRv subjects (19 with ATTRv-wPN, 18 with ATTRv-woPN) and 41 HC performed the CRTs. Of these 37 subjects with ATTRv, four (11%) presented neurogenic orthostatic hypotension the during head-up tilt test. Based on the results of the CRTs, autonomic dysfunction characterized by either sympathetic or parasympathetic impairment was detected in 37% and 63% of ATTRv-wPN subjects, respectively. Subjects with ATTRv-woPN presented a significant impairment of autonomic responses to the Valsalva manoeuvre compared to the HC (overshoot p = 0.004; Valsalva ratio p = 0.001). CONCLUSION: Autonomic dysfunctions are frequent in subjects with ATTRv when investigated by means of standardized CRTs, and are also relevant in the pre-symptomatic stage. Cardiovagal functions are the primary functions affected, among others. This may be crucial in defining the proper diagnostic workout for early diagnosis and improving the likelihood of providing the patient with prompt administration of disease-modifying treatments.

Whole-Brain DTI Assessment of White Matter Damage in Children with Bilateral Cerebral Palsy: Evidence of Involvement beyond the Primary Target of the Anoxic Insult.

BACKGROUND AND PURPOSE: Cerebral palsy is frequently associated with both motor and nonmotor symptoms. DTI can characterize the damage at the level of motor tracts but provides less consistent results in nonmotor areas. We used a standardized pipeline of analysis to describe and quantify the pattern of DTI white matter abnormalities of the whole brain in a group of children with chronic bilateral cerebral palsy and periventricular leukomalacia. We also explored potential correlations between DTI and clinical scale metrics. MATERIALS AND METHODS: Twenty-five patients (mean age, 11.8 years) and 25 healthy children (mean age, 11.8 years) were studied at 3T with a 2-mm isotropic DTI sequence. Differences between patients and controls were assessed both voxelwise and in ROIs obtained from an existing DTI atlas. Clinical metrics included the Gross Motor Function Classification System, the Manual Ability Classification System, and intelligence quotient. RESULTS: The voxel-level and ROI-level analyses demonstrated highly significant (P < .001) modifications of DTI measurements in patients at several levels: cerebellar peduncles, corticospinal tracts and posterior thalamic radiations, posterior corpus callosum, external capsule, anterior thalamic radiation, superior longitudinal fasciculi and corona radiata, optic nerves, and chiasm. The reduction of fractional anisotropy values in significant tracts was between 8% and 30%. Statistically significant correlations were found between motor impairment and fractional anisotropy in corticospinal tracts and commissural and associative tracts of the supratentorial brain. CONCLUSIONS: We demonstrated the involvement of several motor and nonmotor areas in the chronic damage associated with periventricular leukomalacia and showed new correlations between motor skills and DTI metrics.

Loss of autonomy of hospitalized elderly patients: does hospitalization increase disability?

AIM: The study of the determinants of loss of autonomy during hospitalization may be valuable in the identification of the most effective interventions and to achieve better outcomes. The aim of this study was to describe changes in the level of autonomy of the elderly admitted to the hospital at the entrance and at discharge in relation to a rehabilitation program. METHODS: Prospective observational study conducted at the INRCA Geriatric Hospital of Ancona. The study included patients aged 65 years and over, daily admitted to INRCA Hospital of Ancona between September and December 2010. Criteria for inclusion were age ≥ 65 years, length of stay > 24 hours and signed informed consent. Patients admitted for less than 24 hours or in day hospital or day surgery were excluded from the beginning. A total of 1266 elderly patients were recruited in the period. From this sample, 74 people who died during hospitalization were excluded. At the time of hospitalization (within 24 hours) and at discharge, patients were evaluated with the Barthel Index (BI), the Rankin scale, and a short assessment of cognitive status derived from the Mini Mental State Examination (MMSE). RESULTS: Referring to 1192 subjects who participated to the study, the mean age was 82.13 years ±7.39, age range between 65 and 100 years. The average BI was 56.6±36.16 (SD) (median value =60) at admission and 63.84±34.7 (SD) (median value=70) at discharge. The average Rankin score at admission was 2.63±1.5 (SD) (median value=3). CONCLUSION: Patients presented better score of the BI at discharge and this figure was associated to the implementation of a rehabilitation treatment. Hospitalization of the elderly patient in a suitable environment, such as a geriatric hospital, contrary to some theories highlighting only the negative aspects of removal from the living environment, can be a measure of benefit for the reduction of disability and the recovery of compromised activities along and after the acute event. The collection of data on the level of autonomy of the subjects before and after hospitalization can be a useful element for clinical evaluation in a geriatric hospital.

BMI, life-style and psychological conditions in a sample of elderly Italian men and women.

OBJECTIVES: To identify the relationship among cognitive status, psychological conditions, anthropometric measurements and life-style in a sample of elderly Italian men and women. METHODS: Three hundred and six volunteers for ZINCAGE Project recruited. The sample was made up of healthy older adults living in the Marche Region aged 65 and over. All elderly were given a complete medical, anthropometric assessment, and psycho-social evaluation. RESULTS: Overall, the participants perceived themselves to be in very good or good (22%) or fair (69%) health; only 9% reported a poor health status. The 46% of the sample fell within the normal body mass index (BMI) range, though 38% were overweight, 12% were obese, and only 4% were underweight. In both sexes, BMI significantly decreased with age (p<0.001). BMI was positively associated with performing sedentary activities (r=0.188; p<0.001). Levels of both sedentary (r=0.221; p<0.001) and non-sedentary (r=0.258; p<0.001) leisure activities were positively associated with education level (p<0.05). It was found that lower scores of physical activity were associated to higher scores of Geriatric Depression Scale (r=-0.425; p<0.01), lower scores of Mini Mental State Examination (r=0.266; p<0.001) and higher score of Perceived Stress Scale (r=-0.131; p<0.05). CONCLUSION: Men and women lead different lifestyles and have a different psychological status, with advancing age consequently stressing the need for healthy lifestyle programmes particularly in the case of overweight and obese elderly people.

Kinetics of pronuclear development and the effects of vector type and timing of injection on the efficiency of gene transfer into rhesus macaque embryos.

A series of experiments was performed to determine the dynamics of pronuclear development as well as the efficiency of either adenovirus-associated (AAV) or lentivirus-derived vectors to introduce a green fluorescent protein (GFP) reporter gene into rhesus macaque (Macaca mulatta) embryos. Assessment of pronuclear development at various times after fertilization revealed that the appearance of pronuclei was determined by the presence of the first and the timing of the second polar body. The dynamics of pronuclear formation was a significant determinant of whether an oocyte reached the blastocyst stage, however, when the percentage of blastocysts were based on the number of zygotes, the timing of the appearance of polar bodies did not appear to have any effect on subsequent development. Injection of different AAV-derived vectors showed that the serotype of the vector did not affect development or the proportion of transgenic embryos. Moreover, all putative transgenic embryos proved to be expression mosaics. Injection of embryos with lentiviral vectors showed that timing of injection (before or after fertilization) had no effect on subsequent transgene expression, but that the type of reporter gene determined post-injection development and rate of transgenesis. The transfer of embryos following injection of a lentiviral vector into three recipients resulted in one pregnancy which was lost during the second trimester. Analysis of fetal tissues showed ubiquitous presence of the transgene and GFP expression in all tissues examined. These results show that lentivirus-derived vectors can efficiently transform rhesus embryos and are suitable for the generation of transgenic rhesus monkeys.

In vitro fertilization in the pigtailed macaque (Macaca nemestrina).

The objective of this study was to investigate the possibility of collecting oocytes and semen from pigtailed macaques (Macaca nemestrina) and to establish a protocol for the production of viable embryos that would be suitable for transfer into surrogate females. A total of 82 oocytes were collected from a total of four females (on 2 d with two females each). Semen was collected from the same male on both occasions with respective ejaculate volumes of 0.55 and 0.1 mL containing 2 x 10(9) and 6.6 x 10(8)sperm/mL. Following insemination and after 48 h in culture, 42 (51.2%) of the oocytes had cleaved. Of these, 21 were selected based on developmental stage and their morphology and cryopreserved. The remainder was kept in culture for an additional 5 d, at which time three had reached the expanded blastocyst stage. A total of five transfers were performed with frozen-thawed embryos; two of these resulted in pregnancies and the birth of infants. The results of this study demonstrated that oocytes can be retrieved from pigtailed macaques and that such oocytes can be inseminated and cultured in vitro to the blastocyst stage and give rise to viable offspring after transfer into surrogate females.

Can epsilon-aminocaproic acid balance the off-pump bleeding advantage?

BACKGROUND: Aprotinin improved the control of bleeding in patients undergoing surgery with cardiopulmunary bypass, but its use was halted because of the risk of bovine spongiform encephalopathy. We then started to use epsilon-aminocaproic acid and the results in the control of bleeding were satisfactory. To assess its effectiveness in the control of postoperative bleeding precisely, we compared the results for patients operated on for myocardial revascularization on-pump and treated with epsilon-aminocaproic acid with those for patients who decidedly bleed less: off-pump patients. METHODS: Two groups of patients who had had either on- or off-pump double aortocoronary bypass surgery were retrospectively reviewed for postoperative bleeding. These two almost homogeneous group had two grafts only: left anterior descending and circumflex arteries operated on with cardiopulmonary bypass and treated with the epsilon-aminocaproic acid, and left anterior descending and right coronary arteries operated on off-pump. RESULTS: Postoperative bleeding through chest drainage at 4 h was 265+/-91.7 mL in the off-pump group and 328.4+/-131.4 mL in the on-pump group (p=0.004). But at 24 h it was 671.6+/-311.5 mL in the off-pump group and 827.8+/-514.4 mL in the on-pump group (p=0.07). CONCLUSIONS: epsilon-Aminocaproic acid is effective in controlling postoperative bleeding in patients operated on for myocardial revascularization with the aid of cardiopulmonary bypass.

Manejo interdisciplinario de los tumores del macizo facial con afectación de la fosa creaneal anterior / Interdisciplinary handling of the tumors of the face bulk with affectation of the anterior craneal cave

Los tumores que invaden la fosa craneal anterior pueden originarse en el seno frontal, las celdillas etmoidales, el seno esfenoidal, el seno maxilar, la orbita y en las estructuras propias de la región como es el caso de los meningiomas y gliomas con afectación rinosinusal. El objetivo del presente trabajo es postular la resección en monobloque de un sector del macizo facial realizada a través de un abordaje combinado transcraneal y transfacial. La filosofía del método está basada en que la resección transfacial pura es insuficiente para asegurar la radicalidad del tratamiento. El procedimiento fue usado por diversos autores desde Dandy en 1941, ampliándose sus indicaciones y poniéndose a puntosu técnica hasta la década del 80. Esta técnica esta indicado en: Carcinomas T3 y T4 de etmoides, tumores con invasión endocraneana o de la lámina cribosa del etmoides, tumores con invasión de las paredes superior y/o posterior de la órbita, tumores con invasión de la base de la apófisis pterigoides o el techo de la fosa infratemporal. Sus limitaciones son: invasión masiva del parénquima cerebral y/o del seno cavernoso. Se reconocen tres tipos de resección, de acuerdo con su topografía, la que se basa en el aspecto topovolumétrico del tumor a tratar. 1) Reseccion anterior cráneoetmoidal - 2) Resección anterior craneoorbitaria - 3) Resección lateral. Las complicaciones más graves son las endocraneanas, fundamentalmente la licuorrea y la meningitis que oscilan en las distintas series entre el 1 y el 7 por ciento siendo otras menos frecuentes el neumoencéfalo y los abscesos subdurales y encefálicos. La mortalidad operatoria de las distintas series oscila entre el 2 y el 10 por ciento. Las secuelas son funcionales distinguiéndose las neurológicas, oculares y bucofaríngeas, y estéticas. Los resultados citados en la literatura son satisfactorios, teniendo en cuenta la gravedad de las lesiones, con un promedio de mas de 50 por ciento de sobrevida en tumores malignos que involucran la base del cráneo. Nuestras cifras en una serie de 48 pacientes son similares en cuanto a resultados, complicaciones y secuelas.Como conclusión creemos que la resección craneofacial demuestra: 1) Que es el método más adecuado para tratar tumores que involucran la base del cráneo. 2) Que a pesar de lo formidable del procedimiento su morbimortalidad es escasa, 3) Que el uso y combinación de abordaje estéticos no compromete la radicalidad del método y asegura mejor calidad de sobrevida

Mid-term results of the valve-on-valve technique for bioprosthetic failure.

OBJECTIVE: Redo operations for bioprosthesis malfunction can sometimes be technically very demanding and cardiac structures may be damaged. Excising only the leaflets of the damaged bioprosthesis and leaving the old ring in situ on which the 'new' mechanical valve is sutured can, in very selected cases, represent a solution. METHODS: Twenty-two patients were operated on, with the valve-on-valve technique, from September 1991 through December 1992. There were three operative deaths. RESULTS: The surviving 19 patients were followed-up from 83 to 98 months (mean 90.5 months.). There were two late deaths. The patients were examined clinically and with transthoracic and transesophageal echocardiograms. All patients were in good condition and the echocardiographic examinations showed no clinically important gradients across the prostheses. CONCLUSIONS: The valve-on-valve technique, in certain difficult situations, can give successful mid-term results.

Oligodendroglioma multicéntrico / Multicentric oligodendroglioma

Se presenta el caso de una paciente de 74 años, que concurrió a nuestro servicio por haber presentado un episodio convulsivo, de tipo parcial simple y de carácter tónico-clónico. En la RMI posteriormente solicitada se evidenciaron múltiples nódulos en hemisferio izquierdo. La evaluación clínica desarrollada en intento de determinar patología metastática, resultó negativa. En forma seguida, la paciente desarrolló un cuadro comicial, acompañado de una hemiparesia derecha y una afasia de expresión, demostrándose una hemorragia intratumoral por medio de imágenes. Se realiza la exéresis tumoral y en el estudio patológico se demostró, que se trataba de un oligodendroglioma. Dada la particular localización de los nódulos tumorales, se concluye que con alta probabilidad, este suceso haya correspondido a un verdadero caso de multicentrismo. Y por fin sostenemos, que ante la presencia de un paciente con múltiples imágenes nodulares intra-axiales, esta entidad clínico-patológica debe ser tenida en cuenta.

Bioprosthetic replacement after bioprosthesis failure: a hazardous choice?

BACKGROUND: Following bioprosthetic failure, replacement is usually done with mechanical valves to avoid repeated reoperations. METHODS: From 1986 to 1996 we operated on 130 patients with bioprosthetic failure, implanting a new bioprosthesis; this group included patients with contraindication to anticoagulation, tricuspid replacement, and specific patient requests. Mean age was 63+/-8 years. RESULTS: The perioperative mortality was 13.8%. At 10 year follow-up the actuarial estimate of survival was 77.4%+/-6.6%. Freedom from structural valve deterioration was estimated at 81.8%+/-6.3%. Freedom from a third operation was estimated at 85.5%+/-5.2%. No patient was permanently anticoagulated. Freedom from thromboembolism was estimated at 91.5%+/-4%, and there were no hemorrhages. Freedom from cardiac-related deaths was estimated at 85.7%+/-5%. CONCLUSIONS: This group of patients received the first valve between 1976 and 1986; the range of the cumulative follow-up reaches 20 years, and the extended survival compares favorably with survival of mechanical valves.

Gonadotropin-releasing hormone agonist administration in early human pregnancy is associated with normal outcomes.

OBJECTIVE: To evaluate the reproductive outcomes of early human gestations exposed to GnRH agonist (GnRH-a). Gonadotropin-releasing hormone agonist is commonly used as an adjunct to ovulation induction regimens, and sometimes early pregnancies are inadvertently exposed to the drug. There has been concern regarding possible teratogenic effects of GnRH-a on these gestations, but there is a paucity of data regarding human subjects. DESIGN: Identified pregnancies were followed for obstetric and fetal outcomes. PATIENTS, PARTICIPANTS: Over 4 years 18 early pregnancies among 17 women were found to be exposed to GnRH-a. During the month of conception, daily injections were begun on menstrual day 22 after documenting an ovulatory P level on day 21. Gonadotropin-releasing hormone agonist was discontinued from 10 to 24 days later, immediately after pregnancy was recognized. Obstetric and fetal outcomes were ascertained by chart review and telephone follow-up with mothers. RESULTS: Five first trimester losses were observed in 18 hCG confirmed pregnancies for a loss rate of 28%. Thirteen pregnancies produced apparently normal babies. One normal fetus was lost at 20 weeks' gestation because of cervical incompetence. CONCLUSION: There does not appear to be an increased risk of birth defects or pregnancy wastage in human pregnancies exposed to daily low-dose GnRH-a therapy in the first weeks of gestation.

Utility of gonadotropin-releasing hormone agonists in programs of ovarian hyperstimulation with intrauterine insemination.

The GnRH agonists have practical and theoretic advantages for adjunctive use in ovulation induction. The IVF cycles demonstrate a decrease in the cancellation rate, an increase in the ease of scheduling, and an increase in the number of oocytes obtained per retrieval when GnRH agonists are employed. Other advantages, such as an improvement in the fertilization and cleavage rate, an increased length of the luteal phase, and an increased pregnancy rate, are suggested but not universally accepted. The utility of adding GnRH agonists to human menopausal gonadotropin-intrauterine insemination cycles is similarly in dispute. Although controlled ovarian hyperstimulation with both human menopausal gonadotropins alone and in conjunction with GnRH agonists have produced pregnancies when coupled with intrauterine insemination, it was demonstrated that there was a significantly greater pregnancy rate per cycle with the use of a GnRH agonist in a recalcitrant infertile population. Others did not substantiate this improvement in pregnancy rate per cycle in their patient population of regularly ovulating women undergoing their first controlled ovarian stimulation cycle either with or without GnRH agonist therapy. This suggests that women with ovulatory dysfunction, and particularly women who previously have not responded to therapy with human menopausal gonadotropin therapy, will reap the most benefits from the addition of a GnRH agonist to their ovulation induction regimen. The addition of a GnRH agonist to controlled ovarian hyperstimulation is a highly effective method of inducing pregnancy in a recalcitrant infertile population. Patients who did not conceive with human menopausal gonadotropins-intrauterine insemination may conceive with GnRH agonist-human menopausal gonadotropins-intrauterine insemination therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Bioprosthesis replacement with mechanical valve implantation on the bioprosthetic ring. Surgical and 2D echo considerations.

Removal of a failing bioprosthesis can be a delicate operation and extensive damage can be caused. Eighteen patients with failing bioprostheses underwent excision of the leaflets, then the "new" mechanical valve was sewn onto the "old" bioprosthetic ring. At follow-up, clinical and 2D color-flow echo-Doppler evaluations showed good hemodynamic performance of the mechanical valves.

Empleo de la inmunofluorescencia indirecta para el reconocimiento de anticuerpos contra el coccidioides immitis / Indirect in inmunofluorescence for the diagnostic of coccidioidomycosis

San Luis es considerada zona endémica de coccidioidomicosis. En trabajos anteriores, empleando pruebas cutáneas, hemos encontrado porcentajes de reactores positivos que van del 10%al 36%en distintos departamentos y poblaciones encuestadas. En este trabajo empleamos la inmunofluorescencia indirecta, utilizando como antígeno esférulas del hongo provenientes de ratones infectados en la almohadilla plantar. El material purulento obtenido se empleó en la preparación de improntas. Para la búsqueda de anticuerpos se usaron dos controles positivos enviados por la División of Mycotic Diseases-Center for Infectious diseases y un control negativo. No encontramos buena diferenciación entre los controles positivos y negativos; se observó en todos fluorescencia difusa en la pared de los endosporos y en el contenido de las esférulas. En las condiciones empleadas por nosotros no resulta útil esta técnica, tal vez pueda serlo si se realizana algunas modificaciones como la forma antigénica utilizada, la fijación de los preparados o en los filtros empleados para evitar la fluorescencia difusa o autofluorescencia que observamos

Human chorionic gonadotropin stimulation of relaxin secretion by luteinized human granulosa cells.

OBJECTIVE: To determine the effect of human chorionic gonadotropin (hCG) on relaxin secretion by long-term cultures of luteinized human granulosa cells (GC). DESIGN: Luteinized human GC were collected from 10 women undergoing in vitro fertilization (IVF) cycles. Luteinized human GC from each woman were plated in replicate wells at 1 x 10(5) cells/well and exposed to medium 199 (GIBCO, Grand Island, NY), medium 199 with 1 IU/mL hCG, and/or medium 199 with 100 IU hCG/mL. Luteinized human GC were maintained for up to 40 days in culture. Spent media were changed every 2 days and assayed for relaxin and progesterone (P) at the conclusion of each experiment. SETTING: Tertiary care center. PATIENTS, PARTICIPANTS: Luteinized human GC were obtained from women undergoing controlled ovarian hyperstimulation for IVF with one of the following regimens: (1) clomiphene citrate with human menopausal gonadotropins (hMG); (2) hMG alone; or (3) hMG with leuprolide acetate. All women were less than 40 years of age, in good health, and were not taking medications other than those used in the ovulation-induction regimen. MAIN OUTCOME MEASURES: Levels of P and relaxin in spent media. RESULTS: Relaxin secretion by luteinized human GC was dependent on hCG stimulation and was detected only after a time lag in culture. After relaxin secretion was detected, it was maintained throughout the culture period (10 to 22 days). Luteinized human GC produced P immediately under both basal and stimulated conditions. Progesterone production continued throughout the culture period with hCG-stimulated cells producing significantly greater P after 4 to 8 days in culture. CONCLUSIONS: Luteinized human GC obtained at the time of oocyte retrieval secrete relaxin in response to hCG stimulation and secrete P under both basal and hCG-stimulated conditions, thereby serving as a model to explore luteal function and control.

Bioprosthetic valve endocarditis: factors affecting bad outcome.

Prosthetic valve endocarditis (PVE) remains an uncommon but serious complication of cardiac valve replacement. We analysed several risk factors (active or healed, early or late endocarditis, congestive heart failure, arterial emboli etc.) in order to identify the factors which may predict bad outcome. The overall mortality rate was 46.8% (15/32 patients). There was a significantly higher mortality rate in patients with early endocarditis (80%) than in those with late endocarditis (38%) (p less than 0.01). In the group of patients who underwent reoperation, the mortality rate was higher in those with active endocarditis (70%) than in those with healed endocarditis (28.5%) (p less than 0.05). We believe that combined medical and surgical treatment is the best management for bioprosthetic valve endocarditis, with the institution of appropriate preoperative antibiotic therapy, to attempt to achieve sterilization.

The luteal phase during gonadotropin therapy: effects of two human chorionic gonadotropin regimens.

OBJECTIVE: Luteal phase abnormalities are known to complicate ovulation induction with gonadotropins. This study was performed to test the effect of a modified human chorionic gonadotropin (hCG) regimen on the luteal phase during gonadotropin treatment. DESIGN: Fifteen women from a private practice setting volunteered to be studied during each of two nonconception, gonadotropin-stimulated cycles. After ovarian stimulation with human menopausal gonadotropins (hMG), hCG was administered either as a single dose of 10,000 IU (single dose) or in two divided doses of 5,000 IU given 1 week apart (split dose). MAIN OUTCOME MEASURES: Early, midluteal, and late luteal estradiol (E2) and progesterone (P) levels and luteal phase lengths were measured, and their median values and intraquartile ranges (IQR) compared using nonparametric analysis. RESULTS: Early and midluteal E2 and P levels were similar regardless of which hCG regimen was administered. The median late luteal E2 level was 1,146.0 pg/mL (the IQR ranged from 633 to 1,650, IQR = 1,017) with the split-dose regimen and 240.0 pg/mL (the IQR ranged from 150 to 460, IQR = 310) with the single-dose regimen. The median late luteal P level was 108.0 ng/mL (the IQR ranged from 58.5 to 129, IQR = 70.5) with the split-dose regimen and 4.2 ng/mL (the IQR ranged from 1.9 to 11.7, IQR = 9.8) with the single-dose regimen. Median luteal phase lengths were 16 days (the IQR ranged from 15 to 17, IQR = 2) for the split-dose regimen and 11 days (the IQR ranged from 10 to 12, IQR = 2) for the single-dose regimen. CONCLUSION: In hMG-stimulated cycles, a second dose of hCG given during the midluteal phase significantly increases late luteal E2 and P levels and consistently lengthens the luteal phase.

Gonadotropin-releasing hormone agonist improves the efficiency of controlled ovarian hyperstimulation/intrauterine insemination.

OBJECTIVE: Leuprolide acetate (LA) has improved the efficiency of human menopausal gonadotropins (hMG) in in vitro fertilization cycles. We hypothesized that the combination of LA/hMG/intrauterine insemination (IUI) would be more efficacious than hMG/IUI cycles. DESIGN: During an 18-month period, all patients completing either a hMG/IUI cycle (group I) or a LA/hMG/IUI cycle (group II) had the characteristics and outcomes of their stimulation cycles assessed. The groups were not prospectively randomized. SETTING: Referral center at a tertiary care hospital. PATIENTS: One hundred twenty three patients in group I completed 219 cycles, and 64 patients in group II completed 102 cycles. Twenty-eight of the patients who failed to conceive with hMG/IUI were advanced to group II. MAIN OUTCOME MEASURES: Pregnancy/IUI is compared between the two groups. RESULTS: Group II demonstrated significantly greater clinical pregnancy/IUI than group I (26.5% and 16.0%, respectively, P less than 0.05), as well as a higher live birth/IUI (21.6% and 12.8%, respectively, P less than 0.05). No difference was present in the rate of fetal wastage or multiple births. CONCLUSIONS: In our patients with recalcitrant infertility, the addition of a gonadotropin-releasing hormone agonist to hMG/IUI improved the pregnancy rate, without increasing the rate of multiple births or fetal wastage.