Adverse pregnancy outcomes after in vitro fertilization due to undiagnosed urogenital tuberculosis and proposed screening algorithm for patients from tuberculosis-endemic countries.

Objective: To report 2 cases of adverse pregnancy outcomes due to delayed diagnosis of urogenital tuberculosis and propose a screening algorithm for patients from tuberculosis-endemic countries. Design: Case report. Setting: Academic medical center. Patients: Two patients with delayed diagnosis of urogenital tuberculosis leading to a fetal loss and a preterm delivery of an infant with congenital tuberculosis. Interventions: Endometrial biopsy, acid-fast bacilli culture of urine, and endometrium. Main outcome measures: Pregnancy outcomes. Results: Fetal loss at 19 weeks and preterm delivery of an infant with congenital tuberculosis before urogenital tuberculosis treatment. Conclusions: Patients who are at risk of urogenital tuberculosis should be screened in advance of infertility treatment to potentially prevent adverse pregnancy outcomes.

A new model of reproductive aging: the decline in ovarian non-growing follicle number from birth to menopause.

BACKGROUND: The primary determinant of reproductive age in women is the number of ovarian non-growing (primordial, intermediate and primary) follicles (NGFs). To better characterize the decline in NGF number associated with aging, we have employed modern stereology techniques to determine NGF number in women from birth to menopause. METHODS: Normal human ovaries were collected from 122 women (aged 0-51 years) undergoing elective oophorectomy, organ donation or autopsy. After gross pathologic examination, systematic random sampling was utilized to obtain tissue for analysis by the fractionator/optical disector method. Models to describe the resulting decay curve were constructed and evaluated. RESULTS: NGF decay was best described by a simple power function: log (y) = ax(b) + c, where a, b and c are constants and y = NGF count at age x (R(2) = 0.84, Sums of Squares Error = 28.18 on 119 degrees of freedom). This model implies that follicles decay faster with increasing age. CONCLUSIONS: Unlike previous models of ovarian follicle depletion, our model predicts no sudden change in decay rate, but rather a constantly increasing rate. The model not only agrees well with observed ages of menopause in women, but also is more biologically plausible than previous models. Although the model represents a significant improvement compared with earlier attempts, a considerable percentage of the variation in NGF number between women cannot be explained by age alone.

Intraoperative ultrasound during a laparoscopic myomectomy.

OBJECTIVE: To report a gynecologic use of a laparoscopic ultrasound transducer to isolate a myoma for surgical removal. DESIGN: Case report. SETTING: University-based infertility practice. PATIENT(S): A 44-year-old woman gravida 1 para 1 with history of a first trimester miscarriage who desired pregnancy as a participant in the donor egg program. INTERVENTION(S): Before she entered the assisted reproduction program, a patient was found to have a myoma that was greater than 2 cm with both intramural and submucosal components. During the laparoscopic evaluation, a laparoscopic ultrasound transducer helped identify and properly locate the myoma in what otherwise appeared to be a normal uterus. Appropriate laparoscopic hysterotomy incision was then made, thereby minimizing uterine trauma. MAIN OUTCOME MEASURE(S): Appropriately placed hysterotomy incision and successful reconstruction of uterus. RESULT(S): After the successful laparoscopic myomectomy, the patient achieved a pregnancy in our donor oocyte program. CONCLUSION(S): Laparoscopic intraoperative ultrasound can help gynecologic surgeons complete a laparoscopic myomectomy.

Reproductive aging and variability in the ovarian antral follicle count: application in the clinical setting.

OBJECTIVE: To determine the extent of intercycle and interobserver variability in antral follicle (AF) count and their impact on stimulation quality in IVF. DESIGN: Prospective evaluation of the impact on AF count of GnRH agonist down-regulation and interobserver variability. Retrospective evaluation of intercycle variability in AF count. SETTING: University ART clinic. PATIENT(S): Twenty subjects were used to evaluate the effect of GnRH agonist down-regulation upon AF count; six of whom were used to evaluate interobserver variability. Fifty patients experiencing two or three cycles of IVF within a 1-year interval. INTERVENTION(S): Transvaginal ultrasound exams before and after down-regulation with a GnRH agonist. Videotaped day-3 transvaginal ultrasound exams. MAIN OUTCOME MEASURE(S): [1] Intercycle and interobserver variability in antral follicle count. [2] Oocytes retrieved, peak estradiol, gonadotropin dose, duration of stimulation and cancellation rates. RESULT(S): There is moderate intercycle and interobserver variability in AF counts. GnRH agonist down-regulation does not significantly change AF count. In infertility patients undergoing IVF, paired analysis between the low- and high-AF count cycles did not show a difference in quality of stimulation or cycle cancellation rates. CONCLUSIONS: Within an individual patient, higher AF count in a given cycle was not predictive of better stimulation compared with the case of a lower count cycle.

Estimating human ovarian non-growing follicle number: the application of modern stereology techniques to an old problem.

BACKGROUND Previous published reports on the number of non-growing follicles (NGFs) in the human ovary have employed model-based methods for number estimates. These methods are time-intensive, and require correction factors and assumptions that ultimately limit their accuracy. Here, we describe the modification, application and validation of a modern fractionator/optical disector technique for the estimation of human ovarian NGF number. METHODS Forty-eight pairs of normal human ovaries were collected from women (age 8-51 years) undergoing elective bilateral oophorectomy, organ donation, or from autopsy. After gross pathologic examination, systematic random sampling was utilized to obtain tissue for analysis by the fractionator/optical disector method. The precision of individual NGF counts was determined by calculating the observed coefficient of error (OCE). Intra-observer variability and variation in NGF number between ovaries within a pair were also determined. RESULTS The mean OCE was 16.6% with larger variations observed at lower follicle counts. In recount experiments of the same ovary, NGF number estimates varied by 15-29%, except at very low follicle counts where variation was greater, but absolute differences were small. There was no significant difference in NGF number between ovaries within a pair (Wilcoxon signed rank test, P = 0.81). CONCLUSIONS Modern stereology methods provide an unbiased, efficient method for estimating NGF number in the human ovary. Both ovaries within a pair contain similar numbers of NGFs.

Elective single blastocyst transfer reduces twin rates without compromising pregnancy rates.

OBJECTIVE: To compare IVF outcome in single versus two blastocyst transfer in good-prognosis patients. DESIGN: Retrospective data analysis. SETTING: University-based IVF practice. PATIENT(S): Assisted reproductive technology outcome was compared in 41 patients who underwent elective single blastocyst transfer and 66 patients who underwent two blastocyst transfer. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Implantation rates, clinical pregnancy rates, cumulative pregnancy rates, twin pregnancy rates. RESULT(S): Blastocyst cycles between January 2003 and August 2004 (n = 238) were reviewed. Criteria for elective single embryo transfer established by our clinic were applied retrospectively to blastocyst cycles. Patients who met the criteria were divided into two groups, those who underwent elective single embryo transfer (eSET) and those who underwent two embryo transfer (2ET). Patient and cycle characteristics were similar for both groups. There were no differences in implantation rate (76% vs. 66%) or pregnancy rate (76% vs. 79%) between the eSET and 2ET groups. There was a significant difference in the number of twin pregnancies (3.2% vs. 62%) in the eSET versus 2ET group. Cumulative pregnancy rates were found to be 83% for both groups. CONCLUSION(S): Single blastocyst transfer can be performed in good-prognosis patients without compromising pregnancy rates. Twin pregnancy rates can be significantly reduced with eSET.

Effect of chromium supplementation on insulin resistance and ovarian and menstrual cyclicity in women with polycystic ovary syndrome.

In women with polycystic ovary syndrome, chromium picolinate (200 microg/d) improves glucose tolerance compared with placebo but does not improve ovulatory frequency or hormonal parameters. This pilot study indicates that future studies in the polycystic ovary syndrome population should examine higher dosages or longer durations of treatment.

Reproductive ageing and ovarian function: is the early follicular phase FSH rise necessary to maintain adequate secretory function in older ovulatory women?

BACKGROUND: Serum FSH elevations and decreases in inhibin B have been consistently demonstrated in the early follicular phase of cycles in women of advanced reproductive age. However, secretory products of the dominant follicle (estradiol and inhibin A) in the serum of older ovulatory women are maintained at levels similar to those of their younger counterparts. The goal of this investigation was to determine if ovarian secretory capacity is dependent on relative FSH levels and if basal measures of ovarian reserve reflect ovarian secretory capacity. METHODS: We administered equivalent low, but effective doses of recombinant FSH for 5 days to a group of older subjects (40-45 years, n=9) and younger controls (20-25 years, n=10) after pituitary suppression with a GnRH agonist. Outcome measures included follicular development as determined by serial transvaginal ultrasound examinations and serum levels of estradiol, inhibin A and inhibin B. RESULTS: Serum levels of estradiol and inhibin A were not statistically different between the two groups, while the number of large follicles formed was greater in the younger subjects. Basal parameters of ovarian reserve were not significantly correlated with ovarian secretory capacity, but did correlate with the number of follicles recruited in response to low-dose FSH. CONCLUSIONS: By providing equivalent serum levels of FSH in older and younger reproductive aged women, this study demonstrates that the secretory capacity of recruited follicles is maintained in older reproductive aged women.