Exacerbation of ovarian hyperstimulation by leuprolide reveals a gonadotroph adenoma.

OBJECTIVE: To report a case of a gonadotroph adenoma diagnosed after a dramatic increase in estradiol level and ovarian hyperstimulation in response to a gonadotropin-releasing hormone agonist. DESIGN: Case report. SETTING: Outpatient practice and university hospital. PATIENT(S): A 35-year-old woman who presented with infertility, amenorrhea, and an elevated basal estradiol concentration. INTERVENTION(S): Ultrasonography, laparoscopy, endocrinologic assays, magnetic resonance imaging, transsphenoidal surgery, and immunocytochemical staining. MAIN OUTCOME MEASURE(S): Ultrasonography and laparoscopy demonstrated bilaterally enlarged ovaries containing multiple preovulatory follicles, similar in appearance in those women undergoing controlled ovarian hyperstimulation with exogenous FSH. The serum estradiol level was moderately elevated, the FSH level was within the normal range, and LH was suppressed. Administration of leuprolide acetate resulted in very elevated estradiol concentrations and even larger ovarian cysts. Magnetic resonance imaging demonstrated a sellar mass. Examination of the tissue excised by transsphenoidal excision of the mass showed a pituitary adenoma that stained strongly for FSH. RESULT(S): Regular menses resumed soon after excision of the gonadotroph adenoma, followed by a spontaneous pregnancy. CONCLUSIONS: Gonadotroph adenoma should be suspected in a reproductive age woman with oligomenorrhea or amenorrhea, infertility, multiple preovulatory follicles, and a persistently elevated serum estradiol concentration. Exacerbation of the ovarian hyperstimulation in response to a gonadotropin-releasing hormone agonist in this setting also strongly suggests a gonadotroph adenoma but can be avoided by recognizing the presenting features of this condition.

Factors influencing adverse perinatal outcomes in pregnancies achieved through use of in vitro fertilization.

OBJECTIVE: To determine the associations of specific components of IVF treatment with abnormal perinatal outcomes. DESIGN: Case-control study. SETTING: University-based and community-based infertility centers. PATIENT(S): All viable pregnancies achieved through IVF procedures performed between January 1999 and March 2004. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Infertility etiology, gonadotropin exposure, embryo manipulation, and quality. RESULT(S): Of 455 viable pregnancies identified during the study period, 435 met inclusion criteria. While adjusting for maternal age, race, parity, body mass index, infertility center, and year of IVF procedure, multiple gestations were associated with a 12-fold increased risk of poor perinatal outcome compared to singletons. Ovarian hyperstimulation syndrome significantly increased the risk more than 3-fold (odds ratio = 3.14; 95% confidence interval, 1.08-9.14), while endometrial thickness was found to have a significant protective effect (odds ratio = 0.89; 95% confidence interval, 0.80-0.99). We found no effect of etiology of infertility, dose or type of medication used for stimulation, use of embryo-manipulation techniques, or quality on perinatal outcome. CONCLUSION(S): These data confirm and quantify the risk of perinatal morbidity associated with multiple births. After adjusting for multiple births, ovarian hyperstimulation syndrome and suboptimal endometrial development are associated with adverse outcomes in pregnancies achieved through IVF. Our findings suggest that it may be the endometrium rather than the embryo that influences fetal growth and perinatal outcomes after IVF.

Defining the rise of serum HCG in viable pregnancies achieved through use of IVF.

BACKGROUND: We aimed to characterize the rate of HCG rise associated with viable IVF pregnancies, and to evaluate the association between HCG rise and potentially influential factors. METHODS: We performed a retrospective cohort analysis of all viable pregnancies achieved through IVF at two centres between January 1999 and March 2004. RESULTS: Of the 455 pregnancies resulting in live births, 391 met inclusion criteria and contributed a total of 1052 HCG values. Using random effects models, the best pattern to describe the rise of log HCG was quadratic with the rate of increase slowing at 24 days post-oocyte retrieval. Limiting the analysis to measurements below the discriminatory zone, the linear model adequately characterized the profile. The average slope was 0.403, yielding a predicted increase of 1.50 (50% increase) in 1 day and 2.24 (124%) in 2 days. In the final model, absolute HCG values, but not rate of rise, were significantly higher for twins and triplets and significantly lower for patients with BMI>30 kg/m2. CONCLUSIONS: The HCG profile of viable pregnancies conceived with IVF is quadratic with an earlier plateau than has been reported for non-IVF pregnancies. The average rate of rise is comparable to previous estimates in symptomatic spontaneous conceptions.