Determining the optimal follicle size at trigger in patients undergoing ovarian stimulation with a clomiphene citrate plus gonadotropin and GnRH antagonist protocol for in-vitro fertilization.

BACKGROUND: The aim of this paper was to determine the optimal follicle size at trigger in clomiphene citrate-based in vitro fertilization (IVF) protocols. METHODS: This is a retrospective cohort study performed in at a single academic institution that included first IVF cycles with clomiphene citrate-based protocols at our center between 01/01/2013 and 03/31/2019. Patients were dichotomized by whether they had ≥2 follicles >20 mm on trigger day. Group A consisted of patients with <2 follicles >20 mm on trigger day and Group B consisted of patients with ≥2 follicles >20 mm on trigger day. The primary outcome was the number of mature oocytes retrieved. Secondary outcomes included pregnancy and live birth rates. RESULTS: A total of 635 patients were included: (Group A=399 patients and Group B=236 patients). The median (IQR) diameter of the largest follicle was 20.0 mm (19.0-21.0) in Group A and 22.7 mm (21.8-24.0) in Group B (P<0.001). Among the entire cohort, mean number of oocytes retrieved was significantly higher in Group B (9.9±6.5; RR 1.08 [95% CI 1.03-1.14]) compared to Group A (9.2±6.3). In a subgroup analysis of patients in the upper quartile for age (≥41.7 years), Group B had significantly more oocytes retrieved (8.1±5.9 vs. 6.7±4.5; RR 1.23 (95% CI 1.10-1.38]), more mature oocytes retrieved (6.0±4.0 vs. 5.2±3.4; RR 1.16 [95% CI 1.02-1.33]), and more zygotes (4.7±3.5 vs. 3.6±2.8; RR 1.32 [95% CI 1.13-1.55]). In the secondary analysis, pregnancy and live birth rates after fresh transfer were similar between groups. CONCLUSIONS: In clomiphene citrate-based IVF protocols, administering the ovulatory trigger at larger follicle sizes yielded more total oocytes retrieved without a significant difference in mature oocyte number. In older patients, larger follicle sizes at trigger yielded more mature oocytes and zygotes per retrieval. Based on these results, in older patients it may be advantageous to administer the ovulatory trigger in clomiphene-based IVF cycles when two or more follicles measures >20 mm. However, this benefit was not observed when assessed among all ages combined.

Clinical pregnancy resulting from intracytoplasmic sperm injection of prematurely ovulated oocytes retrieved from the posterior cul-de-sac.

OBJECTIVE: To report a clinical pregnancy resulting from intracytoplasmic sperm injection of prematurely ovulated oocytes retrieved from the posterior cul-de-sac. DESIGN: Case report. SETTING: Academic center. PATIENTS: A 40-year-old nulligravid woman underwent ovarian stimulation for in vitro fertilization (IVF). Daily injections of gonadotropin-releasing hormone antagonist were initiated on cycle day 8. A 10,000 IU dose of human chorionic gonadotropin was administered on cycle day 15 to trigger follicular maturation. The estradiol and luteinizing hormone levels on the trigger day were 1528 pg/mL and 2.4 mIU/mL, respectively. The patient underwent oocyte retrieval 35 hours after the trigger. Transvaginal sonography at the time of the retrieval revealed a large pocket of free fluid in the posterior cul-de-sac. Only 3 follicles measuring 10-12 mm were noted in both ovaries. No lead follicles were visualized. INTERVENTIONS: Aspiration of free fluid from the posterior cul-de-sac. MAIN OUTCOME MEASURES: Clinical pregnancy. RESULTS: The fluid in the posterior cul-de-sac was aspirated, and 3 mature oocytes were retrieved. Aspiration of the smaller ovarian follicles measuring 10-12 mm did not yield oocytes. All mature oocytes retrieved from the posterior cul-de-sac were fertilized with intracytoplasmic sperm injection. Three cleavage-stage embryos were transferred 3 days later. A single intrauterine pregnancy with cardiac activity was confirmed at a gestational age of 7 weeks. CONCLUSIONS: In the setting of premature ovulation, aspiration of free fluid from the posterior cul-de-sac can result in the retrieval of mature oocytes, which may result in clinical pregnancies.

Combined transvaginal and transabdominal oocyte retrieval in a patient with an ectopic ovary and unicornuate uterus.

OBJECTIVE: To report the utility of combined transvaginal and transabdominal oocyte retrieval in a patient with an ectopic ovary and unicornuate uterus. DESIGN: Video case report with demonstration of oocyte retrieval technique. SETTING(S): University-affiliated fertility center. PATIENT(S): A 35-year-old woman, gravida 0, with a 6-month history of infertility who presented to our center for fertility evaluation. Hysterosalpingography revealed a left unicornuate uterus and patent left fallopian tube magnetic resonance imaging and laparoscopy showed a right ectopic ovary located in the upper abdomen. Her partner was a 36-year-old male with isolated teratozoospermia. The couple did not conceive with intrauterine insemination. INTERVENTION(S): Ovarian stimulation for in vitro fertilization (IVF). Transvaginal retrieval of oocytes from the right ovary was not deemed possible due the anatomic location of the ovary, intervening blood vessels, and limited mobility of the ovary. Institutional review board approval was not required for this case report as per our institution's policy; patient consent was obtained for publication of the case. MAIN OUTCOME MEASURE(S): Transabdominal retrieval of oocytes from the right ovary and transvaginal retrieval of oocytes from the left ovary. RESULT(S): The couple underwent two IVF cycles. Nine oocytes were retrieved during the first IVF cycle: seven transabdominal (right ovary) and two transvaginal (left ovary). All oocytes were mature, and five blastocysts were cryopreserved. Eight oocytes were retrieved during the second IVF cycle, of which five oocytes were retrieved transabdominally from the right ovary, and three oocytes were retrieved transvaginally from the left ovary. All oocytes were mature, and four blastocysts were cryopreserved. A single thawed embryo was transferred in the natural menstrual cycle, which resulted in the live birth of a full-term baby boy weighing 2,410 grams. CONCLUSION(S): The current case highlights the safety and feasibility of combined transvaginal and transabdominal oocyte retrieval in patients with an ectopic ovary located in the upper abdomen.

Tubal Ectopic Pregnancy with Undetectable Initial Serum ß-Human Chorionic Gonadotropin Level.

We present a case of a tubal ectopic pregnancy (EP) in a patient with an initially undetectable serum ß-human chorionic gonadotropin (ß-hCG) level. A 33-year-old woman in a same-sex relationship underwent timed donor intrauterine insemination. Her serum ß-hCG level was <5 mIU/mL 14 days after the intrauterine insemination. She reported menstrual bleeding 3 days after her negative pregnancy test and returned to the office 10 days later to begin a new treatment cycle. Her serum levels of estradiol, progesterone, and ß-hCG were 119 pg/mL, 6.1 ng/mL and 1157 mIU/mL, respectively. Transvaginal ultrasonography did not show an intrauterine pregnancy. Her ß-hCG level increased to 1420 mIU/mL the next day. She was diagnosed with a pregnancy of unknown location and treated with methotrexate. Her ß-hCG levels continued to increase despite 3 methotrexate doses, necessitating laparoscopy. The diagnostic laparoscopy demonstrated approximately 100 mL of hemoperitoneum in the posterior cul-de-sac with an intact right fallopian tube that was dilated at its distal end by the EP. A total right salpingectomy was performed. Her ß-hCG level was <5 mIU/mL 3 weeks later. The current case supports that although rare, an undetectable serum ß-hCG level does not completely rule out the diagnosis of an EP.

Fertility preservation with random-start controlled ovarian stimulation and embryo cryopreservation for early pregnancy-associated breast cancer.

We report a case of fertility preservation using random-start controlled ovarian stimulation (COS), intracytoplasmic sperm injection (ICSI) and embryo cryopreservation in a patient with early pregnancy-associated breast cancer. A 34-year-old nulliparous woman at 5 weeks of gestation was diagnosed with estrogen receptor (ER) positive, progesterone receptor (PR) positive and human epidermal growth factor receptor-2 (HER-2) negative infiltrating intraductal carcinoma. Urgent neoadjuvant chemotherapy was deemed necessary and the patient decided to terminate the pregnancy. Random-start COS was initiated 5 days after pregnancy termination using a letrozole-based protocol. The beta human chorionic gonadotropin level on the day of COS start was 119.8 mIU/mL. Twenty-nine oocytes were retrieved after 11 days of COS. Seventeen oocytes underwent successful fertilization and 10 blastocysts were cryopreserved. The patient subsequently initiated neoadjuvant chemotherapy with her oncologist. The current case highlights the feasibility of random-start COS and embryo cryopreservation for fertility preservation immediately after the termination of an early pregnancy in a patient with pregnancy-associated breast cancer.

Novel Fumarate Hydratase Mutation in Siblings With Early Onset Uterine Leiomyomas and Hereditary Leiomyomatosis and Renal Cell Cancer Syndrome.

Hereditary leiomyomatosis renal cell cancer syndrome is an autosomal dominant disorder characterized by uterine and cutaneous leiomyomas and increased predisposition to renal cell carcinoma, papillary type II. The syndrome is caused by heterozygous mutations to the fumarate hydratase (FH) gene located on chromosome 1. Affected females generally present with early onset, atypical uterine leiomyomas and cutaneous findings, however, delays in diagnosis are very common in patients with isolated uterine findings. We present a case series of 2 sisters in their 20s who presented with isolated uterine leiomyomas and were found to carry a novel mutation for the fumarate hydratase gene. One patient was referred for treatment of infertility and recurrent miscarriages and the other was referred for acute symptomatic anemia due to myomas. Prompt diagnosis of hereditary leiomyomatosis renal cell cancer was made due to a high index of clinical suspicion based on early onset disease and familial clustering as well as characteristic pathologic findings on uterine leiomyoma surgical specimen. Timely diagnosis not only allowed for genetic counseling and renal cancer surveillance, but also for fertility counseling given the increased morbidity associated with uterine leiomyoma due to hereditary leiomyomatosis and renal cell cancer syndrome.

Severe ovarian hyperstimulation syndrome after combined GnRH-agonist and low-dose human chorionic gonadotropin trigger in a patient with a single kidney.

Ovarian hyperstimulation syndrome (OHSS) following gonadotropin-releasing hormone agonist (GnRH-a) trigger is rare. Here, we report a case of severe OHSS after combined GnRH-a and low-dose human chorionic gonadotropin (hCG) trigger in a patient with a single kidney. The patient is a 32-year-old women with a two-year history of infertility. The patient's history was significant for a single kidney, that is, she had donated a kidney to a family member three years ago. The patient underwent controlled ovarian stimulation (COS) for in vitro fertilization (IVF) and received a combined 2 mg GnRH-a and 1500 IU hCG ovulatory trigger. Estradiol (E2) levels on the day of and after the trigger were 3800 pg/mL and 4001 pg/mL, respectively. Four days after the trigger, the patient began experiencing nausea, abdominal distention and dyspnea, and her blood testing revealed hemoconcentration (hemoglobin: 16.9 g/dL; hematocrit: 51.0%) and an elevated creatinine level (1.16 mg/dL). Fresh embryo transfer was deferred. The patient was admitted to the hospital for fluid monitoring and prophylactic anticoagulation. Following inpatient management, her hemoglobin, hematocrit and creatinine levels normalized. The current report highlights that the systemic effects of OHSS can be accentuated in patients with preexisting renal disease or a single kidney.

Clinical implications of accessory fallopian tube ostium in endometriosis and primary infertility.

Several variations in fallopian tube anatomy may be noted during the evaluation of infertility. Some anatomical variants such as accessory tubal ostia are rare. A 31-year-old woman presented to our center with a 2-year history of primary infertility. Given her history of dysmenorrhea, a diagnostic laparoscopy was performed. Laparoscopy revealed a left utero-sacral endometriosis implant, which was resected. Although the left fallopian tube was normal, the right fallopian tube was noted to have two prongs with individual ostia. Tubal cannulation confirmed two separate ostia, with chromotubation showing free flow of dye through separate fimbrial ostia of the right fallopian tube. The current case highlights that accessory tubal ostia are rare müllerian duct anomalies seen during laparoscopy and can be associated with endometriois or primary infertility.

Female patients with lymphoma demonstrate diminished ovarian reserve even before initiation of chemotherapy when compared with healthy controls and patients with other malignancies.

PURPOSE: The purpose of this study is to investigate if female patients with lymphoma demonstrate diminished ovarian reserve prior to initiation of the lymphoma treatment. METHODS: Sixty-four patients with newly diagnosed lymphoma undergoing controlled ovarian hyperstimulation for fertility preservation were compared with 365 healthy controls undergoing elective oocyte cryopreservation (controlled ovarian hyperstimulation (COH)) and 128 patients with other types of malignancy prompting fertility preservation. The data of all lymphoma patients, all elective, and all the patients with other types of malignancy who met the inclusion criteria and underwent COH for fertility preservation during the study period were retrospectively analyzed. Primary outcomes included serum anti-Müllerian hormone (AMH) levels (ng/mL) and antral follicle count (AFC). RESULTS: Patients in the lymphoma group demonstrated significantly lower AMH levels and AFC and had less oocytes harvested and cryopreserved when compared to healthy controls as well as patients with other malignancies. CONCLUSION: Patients with lymphoma demonstrate diminished ovarian reserve when compared with healthy controls and patients with other malignancies. This should be taken into consideration when deciding on the dose for COH.

Pretreatment of normal responders in fresh in vitro fertilization cycles: A comparison of transdermal estradiol and oral contraceptive pills.

OBJECTIVE: The aim of this study was to investigate the impact of pretreatment with transdermal estradiol (E2) compared to oral contraceptive pills (OCPs) on controlled ovarian stimulation (COS) response in normal responders undergoing fresh in vitro fertilization (IVF)-embryo transfer (ET) cycles. METHODS: A retrospective cohort study was performed of normal responders undergoing fresh IVF-ET cycles who received pretreatment with transdermal E2 versus OCPs prior to fresh IVF-ET. The total days of ovarian stimulation, total dosage of gonadotropins, total number of oocytes, and mature oocytes retrieved were noted. Pregnancy outcomes after ET were also recorded. RESULTS: A total of 2,092 patients met the inclusion criteria: 1,057 and 1,035 patients in the transdermal E2 and OCP groups, respectively. Patients in the OCP group had a longer duration of COS (10.7±1.63 days, p<0.01) than the E2 group (9.92±1.94 days). Patients in the OCP group also required higher cumulative doses of gonadotropins (2,657.3±1,187.9 IU) than those in the E2 group (2,550.1±1,270.2 IU, p=0.002). No statistically significant differences were found in the total and mature oocytes retrieved or in the rates of biochemical pregnancy, clinical pregnancy, spontaneous miscarriage, and live birth between the groups. CONCLUSION: Our findings suggest that compared to OCPs, pretreatment with transdermal E2 is associated with a shorter duration of ovarian stimulation and lower gonadotropin utilization, without compromising the oocyte yield or pregnancy outcomes in normal-responder patients undergoing fresh IVF.

Routine Monitoring of Liver, Renal, and Hematologic Tests After Single- or Double-Dose Methotrexate Treatment for Ectopic Pregnancies After In Vitro Fertilization.

STUDY OBJECTIVE: To investigate the trends in liver function tests (LFTs), renal function tests (RFTs), and complete blood count (CBC) between day 1 and day 7 after single- or double-dose methotrexate (MTX) treatment for sonographically confirmed ectopic pregnancies. DESIGN: Single center, retrospective chart review (Canadian Task Force classification II-3). SETTING: University-affiliated center. PATIENTS: All patients with a sonographically confirmed ectopic pregnancy after fresh in vitro fertilization-embryo transfer cycles between January 2004 and June 2013 treated with MTX were included. INTERVENTIONS: Single- or double-dose MTX treatment. MEASUREMENTS AND MAIN RESULTS: LFTs, specifically alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin, and total bilirubin levels, were measured on day of MTX administration (baseline) and 7 days later (day 7). Similar measurements of RFTs (blood urea nitrogen [BUN] and creatinine) and CBC (white blood cell [WBC] and platelets) were also performed. The change in LFTs, RFTs, and CBC (Δ) between baseline and day 7 was calculated for both single- and double-dose MTX protocols. Furthermore, the change in LFTs, RFTs, and CBC (Δ baseline vs day 7) for single- and double-dose MTX protocols were compared. Complete data was available for 107 patients: 89 (83.2%) and 18 (16.8%) patients received single- and double-dose MTX treatment, respectively. For either single- or double-dose treatment, no significant difference was found between baseline and day 7 ALT, AST, albumin, total bilirubin, BUN, creatinine, WBC, or platelet levels after MTX treatment. A comparison of post-treatment changes in LFTs, RFTs, and CBC (Δ baseline vs day 7) also showed no difference between single- and double-dose protocols. CONCLUSION: Our study suggests that repeating LFTs, RFTs, or CBC on day 7 after single- or double-dose MTX treatment for sonographically confirmed ectopic pregnancies may not be necessary in patients with normal baseline testing on day 1.

Reproductive and oncologic outcomes after progestin therapy for endometrial complex atypical hyperplasia or carcinoma.

OBJECTIVES: This study evaluated fertility and oncological outcomes in women with complex atypical hyperplasia (CAH) or nonmyoinvasive grade 1 endometrioid endometrial carcinoma (EM) who desired fertility-sparing therapy. STUDY DESIGN: The retrospective cohort study included women younger than 45 years with CAH or EM who desired fertility-sparing treatment at our institution. Only patients for whom both oncological treatment and pregnancy outcomes were available were included. Statistical analyses were performed using a Fisher exact test, Pearson χ(2) test, and Spearman rank correlation test, as appropriate. RESULTS: Seventy-five patients were identified, and 23 (13 CAH, 10 EM) met the inclusion criteria. All 23 patients had at least 1 prior pregnancy. Treatment was split between oral progesterone only (38.5% CAH, 40% EM), levonorgestrel intrauterine device only (30.8% CAH, 20% EM), and both (30.8% CAH, 40% EM). After a median follow-up of 13 months (range, 3-74 months), 9 patients (46.2% CAH, 30% EM, P = .39) had persistent/progressive disease. Eight patients (30.8% CAH, 40% EM, P = .69) ultimately had a hysterectomy, and 3 of these (13.0%) were found to have persistent/progressive disease. Median time from diagnosis to hysterectomy was 13 months (range, 4-56 months). Fourteen of the 23 patients utilized assisted reproductive techniques (60.9%); 12 underwent IVF and 2 chose a gestation carrier. Seven clinical intrauterine pregnancies (30.4%) resulting in 6 live births (26.1%) were found in the entire cohort. CONCLUSION: Fertility-sparing treatment for CAH and grade 1 endometrial cancer is feasible with progestin therapy and leads to clinically meaningful rates of pregnancy in young women who desire fertility.

Unsuccessful planned conservative resection of placental site trophoblastic tumor.

BACKGROUND: Placental site trophoblastic tumor is a rare subtype of gestational trophoblastic neoplasia affecting women of reproductive age. The preferred method of treatment is surgical resection. CASE: A 33-year-old woman, gravida 3 para 1111, was incidentally diagnosed with placental site trophoblastic tumor during an evaluation for infertility. As a result of persistent pathologic evidence of disease, she underwent a hysterectomy. The site of disease on pathologic review of the hysterectomy specimen was widely discordant from the preoperative imaging and hysteroscopic evaluations. CONCLUSION: Wedge resection of the uterus has been suggested as an acceptable alternative to hysterectomy in women with placental site trophoblastic tumor who wish to preserve future fertility. However, this case demonstrated that preoperative imaging may not correlate with the tumor site, making wedge resection treatment ineffective.

Can in vitro fertilization cycles be salvaged by repeat administration of intramuscular human chorionic gonadotropin the day after failed injection?

OBJECTIVE: To investigate the incidence of negative serum hCG level after initial IM trigger injection and whether such cycles can be salvaged through repeat administration of IM hCG. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): All patients undergoing IVF at the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, from January 1, 2005 to November 1, 2011. INTERVENTION(S): Repeat hCG administration in cases of failed initial trigger. MAIN OUTCOME MEASURE(S): Fertilization, implantation, clinical pregnancy, and live birth rates were analyzed in the index population compared with a control population matched for age, year of cycle start, diagnosis, stimulation protocol, number of prior IVF attempts, oocyte yield, and number of embryos transferred. RESULT(S): The incidence of failed initial IM hCG injection was low, occurring in only 0.25% of the 17,298 fresh IVF cycles at our center during the study period. Of the 41 patients undergoing retrieval who received a second IM injection of hCG approximately 24 hours after the first, the live birth rate was 39.02%. Compared with matched controls, there were no statistical differences in oocyte maturity, fertilization, implantation, clinical pregnancy, or live birth rates. CONCLUSION(S): Although the incidence of failed hCG injection is rare, this study reveals that cycles characterized by incorrect initial administration or failed absorption of hCG can be salvaged by early detection and repeat injection. Assisted reproductive technology (ART) programs may benefit their patients through the assessment of either urine pregnancy tests or measurement of quantitative serum ß-hCG levels before retrieval, thereby preventing empty follicle syndrome.

Stimulation of the young poor responder: comparison of the luteal estradiol/gonadotropin-releasing hormone antagonist priming protocol versus oral contraceptive microdose leuprolide.

OBJECTIVE: To evaluate in vitro fertilization (IVF) cycle outcomes in young poor responders treated with a luteal estradiol/gonadotropin-releasing hormone antagonist (E(2)/ANT) protocol versus an oral contraceptive pill microdose leuprolide protocol (OCP-MDL). DESIGN: Retrospective cohort. SETTING: Academic practice. PATIENT(S): Poor responders: 186 women, aged <35 years undergoing IVF with either E(2)/ANT or OCP-MDL protocols. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical pregnancies, oocytes retrieved, cancellation rate. RESULT(S): Patients in the E(2)/ANT group had a greater gonadotropin requirement (71.9 ± 22.2 vs. 57.6 ± 25.7) and lower E(2) level (1,178.6 ± 668 vs. 1,627 ± 889), yet achieved similar numbers of oocytes retrieved and fertilized, and a greater number of embryos transferred (2.3 ± 0.9 vs. 2.0 ± 1.1) with a better mean grade (2.14 ± .06 vs. 2.7 ± 1.8) compared with the OCP/MDL group. The E2/ANT group exhibited a trend toward improved implantation rates (30.5% vs. 21.1%) and ongoing pregnancy rates per started cycle: 44 out of 117 (37%) versus 17 out of 69 (25%). CONCLUSION(S): Poor responders aged <35 years may be treated with the aggressive E(2)/ANT protocol to improve cycle outcomes. Both protocols remain viable options for this group. Adequately powered, randomized clinical comparison appears justified.

Withholding gonadotropins until human chorionic gonadotropin administration.

Withholding gonadotropins in women who exhibit high estradiol responses before follicles reach full maturation is called "coasting." Coasting, or suspending gonadotropin administration, can be an effective strategy for decreasing the risk of ovarian hyperstimulation syndrome (OHSS) while reducing cancelation rates. In in vitro fertilization cycles, mechanistically it is believed that withholding gonadotropins starves smaller follicles, induces apoptosis, and decreases the potential for these follicles to elaborate vascular endothelial growth factor, a known mediator of OHSS. It is generally accepted that coasting should be initiated when the estradiol (E2) level is >3000 pg/mL in the setting of immature follicles. The human chorionic gonadotropin (hCG) trigger should be administered when the E2 level subsequently drops to a "safe" level. Cycle cancellation should be considered if, after 3 to 4 days of coasting, the E2 level remains excessively elevated. Oocyte retrieval may also be cancelled if the E2 level on the day after hCG trigger drops precipitously. In gonadotropin-releasing hormone agonist (GnRHa)-based protocols, one can consider withholding GnRHa administration if the E2 level continues to increase after a few days of coasting. Current data seem to show that the coasting period is short and/or is less likely to be required in GnRH-antagonist protocols as compared with GnRHa-based protocols. Large randomized control trials are still needed to establish the relative efficacy of coasting versus embryo cryopreservation in the context of OHSS prevention.

Immunohistochemical expression of endometrial L-selectin ligand is higher in donor egg recipients with embryonic implantation.

OBJECTIVE: To correlate L-selectin ligand (LSL) expression in human endometrium with embryonic implantation. DESIGN: Retrospective cohort analysis. SETTING: University-based fertility center. PATIENT(S): Donor egg recipients (DERs) who underwent programmed hormonal replacement for ET with prior mock cycle luteal phase endometrial biopsy. INTERVENTION(S): Immunohistochemical expression of LSL using MECA-79 antibody was examined. Slides were scored with a new scoring system, the IHC-Level (range 0-4) as follows: strength of staining-absent (0), weak (1), or strong (2); plus distribution of staining-absent (0), <50% of tissue (1), and >50% (2). Cellular apex and cytoplasm were scored independently in both the endometrial glandular and surface epithelium. MAIN OUTCOME MEASURE(S): Endometrial LSL expression in pregnant versus nonpregnant patients. RESULT(S): MECA-79 IHC-Level of the apex of surface epithelium was significantly higher for pregnant versus nonpregnant DERs (3.8 vs. 3.4). When controlling for embryo morphology, there continues to be a significant difference in apex score on surface epithelium (3.8 vs. 3.3, respectively). The new scoring system results correlated with an established scoring system, the HSCORE. CONCLUSION(S): We demonstrate significantly higher expression of LSL at the apex of human endometrial surface epithelium obtained from DERs with embryonic implantation. Furthermore, we present the IHC-Level, a method of evaluating immunohistochemistry that may be applied to other markers of endometrial receptivity.

Safety and efficacy of infertility treatment after conservative management of borderline ovarian tumors: a preliminary report.

OBJECTIVE: To evaluate the safety and efficacy of infertility treatment in a group of patients after conservative management of borderline ovarian tumors. DESIGN: Retrospective study. SETTING: University IVF unit. PATIENT(S): Five patients with previous conservative treatment of borderline ovarian tumor. INTERVENTION(S): Seventeen IVF cycles. MAIN OUTCOME MEASURE(S): Recurrence, IVF outcome. RESULT(S): At the time of diagnosis, the mean age of the patients was 32.2 +/- 6.9 years. The mean time elapsed between the initial diagnosis of a borderline tumor and the performance of IVF was 42.2 months. After IVF, the mean number of oocytes retrieved was 7.9 +/- 4.0 with a mean fertilization rate of 57.1% and a mean number of 3.1 +/- 1.4 day 3 embryos transferred. Six pregnancies were achieved in three of the five patients with a pregnancy rate per retrieval of 37.5% and per transfer of 42.9%. The mean follow-up time that elapsed since the first IVF cycle was 39.2 months (range 9-78 months). One patient had three recurrences 13, 27, and 43 months after her first IVF cycle, all of which remained histologically serous borderline tumor. All patients were without evidence of disease at the time of last follow-up. CONCLUSION(S): At a mean follow-up time of 39.2 months, our results suggest that IVF may be considered for patients with conservatively treated borderline tumors. Furthermore, overall IVF success rates were very satisfactory, suggesting no perceptible negative impact of prior borderline ovarian neoplasia on pregnancy rates after IVF.