Clinical management of functional ovarian cysts: a prospective and randomized study.

Most ovarian cysts in women of reproductive age are physiological (functional) and patients have been treated for years with oral contraceptives to obtain the resolution of these cysts. Expectant management has been suggested to have the same effectiveness as hormonal treatment but such suggestions come from studies including all kinds of cysts. The objective of the present study was to assess the resolution of functional ovarian cysts, observed after ovulation induction, with expectant management and hormonal treatment and also to determine the period of time necessary for the resolution of the cysts. For this purpose, 53 patients with ovarian cysts, observed by transvaginal ultrasound within the first 5 days of a cycle after ovulation induction, were randomized to have expectant management (group A) or to receive oral contraception (group B) for one cycle. If the cyst persisted, the patient was followed for another cycle, without any treatment. Within the 50 women who completed the trial, a complete resolution of the cysts was observed in 19/25 (76%) and 18/25 (72%) in groups A and B respectively. On the other hand, all the persistent cysts disappeared after a second cycle without any treatment. In conclusion, expectant management is as effective as oral contraceptives for the resolution of functional ovarian cysts induced by ovarian stimulation. However, studies with a larger number of cases are needed to increase the power of the results and to obtain a firm conclusion.

Prospective randomized trial to evaluate the efficacy of a vaginal ring releasing progesterone for IVF and oocyte donation.

A polysyloxane vaginal ring containing 1g of natural progesterone was developed as luteal supplementation for women treated with IVF-embryo transfer and for agonadal women participating in an oocyte donation programme. The ring provides continuous release of progesterone (10-20 nmol/l) for 90 days. The efficacy of this form of progesterone supplementation was evaluated in two multicentre prospective randomized trials. IVF-embryo transfer trial: After oocyte aspiration, 505 women were randomly allocated to progesterone supplementation with vaginal ring or i.m. progesterone (50 mg/day). The clinical pregnancy rate was 36.6% in both groups. Implantation rate was 15.9% in the vaginal ring and 16.0% in i.m. progesterone. Oocyte donation trial: After endometrial proliferation with micronized oestradiol, 153 women were allocated to progesterone replacement with a vaginal ring or i.m. progesterone (100 mg/day). Clinical pregnancy rate was 39.8 and 28.6% respectively. Implantation rate was significantly higher with the vaginal ring compared with i.m. progesterone (19.9 and 11.6% respectively, P = 0.006). The vaginal ring is a novel development which provides continuous release of progesterone for 90 days. In IVF-embryo transfer, its effectiveness is similar to daily i.m. injections. In oocyte donation the ring provides a progestative milieu which improves the implantation rate and eliminates the discomfort of daily i.m. injections.

Preliminary results on the role of embryonic human chorionic gonadotrophin in corpus luteum rescue during early pregnancy and the relationship to abortion and ectopic pregnancy.

The precise mechanisms by which corpus luteum (CL) function is modulated during early pregnancy are not known. Evidence in failed pregnancies (ectopic, abortions), shows that factors other than human chorionic gonadotrophin (HCG) could be involved in its regulation. The objective of this study was to investigate the dynamics of beta-HCG, progesterone and oestradiol production in early pregnancy and its relation to embryonic quality and topographic localization. Plasma concentrations of progesterone, oestradiol and beta-HCG were studied between days +12 and +21 after an in-vitro fertilization (IVF) embryo transfer in 11 intrauterine pregnancies, 10 intrauterine abortions and seven tubal pregnancies. Tubal pregnancies and abortions were grouped according to doubling time (DT) of HCG. Results showed that oestradiol concentrations were apparently reduced in both ectopic pregnancies and abortions compared with normal pregnancies. The fall in oestradiol concentrations was seen in ectopic pregnancies with an abnormal DT for HCG and in all abortions. When the ectopic pregnancy had a normal DT, oestradiol and progesterone concentrations were normal. In abortions, the fall in oestradiol and progesterone concentrations was less influenced by the DT of HCG. These findings suggest that corpus luteum function depends on an adequate DT of HCG more than an absolute value, and with normal trophoblastic tissue the site of implantation does not affect CL function.

Comparison of ultrasonography and hysteroscopy in the diagnosis of intrauterine lesions in infertile women.

STUDY OBJECTIVE: To compare the effectiveness of transvaginal ultrasound versus hysteroscopy in the diagnosis of benign intrauterine lesions, with histology as the gold standard. DESIGN: Retrospective study (Canadian Task Force classification II-1). SETTING: Unit of Reproductive Medicine, Department of Obstetrics and Gynecology of Clinica Las Condes, Santiago, Chile. PATIENTS: Infertile women who had undergone complete fertility evaluation. INTERVENTION: Transvaginal ultrasound, hysteroscopy, and histologic evaluation of endometrial samples performed in all 126 women. MEASUREMENTS AND MAIN RESULTS: The most frequent condition was a normal cavity (59.5%), followed by endometrial polyps (34.9%) and fibromyomas (3.9%). Synechiae and bone metaplasia were extremely rare. Sensitivity of transvaginal ultrasound for the diagnosis of endometrial polyps was 95.6% compared with 89.9% for hysteroscopy (NS). Specificity was 97.4% with transvaginal ultrasound versus 93. 3% with hysteroscopy (NS). Positive and negative predictive values were similar for both methods. CONCLUSION: Transvaginal ultrasound is as effective as hysteroscopy in diagnosing benign intrauterine lesions. It could be the first clinical diagnostic test in the investigation of the uterine cavity.

Hysteroscopic Correction of Cesarean Section Scars in Women with Abnormal Uterine Bleeding

Abnormal postmenstrual uterine bleeding may occur in women with history of cesarean section. To study the etiology of this anomaly, transvaginal ultrasound (TVU) was performed during follicular phase in 20 such patients, and hysteroscopy in 7. The TVU revealed the presence of fluid in the isthmus in relation to the cesarean section scar, where a kind of pouch or bursa was observed. Cervical introduction of a catheter showed that the fluid was blood. The TVU observation was confirmed in women in whom hysteroscopy was performed. Resection of ring-shaped fibrotic tissue on the inferior part of the scar stopped abnormal bleeding. Four women were infertile and two conceived, probably because stopping postmenstrual bleeding could interfere with the quality of cervical mucus. These findings suggest that abnormal uterine bleeding in women with an abnormal uterine scar could be resolved by minimally invasive endoscopic surgery, and TVU is a valuable diagnostic tool.

[Follicular and endometrial growth profiles in stimulated cycles with clomiphene citrate]. / Perfil de crecimiento folicular y endometrial en ciclos estimulados con citrato de clomifeno.

To study follicular and endometrial growth patterns in Clomiphene Citrate (CC) stimulated cycles, 50 CC cycles of 31 infertile women with patient Fallopian Tubes, were followed, 17 spontaneous conceptional cycles of fertile women were followed as controls. The pattern of follicular growth was similar in both groups until the day before ovulation in which CC cycles showed larger follicular diameters than spontaneous ones; 23.8 +/- 3.1 mm versus 21.6 +/- 2.9 mm (p = 0.013). Follicular rupture occurred on day 16.1 +/- 2.9 in CC cycles, and on day 15.1 +/- 1.85 on spontaneous conceptional ones. This suggests that the follicle, under the influence of CC, has to reach a larger critical mass to produce enough estradiol to revert the hypothalamic blockage produced by the drug, thus permitting the preovulatory LH surge. Endometrium under CC action, was always thinner than in natural cycles. On the day of follicular rupture, the CC cycle's endometrium measured 11.1 +/- 2.02 mm and the natural cycle's endometrium measured 10.6 +/- 1.8 mm (ns). This finding could be attributed to a antiestrogenic effect of CC on the endometrium. It is concluded that cycles under CC action have different follicular and endometrial growth patterns than spontaneous conceptional cycles.

[Simplified management of an in vitro fertilization program]. / Manejo simplificado de un programa de fertilización in vitro.

The development of in vitro fertilization has accelerated in a dramatic way the understanding on gamete physiology. Results obtained with the technique are easily reproducible and consistent between different centers. It is well known that cumulative pregnancy rates with 5 or 6 cycles can reach up to 60% of couples being pregnant. However, the main limitations to successive attempts have been the cost of the procedure and the surgical transfer of the embryos. In an attempt to overcome this difficulties, efforts has been made to simplify the monitoring of induction of ovulation, use of GnRh analogs and non surgical transfers whenever it is possible. Results presented in 47 of these cycles show non significant differences, with data published elsewhere, on oocyte maturity, fertilization and cleavage rates. Moreover pregnancy rates per aspiration are 28.6% and per transfer 33.3%. We can conclude that ultrasonography alone to monitor ovulation induction as well as uterine transfers do not affect the outcome of the cycle.

[The gestrinone (R-2323) treatment of endometriosis]. / Tratamiento con gestrinona (R-2323) de la endometriosis.

Results of medical treatment with gestrinone are evaluated in 29 women with minimal (10), mild (9) and moderate (7) endometriosis. After a diagnostic laparoscopy, patients started gestrinone 2.5 mg/day 2 times a week per 6 months. Clinical evaluations and blood samples were performed at the end of the ist, 3rd and 6th month of treatment. A second look laparoscopy, in 26 out of the 29 patients, was performed within a month after discontinuation of the drug. Nineteen patients (73.1%) showed a diminishing in endometriosis score. Moreover, 2 of them presented with a normal pelvis at the time of the 2nd laparoscopy. Overall post treatment scores were significantly lower than pre treatment scores (6.1 +/- 6.9 versus 11.3 +/- 10.2 respectively, p < 0.025). Nineteen out of the 26 patients had amenorrhea, most of them (18) since the second month of treatment. Nineteen patients presented with dysmenorrhea at the beginning of the treatment and in 13 of them it disappeared during the first 3 months of the drug. Reversible elevation in serum transaminases was observed in 4 patients. Red blood cells count and platelet concentration increased at the end of the treatment. A clear pituitary suppression to basal levels was seen. No significant changes on androgen levels were appreciated. Seven patients achieved a spontaneous pregnancy, out of 22 that desired fertility (31.8%), all of them were clinical pregnancies.

[Intramyoma intrauterine device]. / Dispositivo intrauterino intramioma.

This article describes a cases of "missing strings" of a Zipper IUD embeded in an intracavitary myoma. Two attempts with classical procedures failed to remove it and the diagnosis was done after a hysteroscopy complicated with uterine perforation. It is very difficult to assure if the myoma grew around the IUD or it was perforated at the time of its insertion. Histological evidences lead to the first option.

[Echographic imaging of absence of follicular rupture. Endocrinologic aspects]. / Ausencia ecográfica de ruptura folicular. Algunos aspectos endocrinológicos.

Since Jewelewicz in 1975 first described the luteinization of an unruptured follicle (LUF), clinical evidence for the importance of this syndrome has been given by various groups of investigators. Luteal phase of 14 cycles with ultrasound evidence of unruptured follicles were studied with plasmatic determination of levels of FSH, LH, prolactin, 17 B estradiol and progesterone each one day. Two groups were defined. One, with "ovulatory ranges" of progesterone, probably LUF syndrome and another, with "anovulatory levels", probably follicular cysts.