Assisted hatching reduces the age-related decline in IVF outcome in women younger than age 43 without increasing miscarriage or monozygotic twinning.

PURPOSE: Our purpose was to examine the benefits of assisted hatching in our program and to determine whether the procedure increases the implantation of nonviable embryos or monozygotic twinning. METHODS: Consecutive in vitro fertilization cycles using assisted hatching were compared with historical controls. The impact of assisted hatching was analyzed according to the woman's age. Outcome measures were clinical pregnancy, implantation rate, delivery rate, multiple pregnancy, spontaneous abortion, and incidence of monozygotic twins. RESULTS: The implantation rate was increased in women aged 35-39 and markedly increased in women aged 40-42. There was no change in spontaneous abortions and no increase in monozygotic twins. CONCLUSIONS: Assisted hatching is a safe and highly effective adjunct to in vitro fertilization for women aged 35-42 and did not increase spontaneous abortion or monozygotic twinning.

Cornual pregnancies in patients with prior salpingectomy undergoing in vitro fertilization and embryo transfer.

OBJECTIVE: To examine the frequency of cornual pregnancy in patients with prior salpingectomy undergoing IVF. DESIGN: Review. SETTING: Private fertility practice. PATIENTS: Women undergoing IVF. MAIN OUTCOME MEASURE: Cornual ectopic pregnancy. RESULTS: Of 26 ectopic pregnancies detected after ET during a 7-year period, 7 were located in the cornu or tubal stump after prior salpingectomy. CONCLUSIONS: Patients with prior salpingectomy undergoing IVF are at particular risk for cornual pregnancy.

Successful pregnancies with unstimulated cycle oocyte donation using an antagonist of gonadotropin-releasing hormone.

We achieved two ongoing pregnancies in five older recipients with natural cycle oocyte donation from five young donors using a GnRH antagonist, with hMG and hCG to complete oocyte maturation. This provides a new alternative to ovarian stimulation for both oocyte donation and routine IVF.

Diaphragmatic hernia through the foramen of Morgagni: laparoscopic repair case report.

Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni in a 67-year-old woman with symptoms of partial colon obstruction is described. The patient had a prompt and complete recovery with no evidence of recurrence one year after surgery. The technique, which incorporates the rectus abdominal fascia in the repair, may be suitable for other laparoscopic surgical procedures.

Disruption of follicular maturation and delay of ovulation after administration of the antiprogesterone RU486.

To investigate the role of progesterone in the follicular phase, we examined the effects of RU486 in eight normal cycling women studied with daily and frequent blood sampling (every 10 min for 10 h) during three menstrual cycles (control-treatment-recovery). RU486 (3 mg/kg, orally) was administered for 3 consecutive days after ultrasound documentation of a dominant follicle. In six of the eight women, RU486 was given after emergence of the dominant follicle, while in two women, RU486 was initiated during the preovulatory period when estradiol levels had exceeded 917 pmol/L. In the six women given RU486 after emergence of the dominant follicle, RU486 significantly prolonged the follicular phase duration from 15.6 +/- 1.9 (+/- SD) to 28.6 +/- 9.3 days (P less than 0.01) and extended the treatment cycle length to 42.3 +/- 9.1 (+/- SD) days (P less than 0.01). During RU486 treatment, mean serum estradiol levels decreased from 385 +/- 43 to 228 +/- 28 pmol/L (P less than 0.01), while LH, FSH, ACTH, cortisol, and progesterone levels changed little. LH pulse frequency and amplitude on the last day of RU486 administration did not differ from control values. Collapse of the dominant follicle was evident on ultrasound after RU486 administration and was not accompanied by uterine bleeding. In the two women treated during the preovulatory period, the follicular phase was not prolonged, and RU486 failed to delay the onset of the LH surge. Our findings indicate that RU486 treatment during the follicular phase interrupts normal follicular development, resulting in a delay of ovulation and a reinitiation of follicular recruitment.

PIP: The effect of the antiprogesterone RU486 on the hypothalamic-pituitary-ovarian axis during the follicular phase of the menstrual cycle was investigated in 8 normally cycling women. Frequent, daily blood sampling was conducted during 3 cycles--control, treatment, and recovery. In 6 subjects, RU486 administration was initiated after emergence of the putative dominant follicle (documented by ultrasound). The 2 remaining subjects received RU486 during the preovulatory period when estradiol levels had already exceeded 917 pmol/L. When RU486 was administered after emergence of the dominant follicle, the duration of the follicular phase significantly increased from 15.6 + or - 1.9 days to 28.6 + or - 9.3 days, thus prolonging the intermenstrual length of the RU486 cycle from 28.9 + or - 2.7 days to 42.3 + or - 9.1 days. Endometrial breakdown did not occur during RU486 administration. RU486 further induced a significant decline in estradiol levels from 385 + or - 43 pmol/L to 228 + or - 28 pmol/L, but there was no significant change in luteinizing hormone (LH), follicle-stimulating hormone (FSH), or progesterone levels. RU486 produced a decrease in size or collapse of the putative dominant follicle in 5 of the 6 subjects who received this agent after emergence of the follicle. In the 2 women treated during the preovulatory period, the follicular phase was nor prolonged and RU486 failed to delay the onset of the LH surge. Overall, this study demonstrates that administration of RU486 in the follicular phase disrupts normal follicular development, resulting in functional demise of the dominant follicle, reinitiation of folliculogenesis, and extended menstrual cycle length. These events are not accompanied by uterine bleeding or significant alterations in LH pulsatile frequency and amplitude.

Luteal contraception.

The impact of oral administration of RU 486 on the ongoing functional activity of the hypothalamic-gonadotropin-corpus luteum-endometrial (H-P-CL-E) axis was assessed during the mid-luteal (MLP) and the late-luteal phase (LLP) with and without hCG-induced pseudopregnancy. Longitudinal studies with daily dosing and frequent blood sampling were conducted during three consecutive cycles (control/treatment/recovery). During MLP, uterine bleeding occurred in all subjects within 36-72 h of the first dose of RU 486, but no histological changes were discernible on endometrial biopsy taken 12-24 h before bleeding. There was a significant decrease in LH secretion, pulse amplitude but not frequency. Response to GnRH on the last day of treatment was impaired. This was followed 3 days later by a rebound LH secretion lasting for 5 days. These events were accompanied by an initial decline of estradiol, but not progesterone, and a second peak of 5 days' duration for both estradiol and progesterone. Hence corpus luteum function was prolonged by 5 days, and second bleeding ensued following the spontaneous luteolysis. Recovery cycles were normal. During LLP, a single dose of RU 486 induced uterine bleeding in all cases. This was associated with a decreased LH pulse amplitude and frequency, and a faster decline of both estradiol and progesterone as compared to control cycles. Rescue of corpus luteum function by the administration of incremental doses of hCG failed to prevent the uterine bleeding after a single dose of RU 486. Recovery cycles were normal. While the antiprogesterone effect of RU 486 at the endometrial level was predictably expressed, its effects at the H-P-CL-E axis were also demonstrated. These findings provide important clues for the design of once-monthly contraceptive methods.

Management of postoperative vaginal hemorrhage.

The authors' experience in the management of postoperative vaginal hemorrhage from 1975 to 1980 was reviewed. Recently, success has been achieved using angiographic arterial embolization with the Gianturco minicoil. The results of embolization are compared with those achieved through other more conventional methods. The authors have found angiographic embolization to be safe, simple, and effective, and they recommend that the procedure be performed before laparotomy for intractable postoperative vaginal bleeding.