Recurrence of hydrosalpinges after cuff neosalpingostomy in a poor prognosis population.

PURPOSE: The purpose of this study was to determine the recurrence rate of hydrosalpinges after cuff neosalpingostomy in poor prognosis candidates. METHODS: Forty consecutive patients with hydrosalpinx treated with cuff neosalpingostomy were included. Main outcome measures were recurrence rate of hydrosalpinx after cuff neosalpingostomy, intrauterine and ectopic pregnancy rates. RESULTS: Intraoperatively, the mean size of the hydrosalpinx was 1.9+/-0.7 cm, and 77% of patients had evidence of pelvic adhesions. Recurrence of hydrosalpinx, whether unilateral or bilateral was 70% (28/40) per patient. Intrauterine and ectopic pregnancy rates were 5% (2/40) and 2.5% (1/40), with a total pregnancy rate of 7.5% (3/40). CONCLUSIONS: Most patients experience recurrence of hydrosalpinx after cuff neosalpingostomy, thus requiring additional surgery such as salpingectomy prior to in vitro fertilization (IVF). In a poor prognosis population, salpingectomy should be considered as the primary treatment for hydrosalpinx prior to IVF.

Comparison of vaginal and oral administration of emergency contraception.

OBJECTIVE: To compare the physiologic effects of vaginally and orally administered emergency contraception. DESIGN: Prospective, open-label, crossover study. SETTING: University research center. PATIENT(S): Nine regularly menstruating volunteers. INTERVENTION(S): Five subjects received 1,000 microg of levonorgestrel with 200 microg of ethinyl E2 (twice the standard Yuzpe regimen dose) vaginally, and the standard Yuzpe regimen dose orally 1 week later. Four subjects received 1,500 microg of levonorgestrel (twice the standard Plan B regimen dose) vaginally and received the standard Plan B dose orally 1 week later. Serum samples were obtained at baseline and at frequent intervals after each dose. MAIN OUTCOME MEASURE(S): Serum gonadotropin, hepatic globulin, and androgen levels measured at baseline, at the time of peak levonorgestrel, and 24 hours later. RESULT(S): Gonadotropin, hepatic globulin, and androgen levels were suppressed to a similar degree among the four regimens, with a return to baseline levels after 24 hours. CONCLUSION(S): We conclude that high doses of levonorgestrel found in emergency contraception regimens lead to a transient direct suppression of gonadotropin, hepatic globulin, and androgen levels. This effect is similar after vaginal and oral administration of emergency contraception. Therefore, the vaginal route of administration of emergency contraception regimens may be as efficacious as the oral route.

Pituitary imaging is indicated for the evaluation of hyperprolactinemia.

OBJECTIVE: To evaluate the signs and symptoms associated with hyperprolactinemia and establish guidelines for a minimal serum PRL level for which pituitary imaging is indicated. DESIGN: Retrospective study. SETTING: Reproductive endocrinology clinic in a university hospital. PATIENT(S): One hundred four consecutive patients with hyperprolactinemia, mean age 30 +/- 6.5 (range 19-44) years. INTERVENTION(S): Classification of clinical symptoms, serum hormone measurements, and pituitary magnetic resonance imaging (MRI). MAIN OUTCOME MEASURE(S): Incidence of presenting symptoms, serum PRL levels, and pituitary tumor size. RESULT(S): Median (range) PRL value was 82.6 ng/mL (25-1,342). Reported symptoms from most to least common were infertility (48%), headaches (39%), oligoamenorrhea (29%), galactorrhea (24%), and visual changes (13%). Hypothyroidism was diagnosed in 2 of 104 (1.9%) patients. Of 86 patients who had pituitary imaging, 23 (26%) had normal findings and 63 (74%) had pituitary tumor; of these, 47 (55% of total imaged) had microadenomas and 16 (19% of total imaged) had macroadenomas. There was a statistically significant association between the tumor size and the PRL level. However, 11% of the patients with microadenomas had PRL levels >200 ng/mL, and 44% of the patients with macroadenomas had PRL levels between 25 and 200 ng/mL. CONCLUSION(S): The most common symptoms in the population studied were infertility and headaches. Coexisting thyroid disease was an uncommon finding. Most patients had a pituitary tumor on MRI. Although tumor size correlated with the serum PRL level, some macroadenomas were detected in women with only moderately elevated PRL values. On the basis of these findings, pituitary imaging should be obtained to identify pituitary tumors in all patients with persistently elevated PRL levels.

The insulin resistant subphenotype of polycystic ovary syndrome: clinical parameters and pathogenesis.

OBJECTIVE: This study was undertaken to compare clinical and biochemical characteristics of the insulin resistant (IR) and non-IR subphenotypes of polycystic ovary syndrome (PCOS). STUDY DESIGN: Infertile PCOS women were classified as IR (n=32) or non-IR (n=46) on the basis of fasting glucose and insulin levels. The incidence of acanthosis nigricans (AN), hirsutism, and ovulation in response to clomiphene citrate (CC) was compared between the 2 groups, along with serum levels of gonadotropins, and sex steroids. Blood samples from 28 PCOS patients and 8 controls were analyzed by enzymatic immunoassay for autophosphorylated insulin receptor (APIR) and total insulin receptor (TIR) content. RESULTS: Insulin resistance was associated with obesity (odds ratio [OR]=3.5, P <.05), AN (OR=6.0, P <.05), hirsutism (OR=3.1, P <.05), and resistance to CC (OR=5.0, P <.05). Mean levels of LH, LH/FSH ratios, and testosterone were lower in women with IR (11.5 +/- 6.8 mIU/mL, 2.0 +/- 1.0, and 56.6 +/- 29.0 ng/dL, respectively) compared with women without IR (15.0 +/- 13.4 mIU/mL, 2.4 +/- 1.5, and 72.5 +/- 29.8 ng/dL, respectively) (P <.05). Mean APIR/TIR ratios in IR women were lower than in non-IR women (P <.05 at 100 nmol/L of insulin) and controls (P <.01 at 1, 10 and 100 nmol/L insulin). CONCLUSION: Patients with IR are more likely to be obese and have AN, hirsutism, resistance to CC, and lower LH, LH/FSH ratios, and testosterone levels. Furthermore, IR patients appear to have defective autophosphorylation of the insulin receptor, a key element in insulin action, and a possible mechanism for IR in PCOS.

Accelerated endometrial maturation in the luteal phase of cycles utilizing controlled ovarian hyperstimulation: impact of gonadotropin-releasing hormone agonists versus antagonists.

OBJECTIVE: To evaluate the endometrium obtained during the luteal phase of controlled ovarian hyperstimulation (COH) cycles utilizing gonadotropin-releasing hormone (GnRH) antagonists, and to compare these findings with those obtained in cycles utilizing a GnRH agonist and with artificial cycles among recipients. DESIGN: Prospective evaluation of oocyte donors. SETTING: University-based in vitro fertilization (IVF) center. PATIENT(S): Fifteen oocyte donors undergoing standard COH were enrolled in 1 of 3 COH groups, and 40 recipients of oocyte donation were used as a control group. INTERVENTION(S): Controlled ovarian hyperstimulation and endometrial biopsy. MAIN OUTCOME MEASURE(S): Histological dating of endometrial biopsies, serum estradiol (E(2)) and progesterone levels. RESULT(S): On the day of oocyte retrieval, endometrial maturation was advanced by an average of 5.8 +/- 0.4 days in the antagonist group and 5.9 +/- 0.7 days in the agonist group. This advancement persisted on day 7 postoocyte retrieval. Serum progesterone levels were elevated before human chorionic gonadotropin (hCG) administration, but remained similar in both groups. CONCLUSION(S): Controlled ovarian hyperstimulation is associated with elevated progesterone levels in the late follicular phase and accelerated endometrial maturation in the subsequent luteal phase. No significant differences exist between preretrieval serial serum progesterone levels and luteal phase endometrial histology between cycles utilizing GnRH agonists or antagonists.

Treatment-associated serum FSH levels in very poor responders to ovarian stimulation.

PURPOSE: To compare treatment-associated follicle-stimulating hormone (FSH) response in patients undergoing controlled ovarian hyperstimulation with either microdose flare (MDF) leuprolide acetate or clomiphene citrate and human menopausal gonadotropin (CC/hMG). METHODS: Thirteen patients who were deemed poor responders underwent stimulation with one of two poor responder stimulation protocols (MDF group: n = 8; CC/hMG group: n = 5). Serum FSH, estrone (E1), estrone sulfate (E1S), and estradiol (E2) levels were measured at baseline, day 5 of medication, and on day of hCG administration. Ovarian and uterine responses were evaluated by ultrasound. RESULTS: Treatment-associated FSH levels were consistently higher in the group that took CC/hMG. However, serum E1, E1S, and E2 values were similar in both groups as were the number of oocytes retrieved and the endometrial echo complex. There were no differences between the two groups with regards to the quality of the oocytes obtained, fertilization rate, or the quality of the embryos. CONCLUSION: Clomiphene citrate, when administered in conjunction with exogenous hMG, is a more potent stimulator of FSH production than MDF leuprolide acetate among poor responders to ovarian stimulation. However, the number of oocytes is not increased.

Spontaneous twin gestation after vaginal dilation in a woman with uterus didelphys and bladder exstrophy.

BACKGROUND: Bladder exstrophy is an uncommon anomaly rarely associated with uterus didelphys. Fertility is limited by associated vaginal malformations, which have traditionally required surgical reconstruction. CASE: A woman with a history of bladder exstrophy and hypoplastic vagina presented complaining of painful intercourse. The patient underwent vaginal dilator treatment after corrective surgery for the bladder defect. Without any further fertility therapy she subsequently conceived twins, with one implantation in each horn of a didelphic uterus. CONCLUSION: Bladder exstrophy, uterus didelphys, and vaginal hypoplasia share a common embryological devel-opment, and the finding of one anomaly can alert to the presence of another. Vaginal dilators may be used in place of surgical reconstruction to allow conception.

Pregnancy in the sixth decade of life: obstetric outcomes in women of advanced reproductive age.

CONTEXT: As a result of oocyte donation, women in their sixth decade of life are now able to conceive and carry pregnancies to term. However, little is known about pregnancy outcomes in this population. OBJECTIVE: To describe pregnancy outcomes in women aged 50 years or older who conceived after in vitro fertilization with donor oocytes. DESIGN AND SETTING: Retrospective analysis of cycles conducted at a US university assisted reproduction program during calendar years 1991-2001. PATIENTS: Seventy-seven postmenopausal women with no chronic medical conditions (mean [SD] age, 52.8 [2.9] years; range, 50-63 years) who underwent 121 embryo transfer procedures (89 fresh and 32 frozen). Pregnancy outcomes were ascertained by chart review and telephone follow-up. MAIN OUTCOME MEASURES: Maternal and neonatal outcomes. RESULTS: There were 55 clinical pregnancies for a total pregnancy rate of 45.5%. The live birth rate was 37.2%. Of the 45 live births, 31 were singletons, 12 were twins, and 2 were triplets, for which the mean (SD) gestational ages at delivery were 38.4 (2.1) weeks, 35.8 (2.8) weeks, and 32.2 weeks, respectively. Mean (SD) birth weights were 3039 g (703 g), 2254 g (581 g), and 1913 g, respectively. Apgar scores at 1 and 5 minutes were 8.2 (0.9) and 9.1 (0.5), respectively. Of singletons, 68% were delivered by cesarean, and all multiples were delivered by cesarean. Mild preeclampsia was noted in 25% of patients and severe preeclampsia in 10%. Gestational diabetes required diet modification in 17.5%, and 2.5% required insulin. CONCLUSIONS: Appropriately screened women aged 50 years or older can successfully conceive via oocyte donation and experience similar pregnancy rates, multiple gestation rates, and spontaneous abortion rates as younger recipients. During pregnancy, they appear at increased risk of preeclampsia and gestational diabetes. A majority can expect to deliver via cesarean. However, there does not appear to be any definitive medical reason for excluding these women from attempting pregnancy on the basis of age alone.