The ovarian response as a predictor for successful in vitro fertilization treatment after the age of 40 years.

OBJECTIVE: To determine whether age or response to controlled ovarian hyperstimulation (COH) is a better predictor of IVF outcome in women > or = 40 years. DESIGN: Retrospective analysis. SETTING: A transport IVF program. PATIENT(S): For patients undergoing IVF treatment the correlation between treatment outcome and age and response to COH was analyzed using the data of 2,588 consecutive cycles. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Pregnancy. RESULT(S): The incidence of poor ovarian response rises significantly with increasing age. Analysis of all cycles showed a significant decrease in clinical and ongoing pregnancy rate for women > or = 40 years. Analysis of cycles with a good ovarian response showed no statistically significant differences for these parameters between women > or = 40 years and those younger. A logistic regression analysis on pregnancy showed that ovarian response contributes more to the prediction of pregnancy than age. CONCLUSION(S): Patients aged > or = 40 years with a good response to COH have a good prognosis for IVF treatment. The age limit for acceptance of patients should not be set at 40 years. Instead, the response to COH can be used to predict candidates likely to have a successful IVF outcome.

A triplet pregnancy after in vitro fertilization is a procedure-related complication that should be prevented by replacement of two embryos only.

OBJECTIVE: To investigate whether the incidence and obstetric outcome of triplet pregnancies after IVF treatment justify strict limitation of the number of embryos to be replaced to two. DESIGN: Retrospective analysis. SETTING: A transport IVF program. PATIENT(S): All patients who had more than one embryo replaced. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Obstetric outcome, pregnancy. RESULT(S): High-order pregnancies occurred in 24 cases (23 triplets and 1 quadruplet). Three patients opted for selective embryo reduction (12.5%). Three triplet pregnancies spontaneously reduced to twins. Comparison of 18 triplets, reaching at least 20 weeks' gestation, with 54 twin pregnancies shows a higher perinatal mortality in the triplet group, causing 6 out of 18 patients to be confronted with at least one perinatal death. Triplets were born at a lower gestational age, had a lower birth weight, and a higher hospital admission rate of longer duration. Replacement of two, three, or four embryos did not lead to differences in pregnancy rates in the population studied. When a pregnancy occurred after replacement of three embryos, the risk of having a triplet pregnancy was 7.5%. CONCLUSION(S): The obstetric outcome of triplet pregnancies in our population indicates that triplet pregnancies after IVF treatment have to be prevented. Selective embryo reduction is acceptable for few patients only and can therefore not be seen as a solution. Replacement of three embryos results in triplet pregnancy in an unacceptably high percentage. Replacement of two embryos only gives acceptable IVF results and is the method chosen in the IVF program in Rotterdam to prevent triplet pregnancies.

Results of curettage for postmenopausal vaginal bleeding in women treated with tamoxifen and megestrol acetate for progressive metastatic breast carcinoma.

Tamoxifen and megestrol acetate are used as a hormonal treatment for metastatic breast carcinoma. It is suggested that the use of tamoxifen may induce endometrial cancer. In this article we describe nine patients under hormonal treatment for metastatic breast cancer with, firstly, tamoxifen and, later, megestrol acetate. These nine patients all had symptoms of postmenopausal vaginal blood loss during therapy with megestrol acetate, an indication to perform a diagnostic dilatation and curettage. By histopathological examination the curettings showed a decidualized stroma with an infiltration of lymphocytes, some plasma cells and many eosinophils. In none of the patients was atypical hyperplasia or malignancy found. The dilatation and curettage had also a therapeutic effect, since only one of the patients still had complaints, while the other eight did not complain of postmenopausal bleeding again. We review the literature and discuss the value of a diagnostic dilatation and curettage.

[Vulvovaginal complaints, dyspareunia and oral mucosa abnormalities: erosive lichen planus]. / Vulvovaginale klachten, dyspareunie en orale mucosa-afwijkingen: erosieve lichen planus.

Three women, aged 46, 48 and 73 years respectively, suffered from erosive genital lichen planus. Vulvar irritation, dyspareunia and vaginal discharge are the prominent signs of this disease. Lichen planus is an inflammatory dermatosis, which can involve skin and oral and genital mucosa. Diagnosis and treatment are difficult. Prolonged local application of a corticosteroid cream, e.g. clobetasol, is usually warranted. Narrowing of the vagina and painful mucosal lesions often prevent sexual intercourse. The combination of oral and genital complaints can help in the diagnosis of lichen planus. Strict follow-up is necessary because of the possible malignant degeneration of the disease.

The incidence of major clinical complications in a Dutch transport IVF programme.

Four different major clinical complications were identified in a retrospective analysis of 2495 in-vitro fertilization (IVF) cycles resulting in oocyte retrieval. The severe form of ovarian hyperstimulation syndrome (OHSS) occurred in 18 patients, giving a prevalence for this complication of 0.7%. Seven (39%) of these 18 patients had previously been diagnosed as having polycystic ovaries. Eleven patients were admitted with moderate OHSS. Adnexal torsion was diagnosed in two patients. Ovariectomy was considered necessary in both cases. Complications of the transvaginal procedure occurred in seven cases (0.3%): one patient had an acute appendicitis with puncture holes in the appendix, six patients were admitted shortly after oocyte retrieval with a pelvic inflammatory disease. Of the 624 pregnancies obtained, 13 were ectopic, giving an ectopic pregnancy rate of 2.1%. It is concluded that serious clinical complications of IVF treatment are rare. However, patients should be counselled for the occurrence of serious procedure-related complications before entering an IVF programme.