Recurrent cervical pregnancy after assisted reproduction by intrafallopian transfer.

BACKGROUND: Cervical pregnancy is an uncommon, yet potentially catastrophic form of ectopic pregnancy. Early diagnosis and intervention are important in avoiding short-term and long-term morbidity. Although transcervical embryo transfer is thought to increase the incidence of this phenomenon in patients undergoing in vitro fertilization, its occurrence after intrafallopian transfer is rarely seen. CASE: A 43-year-old nulliparous white female with a history of unexplained infertility experienced recurrent cervical pregnancy after two consecutive gamete/zygote intrafallopian transfer cycles. Abnormally rising beta-hCG levels combined with transvaginal sonography helped establish the diagnosis in each case. Intramuscular (IM) methotrexate combined with intra-amniotic potassium chloride successfully treated this condition initially, and IM methotrexate alone was sufficient for successful treatment in the second case. CONCLUSION: Cervical pregnancy may occur with assisted reproductive techniques involving intrafallopian transfer. Early diagnosis may be important for successful treatment of cervical pregnancy with conservative measures. Even in the case of recurrence, prompt intervention may allow for preservation of a patient's future fertility potential.

The utility of a home urinary LH immunoassay in timing the postcoital test.

OBJECTIVE: To evaluate whether a urinary LH immunoassay improves timing of the postcoital test compared to traditional timing methods in normally ovulating women. METHODS: Subjects included 37 infertile couples evaluated in a tertiary care setting. A randomized, prospective trial was performed of two methods of postcoital test timing: urinary LH assay or the traditional timing by cycle-averaging and/or review of basal body temperature graphs. RESULTS: Similar serum estradiol, progesterone, LH, number of motile sperm per high-power field, cervical mucus scores, and postcoital test scores were identified in both groups. CONCLUSION: Urinary LH immunoassays do not appear to improve timing of the postcoital test as compared with traditional timing methods.

Sonographic assessment of endometrial pattern and thickness in patients treated with human menopausal gonadotropins.

OBJECTIVE: To analyze sonographically the endometrium in patients undergoing controlled ovarian stimulation with menotropins in order to determine the significance of endometrial pattern and thickness on pregnancy rate. DESIGN: This is a prospective, nonrandomized study comparing pregnancy rates in patients with hyperechoic homogeneous patterns with those in patients with isoechoic or hypoechoic trilaminar patterns. SETTING: Tertiary infertility center. PATIENTS: All patients receiving menotropin therapy at a tertiary infertility center. INTERVENTIONS: All patients received individualized dosing of hMG starting on cycle day 3. Transvaginal sonography was performed 15 hours before hCG administration and the endometrium was assessed. MAIN OUTCOME MEASURE: Occurrence of pregnancy as determined by serially rising beta-hCG titers and sonographic confirmation. RESULTS: During the study period, 175 patients were evaluated. Thirty-four (19%) patients had a homogeneous endometrium, whereas 141 (81%) patients had a trilaminar pattern. There was 1 pregnancy (2.9%) among women with a homogeneous endometrial pattern and 33 pregnancies (23%) among those with a trilaminar pattern. No significant differences were found in mean E2 level, follicle numbers, parity, and diagnosis between the two groups. CONCLUSION: In patients receiving menotropins, a homogeneous pattern is a bad prognostic sign, regardless of endometrial thickness.

Sonographic assessment of endometrial pattern and thickness in patients treated with clomiphene citrate, human menopausal gonadotropins, and intrauterine insemination.

OBJECTIVE: To analyze the endometrium sonographically in patients undergoing controlled ovarian stimulation with clomiphene citrate (CC) in addition to menotropins to determine the significance of endometrial pattern and thickness on pregnancy rate (PR). DESIGN: A prospective study analyzing patients receiving sequential CC and hMG followed by hCG and IUI. Patients who exhibited homogeneous endometrial patterns were compared with those who had trilaminar patterns visualized by transvaginal sonography at the end of the follicular phase. Endometrial thickness was emphasized in this group of patients. SETTING: Tertiary infertility center. PATIENT(S): All patients receiving sequential CC and hMG therapy at a tertiary infertility center. INTERVENTION(S): All patients received individualized dosing of hMG after 5 days of CC. Transvaginal sonography was performed 15 hours before hCG administration. Intrauterine insemination was performed 36 hours after hCG injection. MAIN OUTCOME MEASURE(S): Occurrence of pregnancy as determined by serially rising beta-hCG titers and sonographic confirmation. RESULT(S): During the study period, 223 patients were analyzed. Fifty patients had a homogeneous endometrium, whereas 173 patients had a trilaminar pattern. In the homogeneous group, the PR was 8%, and in the trilaminar group it was 21%. There was no significant difference in age, parity, diagnosis, peak E2 level, and mature follicle number between the two groups. Although homogeneous patterns were associated with thinner endometrium, no difference in PRs could be discerned within the trilaminar group on the basis of endometrial thickness. CONCLUSION(S): In patients receiving sequential CC and hMG ovarian stimulation, a homogeneous endometrial pattern on the day of hCG administration predicts a significantly decreased PR compared with a trilaminar pattern.

Detrimental effect of hydrosalpinx fluid on the development and blastulation of mouse embryos in vitro.

OBJECTIVE: To study the effects of human hydrosalpinx fluid on mouse embryo blastulation rate. DESIGN: Comparison of mouse embryo blastulation rate in media containing increasing concentrations of hydrosalpinx fluid. SETTING: Tertiary care center. PATIENT(S): Women undergoing laparoscopic evaluation or treatment for infertility noted to have hydrosalpinx or paratubal cyst. INTERVENTION(S): Exposure of mouse embryos to hydrosalpinx or paratubal cyst fluid collected during laparoscopy. MAIN OUTCOME MEASURE(S): Blastulation rate of mouse embryos. RESULT(S): Culture of mouse embryos at 0% (controls), 0.3%, 0.6%, and 0.9% hydrosalpinx fluid concentrations demonstrated significantly lower blastulation rate at each level compared with the controls. CONCLUSION(S): Hydrosalpinx fluid is highly embryotoxic.

Does ovulation stimulation improve fertility in women with minimal/mild endometriosis after laser laparoscopy?

Cycle fecundity was retrospectively analyzed in a group of infertile women after minimal/mild endometriosis had been treated by carbon dioxide laser laparoscopy. Patients were followed in spontaneous (observation) cycles as well as in treatment cycles using ovulation stimulation. Treatment protocols included clomiphene citrate (CC), sequential CC/human menopausal gonadotropins/human chorionic gonadotropin (CC/hMG/hCG), and hMG/hCG. Some patients who failed to conceive with ovulation stimulation protocols underwent in vitro fertilization (IVF). Eighty-nine patients were followed for a total of 605 cycles, during which 37 pregnancies occurred. Cycle fecundity was 0.028 in observation cycles, and was higher with the use of CC (0.066), and significantly higher (P < .05) with use of CC/hMG/hCG (0.114) and hMG/hCG (0.073). The highest cycle fecundity was attained in IVF cycles (0.222). This retrospective analysis suggests that active ovulation management in patients with minimal/mild endometriosis treated by carbon dioxide laser laparoscopy may significantly increase cycle fecundity.

A prospective study on the lack of development of antisperm antibodies in women undergoing intrauterine insemination.

To test the hypothesis that intrauterine insemination with washed spermatozoa induces antisperm antibody formation, we measured serum antisperm antibody levels by the Immunobead technique in a population of women receiving exogenous gonadotropins. Antibody levels were measured before therapy (baseline) and then serially during subsequent stimulation cycles, for a maximum of six cycles. Twenty-eight patients underwent intrauterine insemination; each patient served as her own control. An additional 25 patients were treated with exogenous gonadotropins but did not undergo intrauterine insemination; they served as external controls. Antisperm antibody levels in women who underwent concomitant intrauterine insemination were compared with levels in those who did not. Of the 53 enrolled patients, 18 completed six treatment cycles, and 35 achieved pregnancy before six cycles. Forty-five patients (85%) had less than 10% Immunobead binding, six (11%) had binding between 10% and 25% (mean 16%, range 14% to 20%), and two had binding greater than 25% (28% and 42%, respectively). Mean binding was similar (less than 10%) in the intrauterine insemination and external control groups. Eighteen patients conceived in the intrauterine insemination group and seventeen in the control group. Of patients who conceived, all but one had less than 10% Immunobead binding at the time of conception (mean 1.6 months). In patients who did not conceive, there was no difference in Immunobead binding between control and intrauterine insemination groups after 6 months of therapy. Our data do not support the hypothesis that serum antisperm antibody levels, as detected by Immunobead binding, will increase in menotropin-stimulated women undergoing intrauterine insemination over a prolonged treatment period.

Identification of hormonal parameters for successful systemic single-dose methotrexate therapy in ectopic pregnancy.

Single-dose methotrexate is an alternative to surgery in treating ectopic pregnancy. Because success rates vary, we sought to identify factors which predict treatment outcome. A total of 44 women with ectopic gestation were treated. The non-laparoscopic diagnosis of ectopic pregnancy was made following history, physical examination, ultrasound, endometrial biopsy and the measurement of serial beta-human chorionic gonadotrophin (HCG) and progesterone concentrations. Methotrexate (50 mg/m2 i.m.) was administered, with a second dose given 1 week later in patients with plateauing or rising beta-HCG concentrations. Of 44 patients, 23 (52.3%) were successfully treated with one dose. An additional 10 women (22.7%) were also successfully managed but required a second dose, giving an overall success rate of 75.0%. In all, 11 women (25.0%) required surgery, four of whom experienced tubal rupture. Receiver operator curves were constructed to optimally select pretreatment beta-HCG and progesterone cut-off concentrations for successful treatment. Using beta-HCG < 1500 IU/l or progesterone < 7.0 ng/ml (22.3 nmol/l) as a cut-off concentration produced a diagnostic test with a sensitivity of 87.5%, a specificity of 90.0%, a positive predictive value of 96.6% and a negative predictive value of 69.2%. Conversely, this model predicts that patients with serum beta-HCG concentrations > or = 1500 IU/l and progesterone concentrations > or = 7.0 ng/ml are at far greater risk of failing single-dose methotrexate therapy.