Resultados maternos y perinatales de los embarazos obtenidos por técnicas de reproducción asistida: revisión de la literatura / Perinatal and maternal outcomes following assisted reproductive technology: a literature review

La utilización de técnicas de reproducción asistida (TRA) ha aumentado en todo el mundo, incluyendo procedimientos como la donación de gametos, la subrogación y el diagnóstico genético preimplantacional. Creciente evidencia confirma que los embarazos de pacientes sometidas a estos tratamientos tienen un mayor riesgo de complicaciones perinatales. No queda claro si la causa de estos hallazgos se debe a la infertilidad subyacente o los tratamientos en sí. Esta revisión tiene como objetivo resumir la evidencia actual acerca de los efectos sobre los resultados maternos y perinatales tanto de los diferentes procedimientos propios de la fecundación in vitro como de algunos tipos de TRA especiales.

The use of assisted reproduction techniques (ART) has increased worldwide, including procedures such as gamete donation, subrogation and preimplantation genetic diagnosis. Growing evidence confirms that pregnancies following these treatments have an increased risk of adverse perinatal outcomes. It is not clear whether the cause of these findings is due to the underlying infertility or the treatments themselves. This review aims to summarize the current evidence regarding the effects of both the different ART procedures and some special types of ART on maternal and perinatal outcomes.

Efectos de la selección y de la superovulación en las pérdidas gestacionales de ratonas CF1 / Effects of selection and superovulation on gestational losses in CF1 mice

En un par de líneas de ratones seleccionadas para alto (s') y bajo peso (s), originadas a partir de una población no seleccionada de la cepa CF1 (t), se modificó la estructura ovárica. El diámetro de los folículos ováricos y el número de folículos y de cuerpos lúteos se incrementaron en las hembras de la línea s', sin expresarse en un mayor tamaño de camada al nacimiento, posiblemente, por un aumento de las pérdidas gestacionales. Se probó si los efectos conjuntos de la selección de peso a largo plazo y de la estimulación ovárica incrementaban las pérdidas gestacionales. Se utilizaron dos grupos de hembras por línea: sin y con estimulación ovárica (5UI de eCG y 5UI de hCG). Las hembras se sacrificaron a las 56-72 hs y a los 7 días postservicio y después de la primera parición. Se observaron los números de cuerpos lúteos (CL), embriones (E) y sitios de implantación (SI) y el tamaño de camada al nacimiento (TC). Se estimaron las pérdidas totales (PT) y las pérdidas de cuerpos lúteos (PCL), de embriones (PE) y de fetos (PF). Los promedios de CL, E, SI y TC variaron en el mismo sentido de la selección practicada y fueron significativamente mayores (P<0,05) para las hembras estimuladas, a excepción de TC. La línea s' tuvo un potencial reproductivo superior pero un mayor costo biológico (mayor PT y más tardía) cuando se la comparó con las otras líneas. La estimulación ovárica produjo menores eficiencias reproductivas totales para las tres líneas y pérdidas gestacionales mayores y más tardías, principalmente de SI. Las hembras de la línea no seleccionada (t), no estimuladas, con pesos intermedios, parieron un mayor número de crías, partiendo de un número intermedio de CL, E y SI, con una menor y más temprana mortalidad embrionaria, demostrando ser las más eficientes desde el punto de vista reproductivo y productivo.

The ovarian structure was modified as a consequence of weight selection in a pair of mouse lines selected for high (s') and low weight (s). Lines were founded from an unselected population of CF1 strain (t). The follicle diameter and the number of the ovarian follicles and the corpora lutea were higher in s' females, but they did not reach a larger litter size at birth, may be, by an increase in the gestational losses. In these lines, the co-effects of long-term weight selection and ovarian stimulation were tested to evaluate if they increased gestational losses. Two groups of females per line were employed: without and with ovarian stimulation (5UI of eCG and 5UI of hCG). Females were slaughtered at 56-72hs and at 7 days post-breeding and after first parturition. The number of corpora lutea (CL), embryos (E) and implantation sites (SI), and litter size at birth (TC) were observed. Total losses (PT) and corpora lutea (PCL), embryo (PE) and fetus (PF) losses were estimated. Mean CL, E, SI and TC varied in the same direction of the selection made and they were significantly higher (P<0.05) in stimulated females, though not for TC. Line s' had a higher reproductive potential but a greater biological cost (higher and later gestational mortality) when compared with the other lines. Ovarian stimulation produced lower total reproductive efficiencies for the three lines and higher and later gestational losses, mainly for implantation sites. Females from unselected line (t), without ovarian stimulation, with intermediate weights, bore larger litters, starting from an intermediate number of CL, E and SI, with a lower and earlier embryo mortality, showing to be the most efficient from a reproductive and productive point of view.

Heterotopic abdominal pregnancy following ovulation induction with clomiphene citrate

Heterotopic abdominal pregnancy is a rare entity which poses unique management challenges. A 24-year-old Gravida 1 woman with history of two years infertility and treatment with clomiphene citrate presented with acute right lower quadrant abdominal pain. Heterotopic abdominal pregnancy was recognized at 16 weeks gestation by transvaginal ultrasound scan. We aimed to remove ectopic pregnancy with prevention of maternal complications and preservation of intrauterine pregnancy [IUP]. Surgical removal of the ectopic fetus and placenta was done. Abdominal pregnancy removed successfully without intra-or post-procedural complications, but the IUP was aborted spontaneously on the second postoperative day. Gynecologists should consider the possibility of heterotopic pregnancy following ovulation induction with clomiphene citrate which is increasing in recent years. A high index of suspicion to heterotopic pregnancy may be followed by a nonsurgical approach safely and affectively, if they are clinically stable and the abdominal pregnancy is recognized early in gestation

[Three case of IBD or exacerbation of IBD after ovulation induction]

Ulcerative colitis [UC] and Crohn's disease [CD], collectively referred to as inflammatory bowel disease [IBD], present with different histology and cytokine profiles. While the precise mechanisms underlying the development of IBD are not known, sufficient data have been collected to suggest that it results from a complex interplay of genetic, environmental, and immunologic factors. An inappropriate mucosal immune response to normal intestinal constituents is a key feature, leading to an imbalance in local pro- and anti-inflammatory cytokines. Neutrophil and monocyte influx occurs with subsequent secretion of oxygen radicals and enzymes, leading to tissue damage. Here we report three patients with sever symptom of IBD after ovarian stimulation. Cytokine profile after ovarian stimulation may contribute to the altered intestinal permeability due to increase in systemic inflammatory cytokines and neutrophil or macrophage activation. In our hypothesis ovulation induction can induce inflammation in intestinal mucosa or exacerbate previous IBD by different cytokines

[Increased risk of early pregnancy loss and lower live birth rate with GNRH antagonist vs long GNRH agonist protocol in PCOS women undergoing controlled ovarian hyperstimulation]

To compare standard long GnRH agonist protocol [Tripnorelin] anti GnRH antagonist regimens [Cetrorelix] in polycystic ovary syndrome [PCOS] patients undergoing controlled ovarian stimulation [COS] for ICSI cycles. Retrospective case-control study. 106 POS patients undergoing COS for ICSI with long GnRH agonist protocol [Tripnorelin] were matched with age and BMI to 106 PCOS patients undergoing COS for ICSI with GnRH antagonist [Cetrorelix] during the same period. Ovarian stimulation with recombinant follicle stimulating hormone [rFSH] was used in the two groups. Oral contraceptive pill pretreatment was used in all patients undergoing ovarian stimulation using GnRH antagonists. ICSI was performed for male infertility in all casts. The main outcome measures evaluated were: cancellation of the cycles, number of aspirated follicles, oocyte maturity, fertilization rate, Embryo quality, pregnancy and implantation rates, clinical abortion rate, multiple pregnancy rate and the live birth rate rate. Kchi2 teat and t Student test were used for differences between normo-ovulatory and PCOS patients and the limit of significantly was net at p<0.0S. There. was no significant difference in term of cancellation rant [2.8%vs 1.8%; NS], Duration of gonadotrophin stimulation [9,7 +/- 0,7 vs 11,2 +/- 1,9 days; p<0,001] and gonadotrophin consumption [2209.0 +/- S4S Vs 1411,1 +/- 217,9 1.11: p<0,001] were significantly decreased with GnRH antagonist. The mean oestradiol level on the triggering day was significantly higher in the agonist group [3347,85 +/- 99 vs 2354,45 +/- 839; p<0,001]. A fall in LH level of a 50%from sitmulation days [S8] to S1was observed in GnRH antagonist group. Risk of ovarian] hyperstimulation syndrome [OHSS] was significantly decreased with GnRH antagonist [1.8%vs 10.7%; p=0.01]. The mean number of retrival oncytes [15.9 +/- 5,9 vs 17.3 +/- 8.3; ns] and the mean number of mature oncytes [11.43 +/- 4.2 vs 11.9 +/- 6.4; ns3 were similar in the two groups. fertilization rate [73.3%va 75.8%; NS], mean number of grade I and 2 embryos [6.3 +/- 2.7 vs 6.9 +/- 3.9; NS], mean number of transferred embryos [1.9 +/- 0.7 vs 1.8 +/- 0,7; NS],implantation rate[13.3%vs 18.45%; ns] and clinical pregnancy rate per transfer [28.6%vs 31.1%;ns] did not differ statistically is she two groups. Twin and triplet pregnancies rates were also similar in the two groups [7.1%vs 9.3%; NS] and [3S%vs 3.1%; NS] respectively. Live birth rate [12,2%vs 20.7%; p<0.001] was significantly lower in GnRH antagonist group and miscarrage rate was significantly higher in this same group [42.8%vs 18.7%;p<0.001]. GnRH antagonist protocol is a short and simple protocol with a significant reduction in incidence of OHSS and amount of gonadotrophins. However. GnRH antagonist protocol provides a lower live birth rate and an increased risk of early pregnancy loss compared no the GnRH agonist long protocol. Further studies are necessary for more solid conclusions

[Ovarian stimulation and granulosa cells tumors, about 5 cases]

Ovarian stimulation for the treatment of the infertility expose the patient and its ovaries to above physiological high concentrations of gonadotrophin. The major complications of the use of these therapeutic are the ovarian hyperstimulation and the multiple pregnancies. We describe 3 cases of granulosa cells tumors of the ovary after stimulation with the clomifene and / or gonadotrophin. A review of the literature does not allow to make the link between these therapeutic and tumoral pathology, however animal experimentation showed a relation between the exposition with gonadotrophin and the granulosa cells tumors. The most confirmed hypothesis being able to explain this association in human race is the increase of intra follicular gonadostimulins which is oncogen for the granulosa cells

Effect of insemination-to-induced ovulation interval on fertilization rate, embryo viability and number of accessory sperms in SOWS

The ideal interval between AI and ovulation (OV) is not well determined yet, varying from 12 to 28 h before up to 4 h after ovulation. Utilization of gonadotrophins to synchronize ovulation would allow the pre-determination of the groups' size, according to the AI-OV intervals, and would contribute to determine a secure interval between AI-Ov. 120 sows received 7.5 mg IM of Luprostiol, between days 12 and 17 of the estrous cycle, 600 lU of eCG 1M 24 h after prostaglandin and 5.0 mg of LH 1M 72 h after eCG injection. The moment of ovulation was diagnosed by transrectal ultrasonography at intervals of 6 h. There were 5 treatments according to IA-OV interval: T1- 48 to 36 h before OV; T2- 36 to 24 h before OV; T3- 24 to 12 h before OV; T4- 12 to 0h before OV and T5-0 to 12 h after Ov. Sows were slaughtered 96. 7±11.37 h after Ov. Recovery rate (RR), number of corpora lutea (NC), total number of structures (ST), fertilization rate (FR), embryo viability (EV) and number of accessory sperm (AS) were analyzed. The synchronization protocol showed an homogenous distribution of the animaIs among treatments (LH-OV interval 39.22±7.6h), and it didn't influenced the results. FR and EV results suggest that 36 h is the time of sperm viability in sow genital tract. There was a strong decline of AS between T3 and T4.

O intervalo ideal entre a AI e ovulação (OV) não está bem determinado ainda, variando entre 12 a 28 h antes até 4 h depois da ovulação. A utilização de gonadotrofinas para sincronizar ovulação permitiria a pré-determinação do tamanho dos grupos, de acordo com os intervalos IA-OV, e possibilitaria determinar um intervalo seguro entre IA-OV 120 porcas receberam 7.5 mg IM de Luprostiol, entre os dias 12 e 17 do ciclo estral, 600 lU de eCG 1M 24 h após o Luprostiol e 5.0 mg de LH 1M 72 h após a injeção de eCG. O momento de ovulação foi diagnosticado pela ultra-sonografia trans-retal a intervalos de 6 h. Definiu-se 5 tratamentos de acordo com o intervalo IA-OV: T1 - 48 a 36 h antes da OV; T2 - 36 a 24 h antes da OV; T3 - 24 a 12 h antes da OV; T4 -12 a 0 h antes da OV e T5 - 0 a 12 h após a OV. O abate ocorreu 96.7±11.37 h após a OV. A taxa de recuperação (RR), número de lutea de corpos (NC), número total de estruturas (ST), taxa de fecundação (FR), viabilidade embrionária (EV) e número de espermatozóides acessórios (AS) foram analisados. O protocolo de sincronização mostrou uma distribuição homogênea dos animais entre os tratamentos (intervalo LH-OV de 39.22±7.6h), e não influenciou os resultados. A FR e os resultados de EV sugerem que 36 h seja o tempo de viabilidade do espermatozóide trato genital da porca. Houve um forte declínio do AS entre T3 e T4.

Comparação entre menotropina altamente purificada e folitropina alfa para hiperestimulação ovariana controlada após supressão hipofásica nos ciclos de ICSI / A comparison of menotropin, highly-purified menotropin and follitropin alfa for controlled ovarian stimulation after pituitary down-regulation in ICSI cycles

OBJETIVO: Comparar a eficácia clínica entre três tipos de gonadotrofinas para a estimulação ovariana após a supressão hipofisária nos ciclos de ICSI. MATERIAL E MÉTODOS: Analisou-se retrospectivamente 865 ciclos consecutivos de ICSI envolvendo supressão hipofisária previamente à hiperestimulação ovariana controlada (HOC). A HOC foi realizada com menotropina (HMG: Menogon, Ferring; n=299), menotropina altamente purificada (HMG-HP: Menopur, Ferring; n=330) e FSH recombinante (r-hFSH: Gonal-F, Serono; n=236). Os protocolos laboratoriais e clínicos permaneceram inalterados ao longo do tempo, os últimos diferindo apenas no tipo de gonadotrofina utilizada, que foram introduzidas seqüencialmente na prática clínica, iniciando com o HMG, seguido pelo HMG-HP, e finalmente o r-hFSH. Os parâmetros de interesse primário foram a taxa de nascidos vivos e as doses totais de gonadotrofina utilizadas por ciclo, por gestação e por nascido vivo. Análise comparativa foi realizada com ANOVA, Kruskal-Wallis e Chi-quadrado quando apropriado. RESULTADOS: As taxas de nascidos vivos não foram significativamente diferentes entre os grupos HMG (26,4%), HMG-HP (34,6%) e r-hFSH (32,4%; p igual a 0,09). A dose total de gonadotrofina utilizada por ciclo foi significativamente superior nos grupos HMG (2.685±720UI) e HMG-HP (2.903 mais ou menos 867UI) em comparação com o r-hFSH (2.268 mais ou menos 747UI; p menor que 0,001). Diferenças relativas de 15,7% e 45,2%, e de 11% e 19,8% foram observadas a favor do r-hFSH em comparação ao HMG e HMG-HP, respectivamente, no que se refere às quantidades de gonadotrofina necessárias para se obter cada gestação e cada nascido vivo. CONCLUSÕES: Taxas de nascidos vivos similares foram obtidas com HMG, HMG-HP e r-hFSH quando utilizadas para HOC após supressão hipofisária nos ciclos de ICSI. Doses totais significativamente menores de r-hFSH foram utilizadas por ciclo em comparação às menotropinas. Para cada nascido vivo, quantidades consideravelmente maiores d...

Indução da ovulação em vacas com gonadotrofina coriônica humana (hCG) purificada por cromatografia de afinidade / Induction of ovulation in cows with affinity chromatography-purified Human Chorionic Gonadotropin (hCG)

O objetivo do presente estudo foi purificar o hCG contido em uma preparação comercial (Pregnyl® Organon) por cromatografia de afinidade e avaliar a taxa de ovulação de vacas injetadas com o hormônio purificado. Uma coluna de cromatografia contendo matriz de Concanavalina-A Sepharose (Con-A) foi equilibrada e cem milunidades internacionais (UI) de Pregnyl® foram aplicadas na coluna. Frações de 3,8mL foram colhidas (4 º C) a cada 5 minutos durante 12,5 horas, resultando em um total de 150 frações. Após a fração 76 adicionou-se à coluna solução tampão contendo 0,3M de alfa−metilglicosidase. A concentração protéica das frações foi estimada por espectrofotometria (280nm). Foram observados dois picos de absorbância, um entre as frações 14 e 19 e outro entre as frações 90 e100. As frações 14 a 19 e 90 a 150 foram reunidas seqüencialmente aos pares, concentradas por ultrafiltração e analisadas por SDS-PAGE. O primeiro pico resultou da eluição das proteínas não adsorvidas pela matriz de Con-A, enquanto o segundo representou as proteínas adsorvidas pela coluna, especialmente o hCG. As frações contendo hCG foram reunidas em uma única amostra cuja concentração protéica foi quantificada pelo método de Lowry. Vacas no 5º dia de um ciclo estral sincronizado, apresentando um folículo dominante maior que 8mm de diâmetro, foram injetadas com 0,1, 0,2 ou 0,3mg de proteína contida na amostra purificada. Após 48 horas, a taxa de ovulação observada foi de 0%, 50% e 75%, respectivamente. Foi demonstrado no presente estudo que a técnica de cromatografia por afinidade foi eficiente para aumentar a concentração relativa do hCG preservando sua atividade biológica.

Objective of the present study was to purify hCG contained in commercial preparation (Pregnyl®- Organon) by affinity chromatography and to evaluate ovulation rates in cows injected with the purified hormone. A chromatography column containing concanavalin-A sepharose (Con-A) matrix was equilibrated and one hundred thousand international units (UI) of Pregnyl® were applied to the column. Fractions of 3,8mL were collected (4 degree C) every 5 minutes for 12,5h, to yield a total of 150 fractions. After fraction 76, a column buffer containing 0,3M alpha-methylglicoside was added to the column. Protein concentrations were estimated by espectrophotometry(280nm). Two peaks of absorbance were observed, between fractions 14 and 19, and fractions 90 and 100. Fractions 14-19 and 90-150 were sequentially grouped in pairs concentrated by ultrafiltration andanalyzed by SDS-PAGE. The first peak of absorbance resulted from proteins contained in the commercial product, eluted from the column and not adsorbed by the Con-A matrix. The second peak represented proteins adsorbed by the column, especially hCG. The fractions containing hCG were grouped in a single sample and protein concentration was measured by the Lowry method. Cows in day 5 of the estral cycle, which had a dominant follicle larger than 8mm, were injected with 0,1, 0,2 or 0,3mg protein of the purificated sample. The ovulation rate 48 hours after treatment was 0%, 50% and 75%,respectively. It was demonstrated that relative concentration of hCG can be increased by affinity chromatography and biological activity of purified hCG was satisfactory preserved.

Associação de FSH e LH recombinantes na estimulação ovariana / Association of recombinant FSH and LH in ovarian stimulation

Os autores revisam a fisiologia do ciclo ovulatório e o papel das gonadotropinas na indução da ovulação, em pacientes com distúrbios ovulatórios e no desenvolvimento folicular múltiplo para técnicas de reprodução assistida. O emprego de gonadotropinas com atividade de LH e o uso do LH recombinante associado ao FSH são discutidos. Os autores reafirmam que a administração de gonadotropinas com atividade de LH é essencial na ovulação por hipogonadismo hipogonadotrópico. O uso do LH recombinante associado ao FSH pode ser particularmente benéfico nos regimes de estimulação ovariana com antagonistas do GnRH, prevenindo a queda nos níveis de estradiol e diminuindo as necessidades de FSH

intra-uterine missed abortion with a simultaneous tubal ectopic pregnancy

A case of heterotopic pregnancy is reported. This case was a 25 years old woman with a chief complain of vaginal bleeding which was spotting in following pregnancy after using clomiphene. An ultra-sonography report showed a missed abortion about 8 weeks of gestation. After a few days, she returned with an acute abdomen. A tubal pregnancy with a missed abortion was suggested as a differential diagnosis. Laparatomy and D and C were performed. Pathologic report also confirmed simultaneous intra-uterine and extra-uterine pregnancy within recent years. The use of reproductive technology and ovulation stimulation has increased the prevalence of this type of rare pregnancy. Thus, heterotopic pregnancy should be considered in the presence of ectopic pregnancy signs and symptoms even if a normal intra-uterine pregnancy was confirmed

Effect of the oral contraceptive pill on patients undergoing controlled ovarian hyperstimulation

This is a retrospective analysis of 89 patients who were undergoing controlled ovarian hyperstimulation for in vitro fertilization and embryo transfer in the Fertility Management Unit of the Department of Obstetrics, Gynaecology and Child Health, The University of the West Indies. Twenty-eight patients (Group A), who did not receive oral contraceptive pills prior to controlled ovarian hyperstimulation (COH) were compared with 61 patients in Group B treated with oral contraceptive pills for two months prior to undergoing COH assisted reproduction using the long protocol. The number of follicles, oocytes, estimated oestradiol levels on the day of administration of human chorionic gonadotrophin (hCG), pregnancy rates, miscarriage rates and the incidence of patients who developed ovarian hyperstimulation syndrome (OHSS) were the main outcome measures. The mean age and haematocrit were the same in each group. The number of follicles retrieved tended to be higher in Group A than in Group B (median 8 versus 6, p = 0.06) with significantly more oocytes being retrieved in Group A than Group B (p < 0.05). There were no statistically significant differences between the two groups in oestradiol levels, the proportion of patients with polycystic ovarian disease, the proportion of women who developed ovarian hyper-stimulation syndrome or pregnancy outcomes. There was no difference between the groups in measures of clinical severity of OHSS. In a logistic regression model the significant predictors of OHSS were haematocrit and oestradiol levels. There appeared to be no significant clinical benefit in administering oral contraceptive pills for two months to patients prior to COH

Valor preditivo do volume ovariano na resposta à induçäo da ovulaçäo na fertilizaçäo in vitro / predictive value of ovarian volume in the response to in vitro fertilization

Determinar a correlaçäo entre o volume ovariano medido pela ultra-sonografia transvaginal (USTV) com o cancelamento da induçäo da ovulaçäo nos ciclos de fertilizaçäo in vitro (FIV) devido à má resposta. Estudamos a resposta de 117 pacientes submetidas a induçäo da ovulaçäo para FIV. As pacientes foram divididas em dois grupos: Grupo I = volume ovariano < 3cm cubicos e Grupo II = volume ovariano >ò 3cm cubicos. As pacientes do grupo I obtiveram uma maior taxa de cancelamento da induçäo da ovulaçäo devido a má resposta (52 por cento) que as pacientes do grupo II (21 por cento) (p<0,001). As pacientes do grupo I tiveram menor número de folículos recrutados (4,66) que a do grupo II (9,5) (P<0,01). Näo houve diferença estatisticamente significativa entre idade, número de dias de induçäo da ovulaçäo e número de ampolas de gonadotrofinas utilizadas. Nossos resultados sugerem uma importante associaçäo da reserva ovariana com o volume ovariano. Os ovários com dimensöes < 3cm cubicos de volume estäo associados ao maior índice de cancelamento da induçäo da ovulaçäo devido à má resposta.

In vitro fertilization. The Jamaican experience

In June 2000, twenty-eight infertile couples were treated by in vitro fertilization and embryo transfer at our initial assisted reproduction programme carried out in conjunction with Midland Fertility Services, Aldridge, Birmingham, England. A pre-requisite for treatment was that on day 3 of the menstrual cycle the levels of follicle stimulating hormone (FSH) and oestradiol (E2) should be < 10 i mu/l and < 100 pg/ml respectively in the female partner. The ages of the women ranged from 26 to 42 years with a mean age of 35.5 years. Down regulation was carried out by using buserelin acetate 0.5 microgram subcutaneously from day 21 of the cycle for 21 days. This process was completed when the ovaries and pituitary gland were quiescent and the endometrial thickness < 4 mm in diameter. On completion of down regulation the gonadotrophin hormone, pergonal (dosage of 150-450 units) was used for ovarian hyperstimulation. A total of 294 oocytes (mean of 10.5, range 2-45) were retrieved of which 138 were fertilized (mean of 4.9, range of 0-28). Twenty-four patients each received a mean of two embryos. Five patients (20.8) had positive pregnancy tests. Three patients (0.1) developed ovarian hyperstimulation syndrome (OHSS), one had the severe, and two, the mild form of the syndrome. All three cases were treated successfully. The success at the initial IVF controlled ovarian hyperstimulation augers well for the future of infertile couples seeking treatment at the Fertility Management Unit, The University of the West Indies, Jamaica.

Ovarian hyperstimulation syndrome associated with clomiphene citrate

Ovarian hyperstimulation is a recognized complication of ovulation induction with gonadotrophins. The syndrome is becoming more common as the number of women undergoing in-vitro fertilization increases. It is rarely seen in conjunction with clomiphene citrate usage. This case report is of moderate to severe ovarian hyperstimulation in a patient who was treated with clomiphene citrate because of infertility secondary to anovulation. She presented with amenorrhoea for five weeks, lower abdominal pain and a positive urinary human chorionic gonadotrophin (hCG) test. Pelvic ultrasonography was suggestive of a possible ectopic pregnancy with a differential diagnosis of a ruptured ovarian cyst. Diagnostic laparoscopy was done followed by laparotomy. Oophorectomy was performed because the ovary was thought to be complex with solid areas. However, conservative management with avoidance of laparotomy is the recommendation in confirmed cases of ovarian hyperstimulation but this requires a high level of suspicion in patients who have ovulation induction.

[Incidence and growth of uterine myoma after ovulation induction on 1100 infertile women in shahid Akbarabadi Hospital and Royan Institute]

The aim of this study was to determine the incidence and growth rate of uterine myomas in users of ovulation induction drugs. Eleven hundred in fertile women who had undagone at least 5 cycles of ovulation induction, refering to Royan Institute and Akbarabadi Hospital were selected on the basis of easy access selection method. To study presence or absence of uterine myoma, all the patients were subjected to sonograply before ovulation induction the sonography was repeated after at least 5 cycles of ovulation induction and was compared with the initial sonography. Of the 1100 patients, 54 had myoma and of the 1046 myoma-free patients, 71 [6.8%] developed myoma later and of the 54 with initial myoma, 40 [%74] showed increased growth of their myoma. This study is a beginning for studies on the effect of ovulation induction on the growth rate of uterine myomas and may be a comparison basis for the incidenee and growth rate of myomas in an age matched control group of women

Cistos ovarianos funcionais na reproduçäo assistida / Functional ovarian cysts in assisted reproduction

Os procedimentos envolvidos na reproduçäo assistida têm apresentado uma rápida evoluçäo, pois o insucesso destas açöes ocasiona frustraçäo aos casais que apresentam alta expectativa quanto a este tipo de tratamento. Na década passada, a introduçäo dos agonistas de GnRH nos protocolos de estimulaçäo da ovulaçäo para a realizaçäo de FIV constituiu um grande avanço, o que se refletiu em melhores taxas de gravidez. Apesar deste benefício, os agonistas de GnRH podem apresentar alguns efeitos adversos, como a formaçäo de cistos ovarianos funcionais. Isto se deve basicamente ao efeito flare-up que acontece no momento da administraçäo dos agonistas. Tem-se verificado que estes cistos influenciam negativamente a reproduçäo assistida, por isso, nos últimos anos muito trabalho tem sido empreendido na tentavia de prevenir o seu surgimento. A utilizaçäo de progestogênios, por aspiraçäo transvaginal destas estruturas, tem surgido num esforço para contornar este efeito. Desta forma, uma adequada compreensäo de como estes cistos se formam e dos aspectos relativos a prevençäo e tratamento deste problema é útil na utilizaçäo destes medicamentos na reproduçäo assistida.

Prevençäo da iatrogenia / Preventing iatrogeny

O principal objetivo no tratamento da infertilidade deve ser aumentar as taxas de gravidez e reduzir os índices de abortamento, resultando em maior taxa de nascimento de crianças saudáveis. Além disso, deve-se procurar reduzir os casos de hiperestimulaçäo, assim como de gestaçöes múltiplas, com uma concomitante reduçäo das complicaçöes gestacionais e obstétricas. Algumas vezes, o especialista se desvia destes objetivos, podendo trazer à paciente uma complicaçäo iatrogênica. Seräo citadas aqui possíveis complicaçöes e condutas para sua prevençäo.

Función el cuerpo lúteo formado a partir de la ovulación de un folículo dominante persistente, en vaquillas holstein tratadas con un dispositivo intravaginal de liberación de progesterona (CIDR-B), en ausencia de un cuerpo lúteo / Function of the corpus luteum developed from the ovulation of a persistent dominant follicle in Holstein heifers treated with a controlled internal drug release-bovine device (CIDR-B) in absence of a corpus luteum

Se evaluó la función del cuerpo lúteo (CL) formado a partir de la ovulación de un folículo dominante persistente, en vaquillas Holstein tratadas con un dispositivo intravaginal de liberación de progesterona (CIDR-B), en ausencia de un CL. Veinticuatro vaquillas recibieron 25 mg de prostaglandina F2Ó (PGF2Ó) im. Once días después a las vaquillas del grupo 1 (n=12) se les insertó un CIDR.B (CIDR-B con CL), a las vaquillas del grupo 2 (N=2) se les insertó sin estradiol y permaneció 12 días. Se evaluó el desarrollo folicular mediante ultrasonografía. En 2 vaquillas (16.6 por ciento) del grupo 1 y en 8 del grupo 2 (66.6 por ciento; P< 0.05) el folículo dominante observado el día de la inserción del CIDR-B persistió y ovuló después del tratamiento; en los animales restantes ovuló un folículo diferente. Se obtuvieron muestras sanguíneas para la determinación de progesterona diariamente, a partir del día del estro (día 1) hasta el día 16 del ciclo de 7 vaquillas del grupo 1, en las cuales ovuló el folículo diferente, y de 7 vaquillas del grupo 2, en las que ovuló un folículo dominante persistente. Las concentraciones de progesterona fueron similares en las vaquillas de ambos grupos (P > 0.05). En el presente trabajo no se encontró evidencia de que el cuerpo lúteo que se desarrolla a partir de la ovulación de un folículo dominante persistente en vaquillas tratadas con un CIDR-B en ausencia de un cuerpo lúteo, tenga afectada su función