Comparison of adnexal torsion between pregnant and nonpregnant women.

OBJECTIVE: The purpose of this study was to compare clinical manifestations, treatment, and pregnancy outcome of adnexal torsion in pregnant and nonpregnant women. STUDY DESIGN: We conducted a retrospective case-control study in the Departments of Gynecology at 2 tertiary centers between 1999-2008. Forty-one pregnant and 77 nonpregnant women with surgically proved adnexal torsion were assessed. RESULTS: Recurrence rate of torsion was 19.5% in pregnant women and 9.1% in control subjects; 73% of pregnant women conceived through assisted reproductive technologies. Doppler blood flow was falsely normal in 61% of pregnant women and in 45% of nonpregnant women; 83.3% of pregnant women delivered at term. Laparoscopic detorsion was the main surgical procedure. CONCLUSION: Presentation of adnexal torsion is similar in pregnant and nonpregnant women. Past assisted reproductive technology is an important risk factor in pregnancy. Doppler blood flow has a high false-negative rate and should not outweigh clinical suspicion. Although pregnancy outcome is favorable, the high rate of recurrence raises the issue of surgical fixation at the first episode.

Ovarian stimulation and emergency in vitro fertilization for fertility preservation in cancer patients.

OBJECTIVE: To evaluate the outcome of ovarian stimulation and in vitro fertilization (IVF) in women undergoing fertility preservation prior to chemotherapy compared with healthy patients with infertility due to tubal factor. STUDY DESIGN: Case control, retrospective study in an academic IVF unit. The study participants were 21 cancer patients and 1 patient with focal proliferative glomerulosclerosis, undergoing emergency IVF or intracytoplasmic sperm injection (ICSI; Group A) and 22 patients undergoing IVF for tubal factor (Group B). All patients underwent controlled ovarian stimulation, ovum pick-up, and embryo freezing or transfer. The outcome measures included: dose of gonadotropins, mean estradiol and progesterone levels, length of stimulation, number of retrieved oocytes, number of 2 pronuclei zygotes, fertilization rate, and clinical pregnancy rate. Student's t-test was used for assessment of group comparisons. RESULTS: Patients in Group A (mean age 32.8+/-5.7 years) underwent 22 emergency IVF cycles for fertility preservation prior to chemotherapy. The mean number of days until human chorionic gonadotropin administration was 10.4+/-4.8. Eleven cycles involved normal insemination while nine involved ICSI. In one cycle three arrested immature oocytes were retrieved, and in one cycle no oocytes were retrieved. Donor sperm was used in 9 cycles. Tamoxifen was part of the treatment protocol in 6 IVF cycles of breast cancer patients. The mean age of the women in Group B was 34+/-4.2 years. There were no significant differences in any of the main outcome measures between the two groups. Thawed embryos were transferred in four cancer patients: two patients had colon cancer, one had breast cancer and one had pseudomyxoma peritonei. Two of these four women conceived and gave birth to healthy newborns. CONCLUSIONS: Emergency IVF is a promising approach for preserving fertility in cancer patients. Current treatment protocols offer a minimal time delay until chemotherapy is commenced, and the ovarian stimulation outcomes are comparable to those of women with tubal factor.

Histologic evaluation of fresh human ovarian tissue before cryopreservation.

Transplantation of cryopreserved tissue from patients with cancer may carry the risk of reactivation or redissemination of micrometastases. This prospective study was conducted to evaluate the potential involvement of micrometastases in ovarian tissue in cancer patients. Ovarian biopsies were collected from patients who underwent ovarian tissue cryopreservation, in our IVF unit before chemotherapy between 2000 and 2008. Indications for cryopreservation included breast cancer (n=13), osteosarcoma (n=13), hematologic malignancies (n=13), uterine cervix carcinoma (n=2), endometrial carcinoma (n=1), colon cancer (n=1), and brain medulloblastoma (n=1). The samples were stained with hematoxylin and eosin, and examined histologically. Immunoperoxidase broad-spectrum cytokeratin staining was also performed on specimens from breast cancer patients. There were 44 patients (age range 5-40 yr) who yielded 40 specimens. No gross pathologic involvement was observed, and the histologic examination revealed normal histology with no evidence of metastases. Our findings showed that for the purpose of considering ovarian tissue cryopreservation in cancer patients, the likelihood of microscopic metastases within ovaries of normal appearance is apparently very low. Clarification of the actual risk of ovarian involvement and any subsequent risk of micrometastases and tumor reimplantation requires further investigation.

Follicular fluid levels of anti-Mullerian hormone as a predictor of oocyte maturation, fertilization rate, and embryonic development in patients with polycystic ovary syndrome.

OBJECTIVE: To test whether the follicular fluid (FF) concentration of anti-Mullerian hormone (AMH) is associated with oocyte maturation, fertilization rate, and embryonic development in patients with polycystic ovary syndrome (PCOS) undergoing IVF. DESIGN: Prospective. SETTING: Academic assisted reproductive technology program. PATIENT(S): Twenty-two samples of FF from 11 patients with PCOS who underwent IVF/ET were analyzed for AMH levels (group A). Twelve women with normal ovulatory cycles served as a control group (group B). The oocytes and preembryos were closely followed until ET. METHOD(S): FF was obtained at oocyte retrieval for IVF/intracytoplasmic sperm injection. AMH levels were studied using immunoenzymometric assay. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): FF, AMH levels, oocyte maturation, fertility rate, and embryonic cleavage rate. RESULT(S): The mean FF AMH level was 57.3 +/- 79.5 pmol/mL in group A, compared with 70 +/- 120.14 pmol/mL in group B. In group A, the mean AMH level of good-quality embryos was 37.4 +/- 23.4 pmol/mL, compared with 61.9 +/- 102 pmol/mL in a the poor-quality subgroup. No significant correlation was observed between FF AMH levels and oocyte maturation, fertilization, or cleavage rate. CONCLUSION(S): This study suggests that there is an association between FF AMH levels and the quality of embryos in patients with PCOS. However, owing to large variance and the number of participants, no statistical significance was reached. The degree of maturation of retrieved oocytes, as well as the success of fertilization, was not found to correlate with FF AMH.

The effect of CGG repeat number on ovarian response among fragile X premutation carriers undergoing preimplantation genetic diagnosis.

OBJECTIVE: To assess ovarian response among carriers of FMR1 premutation who undergo preimplantation genetic diagnosis (PGD). DESIGN: Retrospective study. SETTING: Academic IVF unit. PATIENT(S): Of 18 carriers of FMR1 premutation referred to PGD, eight had <100 CGG repeats and ten had >or=100 CGG repeats. INTERVENTION(S): Controlled ovarian stimulation (COH) and PGD. MAIN OUTCOME MEASURE(S): Correlation between the number of CGG repeats and the level of E2 at day of hCG administration, number of retrieved oocytes, number of two-pronuclear (2PN) zygotes, and dose of recombinant FSH. RESULT(S): There was a positive correlation between CGG repeats and the level of E2 at day of hCG administration, number of retrieved oocytes, and number of 2PN zygotes. There was a negative correlation between number of CGG repeats and the total dose of gonadotropins. The E2 level and the number of retrieved oocytes and 2PN zygotes were significantly higher and the dose of gonadotropins significantly lower for premutation patients with >or=100 CGG repeats compared with <100 CGG repeats. CONCLUSION(S): There is a positive correlation between E2 level, retrieved oocytes, 2PN zygotes, and number of CGG repeats. Premutation carriers with <100 CGG repeats suffer from impaired ovarian response and decreased fertilization rate.

First live birth following IVF-embryo transfer and use of GnRHa alone for ovarian stimulation.

Several case reports have shown that some patients may develop ovarian cysts or ovarian hyperstimulation syndrome following the administration of gonadotrophin-releasing hormone agonist (GnRHa). This is the first report of a live birth following ovarian stimulation and IVF-embryo transfer using sole administration of GnRHa as part of the short protocol. The 31-year-old woman was referred to IVF because of severe male factor. Following spontaneous menses, ovulation induction was started by administering a conventional flare-up regimen (triptorelin 0.1 mg) on day 1 of the cycle. On day 3, the oestradiol concentration was 444 pg/ml and the progesterone concentration was 0.3 ng/ml. On day 4, about 10 follicles, 8-10 mm in size, were detected in each ovary, and the oestradiol concentration rose to 704 pg/ml (progesterone was unchanged). Surprisingly, on day 9, the follicles were 18-19 mm in diameter, oestradiol had increased to 3678 pg/ml and progesterone was now 2.88 ng/ml. Informed consent was obtained for administering human chorionic gonadotrophin and for performing ovum retrieval 36 h later. Nineteen MII oocytes were retrieved, and all were fertilized, yielding high-quality embryos. Two embryos were transferred, and the patient conceived and recently gave birth to a healthy singleton.

Retrieval of immature oocytes after chemotherapy for Hodgkin's disease and prolonged ovarian down-regulation with gonadotropin-releasing hormone agonist.

OBJECTIVE: To describe isolation and in vitro maturation of primary oocytes from the ovarian cortex in the presence of hypothalamic pituitary down-regulation. DESIGN: Case report. SETTING: Tertiary care university-affiliated hospital. PATIENT(S): An 18-year-old patient was given treatment with the ABVD (Adriamycin, bleomycin, vinblastine, and dacarbazine) protocol for Hodgkin's disease. She underwent ovarian tissue cryopreservation while being cotreated with GnRH agonist because of disease relapse. INTERVENTION(S): Laparoscopic oophorectomy, ovarian tissue cryopreservation, and in vitro maturation of primary oocytes. MAIN OUTCOME MEASURE(S): Maturation of primary oocytes isolated from the medium used for preparation of ovarian tissue. RESULT(S): Twenty-one immature germinal vesicle-stage oocytes were isolated from the medium of dissection. All were incubated in in vitro maturation medium, and five were maturated and frozen. CONCLUSION(S): The fact that germinal vesicle-stage oocytes were present in our patient's medium despite hormonal down-regulation demonstrates that GnRH agonist does not completely inhibit antral follicle development.

Assessment of ovarian reserve following ovarian tissue banking and/or GnRH-a co-treatment prior to chemotherapy in patients with Hodgkin's disease.

PURPOSE: To examine ovarian reserve following chemotherapy in women with Hodgkin's disease. METHODS: The study included nine patients who underwent ovarian tissue cryopreservation (OTCP) prior to chemotherapy consisting of the ABVD regimen (Adriamycin, bleomycin, vinblastine, and dacarbazine) and co-treatment with gonadotropin-releasing hormone agonist (GnRH-a) (Group A), and 13 patients treated by the ABVD protocol only without GnRH-a (Group B). The average age was 25.2 +/- 2.7 years for the women in Group A and 31.8 +/- 6.8 years for those in Group B. RESULTS: Six months following the end of chemotherapy, the menstrual cycle resumed in all Group A patients and in four Group B patients who had amenorrhea. Eight Group B patients had regular menses during and after chemotherapy. None of the patients suffered from ovarian failure. Two Group A patients conceived in the first year after completing chemotherapy. CONCLUSIONS: Co-treatment with GnRH-a has little effect on ovarian protection in women with Hodgkin's disease.

Does high serum progesterone level on the day of human chorionic gonadotropin administration affect pregnancy rate after intracytoplasmic sperm injection and embryo transfer?

OBJECTIVE: The present study was conducted to evaluate the effect of serum progesterone (P) levels on the day of human chorionic gonadotropin (hCG) administration on embryo quality and pregnancy rate in intracytoplasmic sperm injection (ICSI) cycles. DESIGN AND SETTING: This was a retrospective analysis conducted in the in vitro fertilization (IVF) unit of a tertiary hospital. PATIENTS: Two hundred and one patients who underwent a total of 280 IVF treatment cycles allocated to ICSI during routine IVF/embryo transfer treatment. Results. In cycles with elevated serum P, higher estradiol levels were noted (1915 pg/ml vs. 1256 pg/ml; p<0.05), more oocytes were retrieved and manipulated, and more embryos were available for transfer. Embryo grading was comparable between the two groups. The average age was lower in the group with elevated P; but the pregnancy rate was significantly lower (16.4% vs. 27.6%, p = 0.03). CONCLUSIONS: Our data demonstrate no deleterious effect of elevated P on embryo quality. However, high serum P adversely affects implantation and pregnancy rates.