Modern lines of management of ectopic pregnancy.

The recent increase in the incidence of ectopic pregnancies was associated with rapid improvement in the diagnostic and therapeutic techniques. Quantitative serum B-HCG radioimmunoassay and high resolution vaginal ultrasonography have facilitated early diagnosis of ectopic pregnancy allowing a more conservative approach to patient management. Different conservative surgical and medical lines of management recently developed were associated with and increased chance of subsequent intrauterine pregnancy with no increase in the incidence of repeat ectopic pregnancy. Outpatient systemic medical treatment seems to be a preferred alternative to conservative surgery. In selected cases, it is associated with a lower complication rate and promising result for fertility.

Human lung mast cell IL-5 gene and protein expression: temporal analysis of upregulation following IgE-mediated activation.

The late-phase of allergic asthma is characterized by infiltration of the airway with eosinophils within 6 h of mast cell activation. Pro-eosinophilic/pro-allergic (TH2) cytokines, originally described as T-lymphocyte products, have recently been ascribed to mast cells as well. To date, however, it is unknown if TH2 cytokine gene expression by the human mast cells is subject to receptor-mediated regulation analogous to that of T-cells, and if messenger RNA (mRNA) expression results in protein secretion occurring in a temporal context consistent with the late-phase response. We examined interleukin-4 (IL-4), IL-5, and IL-6 mRNA expression induced by anti-IgE activation of human lung explants as assessed using reverse transcription/polymerase chain reaction (RT-PCR). Anti-IgE stimulation resulted in rapid and sustained upregulation of IL-5 message, but did not have analogous effects on IL-4 or IL-6. Using quantitative-competitive PCR, we demonstrated that 100 ng of total cellular RNA from human lung contained 1 fg of IL-5 mRNA; this increased to 100 fg 4 h after anti-IgE activation. The source of the anti-IgE-enhanced IL-5 mRNA is likely the mast cell itself, as anti-CD3 activation of lung led to a dissimilar array of cytokine expression. In addition, human lung mast cells purified to near homogeneity expressed IL-5 mRNA after activation, as shown by both RT-PCR and in situ hybridization. In both lung fragments and purified human lung mast cells, the modulation of IL-5 mRNA expression preceded the secretion of IL-5 protein, detected as early as 4 h after activation. Neither isolated purified mast cells nor purified peripheral blood T cells could be induced to secrete detectable amounts of IL-5 protein when activated only with antibodies against IgE or CD3-T cell receptor complex, respectively. However, mast cells (n = 4) and T cells (n = 6) cultured at comparable concentrations (4 x 10(6)/ml) activated through their respective antigen receptors in the presence of phorbol ester yielded comparable IL-5 production (253 +/- 126 pg/ml versus 183 +/- 75 pg/ml, mean +/- SE). We conclude that mast cells are analogous to T cells in the requirement of co-stimuli for the production of IL-5 protein. Moreover, the rapid kinetics of IgE-mediated IL-5 transcription and protein elaboration are consistent with a primary role for mast cell activation directly leading to late-phase airway eosinophilia.

IgE-dependent expression of interleukin-5 mRNA and protein in human lung: modulation by dexamethasone.

mRNA and protein expression of the Th2 cytokines IL-4 and IL-5 from human lung were examined during the first 4 hr following IgE-mediated triggering, a time representative of the evolving late-phase reaction (LPR). Lung explants were incubated for 16 hr at 37 degrees C in culture media alone or with added dexamethasone (10(-6) M), washed, and then challenged with buffer or anti-IgE (3 micrograms/ml). Using RNase protection assays, in 16/16 individual lungs IL-5 mRNA expression was observed at 4 hr following anti-IgE and at no points following buffer challenge. Fragments released 1129 +/- 499 ng of IL-5/g wet wt over a 24-hr period (mean +/- SEM, n = 5). Neither IL-4 transcripts nor protein were detected in any anti-IgE challenges. Both the IgE-mediated IL-5 mRNA and protein responses were below the limits of detection following dexamethasone preincubation, suggesting a mechanism for the potent inhibitory effects of these agents observed in the LPR.

Beneficial effects of a 24 h delay in human chorionic gonadotrophin administration during in-vitro fertilization treatment cycles.

We used a gonadotrophin-releasing hormone agonist (buserelin) and human menopausal gonadotrophin (HMG) for superovulation for in-vitro fertilization (IVF) in 143 patients. The patients were prospectively allocated to two balanced groups. In one group (47 patients) human chorionic gonadotrophin (HCG) was given when the three largest follicles were greater than or equal to 17 mm in diameter, with consistent levels of plasma oestradiol (standard group). In the second group (96 patients), HCG injection was delayed by 24 h (delayed group). In the delayed group of patients, proportionately more had clinical pregnancies (52.1% versus 34.0%). These results suggest that IVF patients will benefit from delayed administration of HCG. The traditional criteria for HCG administration should be changed when buserelin is used.

Programming in vitro fertilization for a 5- or 3-day week.

OBJECTIVE: To schedule oocyte retrievals on either 5 or 3 days per week in in vitro fertilization (IVF) cycles. DESIGN: Human chorionic gonadotropin (hCG) administration was delayed by at least 24 hours in patients undergoing superovulation to avoid egg collections on weekends (group 1). Encouraged by the results, a further prospective study in which oocyte retrievals were programmed for only 3 days a week was undertaken (group 2). SETTING: Hammersmith Hospital, a tertiary referral unit. PATIENTS: All patients undergoing IVF treatment were included. MAIN OUTCOME MEASURES: To schedule oocyte retrievals on either 5 or 3 days per week. RESULTS: Only 4.0% of egg collections (12/303) occurred on weekends compared with 12.6% (22/175) before delaying hCG. In group 2 (n = 215), only four egg collections (2.1%) had to be performed out of schedule. Delaying administration of hCG had no detrimental effects. CONCLUSIONS: Delayed administration of hCG allows scheduling oocyte retrievals on either 5 or 3 days per week, leading to a substantial decrease in out-of-hours oocyte retrievals, reducing cycle costs, and facilitating efficiency. The method is applicable to assisted reproduction specialized units as well as district general hospitals that use gonadotropin-releasing hormone analogs in their superovulation regimens before IVF, gamete intrafallopian transfer, or intrauterine insemination.

Attitudes towards gamete donation among couples undergoing in vitro fertilization.

The attitudes of 234 anonymous couples undergoing in vitro fertilization toward sperm and oocyte donation were explored by questionnaire. All the questionnaires were returned of which 222 (95%) were complete and analysed. A high proportion of couples found the use of donor sperm acceptable for therapeutic, diagnostic and treatment purposes (77%, 90% and 97% respectively) and 72%, 84% and 90% respectively were willing to donate oocytes for these purposes. Of potential oocyte donors 41% would agree to nonanonymous donation, 12% would wish to meet the recipient couple and although only 4% wanted to choose the recipient, a quarter of the couples would prefer a relative or friend as the recipient. Provision of nonidentifying information about the donor to the recipient couple was acceptable to almost 70% whereas 40% found giving the same information to the child acceptable.

Nine cases of heterotopic pregnancies in 4 years of in vitro fertilization.

The incidence of simultaneous intrauterine and extrauterine pregnancy increased after wider use of ovulation induction and the advent of techniques of assisted reproduction. Nine cases of heterotopic pregnancies are reported after in vitro fertilization (IVF) and embryo transfer (ET) between September 1984 and November 1988. The incidence of heterotopic pregnancies in clinical IVF pregnancies was 9 of 312 (2.9%). Superovulation and IVF-ET appear to predispose to heterotopic pregnancy, particularly after tubal disease.

A ten year survey of 193 ectopic pregnancies.

During the period 1977-86, 193 women underwent surgery for ectopic pregnancy in the Medway Health District. 1 ectopic pregnancy was found for every 233 deliveries, an incidence of 0.43%, with a rising trend. The most common presenting symptom was abdominal pain (96%) and the most frequent physical finding was abdominal tenderness (91%). Past histories of appendicectomy (24%), infertility (19%), use of IUD (15%), and pelvic infection (13%) were elicited. In 95% of the cases, the pregnancy was tubal. 56% of the patients required blood transfusions and there were no maternal deaths. These findings confirm the rising incidence of ectopic pregnancy. During the study period, the diagnosis and management of ectopic pregnancy have changed significantly. The early use of plasma hCG, ultrasonography, and laparoscopy decreases the morbidity and mortality associated with ectopic pregnancy, allowing conservative tubal surgery when indicated.