An unexpected triplet heterotopic pregnancy after replacement of two embryos.

We report a case of a triplet heterotopic pregnancy consisting of an intrauterine monozygous twin pregnancy and a tubal pregnancy after replacement of only two embryos in an in-vitro fertilization cycle with donor spermatozoa. This case demonstrates that sonographic demonstration of two intrauterine pregnancies after transfer of two embryos does not exclude the presence of an ectopic pregnancy. As both heterotopic pregnancy and spontaneous monozygotic twinning are more frequent after the use of assisted reproductive techniques, this combination, although extremely rare, must be kept in mind, especially in older patients with pre-existing tubal damage.

Triggering of ovulation in human menopausal gonadotrophin-stimulated cycles: comparison between intravenously administered gonadotrophin-releasing hormone (100 and 500 micrograms), GnRH agonist (buserelin, 500 micrograms) and human chorionic gonadotrophin (10,000 IU).

We studied the peri-ovulatory and luteal phases in 38 human menopausal gonadotrophin (HMG)-stimulated cycles, in which ovulation was triggered with four different i.v. bolus ovulation triggers: 100 micrograms gonadotrophin-releasing hormone (GnRH; group A, n = 9), 500 micrograms GnRH agonist (GnRHa; group B, n = 10), 10,000 IU human chorionic gonadotrophin (HCG; group C, n = 10) and 500 micrograms GnRH (group D, n = 9). Endogenous luteinizing hormone (LH) surges occurred in all cycles of groups A, B and D. The rise was slowest but highest in group B (P < 0.0001) and lowest in group A. Although the t0 serum oestradiol values were similar in all groups, day +8 oestradiol and day +4 and +8 progesterone concentrations were higher in group C (P < 0.05). At day +4 and +8, serum LH concentrations were lowest (P < 0.01) but follicle stimulating hormone (FSH) concentrations were higher. Clinically, day +8 luteal scores showed a more conspicuous degree of ovarian hyperstimulation in the HCG group (P = 0.0292). Luteal insufficiency, defined as cycles with progesterone concentrations of < 8 ng/ml, occurred much more frequently in groups A, B and D than in group C (day +4: P < 0.0003; day +8: P < 0.0001), despite progesterone supplementation. Three pregnancies (one in group C and two in group D) and one moderate case of ovarian hyperstimulation syndrome (OHSS) (in a non-conceptional group D cycle) occurred. These findings show that (i) ovulation occurs and pregnancy can be achieved following an endogenous LH surge induced by GnRH and its agonists, (ii) a high frequency of luteal insufficiency occurs in such cycles even with luteal supplementation and (iii) OHSS cannot be totally prevented by this approach, although cycles with an endogenous LH surge in general result in fewer subclinical signs of ovarian hyperstimulation.

Pregnancy after intracytoplasmic sperm injection of metaphase II oocytes with spermatozoa from a man with complete retrograde ejaculation.

Retrograde ejaculation is an uncommon cause of infertility, which has been treated successfully with different kinds of artificial reproduction technique, e.g. cervical cap artificial insemination by husband, intra-uterine and intraperitoneal insemination, standard in-vitro fertilization, pronuclear stage transfer and gamete intra-Fallopian transfer. All these techniques require a minimal number and motility of spermatozoa obtained after post-masturbation voiding. In some cases, only very few spermatozoa with very poor or no motility are found in the urine voided immediately after masturbation. In such a case, where no more than 14 spermatozoa were recovered over a 3 h search, intracytoplasmic sperm injection of metaphase II oocytes led to the development and replacement of three fair embryos, resulting in an ongoing twin pregnancy. This technique opens up perspectives for the treatment of men with complete retrograde ejaculation and quasi-azoospermic post-voiding specimens.

Serum hCG decline following salpingotomy or salpingectomy for extrauterine pregnancy.

Twenty-five women with ectopic pregnancy were surgically treated, fifteen by conservative salpingotomy and ten by radical salpingectomy. All patients showed a clinically normal postoperative course. Serum human chorionic gonadotropin (hCG) levels were determined serially before and after the surgical procedure until non-pregnant values (< 5 mI.U./ml) were reached. Serum hCG decline was compared between patients treated by salpingotomy versus salpingectomy, using calculated hCG half-life times. We observed a significantly slower decline of serum hCG levels during the early phase of hCG disappearance in patients treated by salpingotomy versus patients treated by salpingectomy.

Triggering of ovulation using a gonadotrophin-releasing hormone agonist does not prevent ovarian hyperstimulation syndrome.

A total of 24 women with primary or secondary infertility due to oligo- or anovulation, were treated with human menopausal gonadotrophin (HMG). In 48 cycles, we used a gonadotrophin-releasing hormone agonist (GnRHa) nasal spray (buserelin) to induce a pre-ovulatory endogenous luteinizing hormone (LH) surge. In 44 cycles, there was a rapid rise of the serum LH concentration within 8 h from the first administration of GnRHa. One patient with pituitary hypogonadotrophic amenorrhoea showed a weak or no response in four treatment cycles. Conception occurred in 10 cycles (pregnancy/cycle (P/C) index = 22.7%), four of which ended in a spontaneous abortion and six of which are ongoing pregnancies. In 27 cycles, there was an increased risk for ovarian hyperstimulation syndrome (OHSS), defined as more than three follicles > or = 18 mm in diameter and/or serum oestradiol > 1200 pg/ml. Three of these treatment cycles gave rise to the development of moderate OHSS in the absence of exogenously administered human chorionic gonadotrophin, two being conception cycles.

Clinical and endocrine effects of laser vaporization in patients with polycystic ovarian disease.

Responses to laparoscopic ovarian laser vaporization were studied in 17 anovulatory patients with clomiphene citrate-resistant polycystic ovarian disease (PCOD). Ovulatory cycles were obtained in 14 patients (82%). A total of 11 patients (65%) conceived within 1-8 months. Measurements of basal serum hormone levels before and after the procedure in 12 patients revealed a significant decline in testosterone, dihydrotestosterone and androstenedione. In addition, luteinizing hormone (LH) levels decreased, but not significantly. On the other hand estradiol levels slightly increased and a surge in luteal progesterone levels was noted. Serum levels of sex hormone binding globulin, prolactin, dehydroepiandrosterone (DHEA) sulfate, 17-OH-progesterone and follicle stimulating hormone (FSH) remained unchanged. These results suggest that ovarian laser vaporization is very useful when clomiphene citrate fails in PCOD, and has no risk of ovarian hyperstimulation syndrome or multiple gestation, which is frequently observed in ovulation induction with drugs. Most of the endocrine abnormalities associated with PCOD are corrected by the laser procedure.

Successful triplet pregnancy in a patient with a unicornuate uterus with a cavitary communicating rudimentary horn.

In a patient with primary infertility, ovulation was induced by monitored stimulation with human menopausal gonadotrophins (HMG) because of polycystic ovarian disease. Infertility work-up had shown a unicornuate uterus with a cavitary communicating rudimentary horn. The husband showed a varicocele-related moderate oligo-asthenoteratozoospermia. A triplet pregnancy occurred in a third HMG ovulation induction cycle combined with intra-uterine insemination of the husband's washed semen. The pregnancy was carefully monitored, and measures to prevent premature delivery were taken. Because of the patient's obvious discomfort in the presence of premature labour, Caesarean section was performed at 33 weeks gestation and three healthy infants were delivered. This is the first report of a successful triplet pregnancy in a women with a unicornuate uterus. The reproductive and obstetric outcome of this condition in general, and in the case of multiple pregnancy, is discussed.

Preliminary results with the use of the ROM-check immunoassay in the early detection of rupture of the amniotic membranes.

The unequivocal presence of amniotic fluid in the vagina is an important clinical sign of rupture of amniotic membranes, entailing impending delivery or risk for chorioamnionitis. Commonly used methods for detection of amniotic fluid in the vagina include pooling, ferning, nitrazine paper, ultrasound measurement of amniotic sac dimensions, dye injection or measurement of prolactin in vaginal secretions. These results are either difficult to interpret or are obtained after an invasive or expensive procedure. Measurement of alphafetoprotein (AFP) in vaginal secretions has also been considered for this application, but has proven unreliable due to its similar concentration in maternal plasma and amniotic fluid in the third trimester of pregnancy. We have evaluated a recently introduced method, the ROM-check Immunoassay (Adeza Biomedical, Sunnyvale, CA, USA) which is based on the detection of a fetal isoform of fibronectin in vaginal secretions when amniotic fluid is present. Our aim was to establish the reliability and clinical efficacy of this test in a number of obstetrical situations with unequivocal or equivocal rupture of the membranes (ROM). We conclude that in cases of unequivocal rupture and/or intactness of membranes, results of the ROM-check Immunoassay correspond well with the clinical findings, whereas in clinically equivocal rupture of the membranes, the test may add proof to the clinical suspicion of ROM but has to be interpreted with caution along with other clinical and non-clinical parameters.