Your browser doesn't support javascript.
loading
Show: 20 | 50 | 100
Results 1 - 20 de 45
Filter
1.
Fertil Steril ; 76(5): 863-70, 2001 Nov.
Article in English | MEDLINE | ID: mdl-11704102

ABSTRACT

OBJECTIVE: To review the literature on the variables affecting embryo transfer success or failure and to define technical factors associated with optimal outcome. DESIGN: Literature review. RESULTS: Avoidance of blood, mucus, bacterial contamination, excessive uterine contractions, and trauma to the endometrium is associated with optimal pregnancy and implantation rates after transcervical embryo transfer. A trial transfer, ultrasonographic guidance, and use of "soft" catheters appear to facilitate successful embryo transfer. CONCLUSION: An understanding of the variables associated with embryo transfer success together with adherence to techniques shown to facilitate atraumatic embryo transfer will enhance the efficiency of IVF by maximizing embryo implantation.


Subject(s)
Embryo Transfer , Blastocyst , Blood Physiological Phenomena , Embryo Transfer/adverse effects , Female , Humans , Mucus , Pregnancy , Treatment Outcome , Ultrasonography , Uterine Contraction/physiology
2.
Fertil Steril ; 75(3): 612-7, 2001 Mar.
Article in English | MEDLINE | ID: mdl-11239550

ABSTRACT

OBJECTIVE: To compare ovarian response and IVF-ET cycle outcome in patients with hydrosalpinges managed by either laparoscopic salpingectomy or proximal tubal occlusion. DESIGN: Retrospective analysis. SETTING: Tertiary-care assisted reproductive technology program. PATIENT(S): One hundred four consecutive fresh IVF-ET cycles in 94 patients with tubal-factor infertility. INTERVENTION(S): Laparoscopic salpingectomy (group 1: 35 cycles) or bipolar proximal tubal occlusion (group 2: 17 cycles), controlled ovarian hyperstimulation, and IVF-ET. Control groups consisted of both tubal-factor patients without hydrosalpinges (group 3: 37 cycles) and those with prior bilateral tubal ligation for sterilization (group 4: 15 cycles). MAIN OUTCOME MEASURE(S): Uterine artery Doppler flow, controlled ovarian hyperstimulation response, and implantation and clinical pregnancy rates. RESULT(S): There were no differences in mean uterine artery pulsatility indices or ovarian response among any of the groups. A trend toward a higher cycle cancellation rate in group 1 did not approach statistical significance. Clinical pregnancy and implantation rates were not significantly different between group 1 (57.1%, 29.2 +/- 5.9%, respectively) and group 2 (46.7%, 19.4 +/- 6.1%, respectively) or compared with those of controls. CONCLUSION(S): [1] Management of hydrosalpinges by laparoscopic salpingectomy or bipolar proximal tubal occlusion yielded statistically similar responses to controlled ovarian hyperstimulation and IVF-ET cycle outcome. [2] The latter approach may be preferable in patients who present with dense pelvic adhesions and easy access only to the proximal fallopian tube.


Subject(s)
Embryo Transfer , Fallopian Tube Diseases/surgery , Fertilization in Vitro , Laparoscopy , Adult , Arteries , Embryo Implantation , Fallopian Tube Diseases/complications , Female , Humans , Infertility, Female/etiology , Infertility, Female/therapy , Laser-Doppler Flowmetry , Ovulation Induction , Pregnancy , Retrospective Studies , Treatment Outcome , Uterus/blood supply
3.
Fertil Steril ; 75(2): 405-10, 2001 Feb.
Article in English | MEDLINE | ID: mdl-11172848

ABSTRACT

OBJECTIVE: Assess the impact of intramural uterine leiomyomata and a normal endometrial cavity on IVF-ET cycle outcome. DESIGN: Retrospective case-controlled analysis. SETTING: Tertiary-care-assisted reproductive technology program. PATIENT(S): Three hundred ninety-nine consecutive fresh IVF-ET cycles were performed in patients with a normal precycle diagnostic hysteroscopy; patients were divided into four groups. Group 1: positive leiomyomata, age <40 years (n = 51 cycles); group 2: negative leiomyomata, age <40 years (n = 57 cycles); group 3: positive leiomyomata, age > or =40 years (n = 22 cycles); group 4: negative leiomyomata, age > or =40 years (n = 59 cycles). A subgroup of all group 2 patients aged 35-39 (group 2A, n = 113 cycles) was also evaluated as an additional control. INTERVENTION(S): Controlled ovarian hyperstimulation, IVF-ET. MAIN OUTCOME MEASURE(S): Implantation (IR), live birth (LBR) rates. RESULT(S): There were no significant differences in LBR among age-matched controls: group 1 (49%) versus 2 (57.5%) or 2A (57%) and group 3 (40.9%) versus 4 (32.2%). IR was significantly lower in group 1 (21.4%) versus 2 (33.3%) or 2A (33.9%) but not in group 3 (17.5%) versus 4 (11.6%). Implantation did not correlate with either mean leiomyoma diameter or volume. CONCLUSION(S): [1] LBR was not affected by the presence of intramural leiomyoma in IVF-ET patients with hysteroscopically normal endometrial cavities. [2] A significant decrease in IR was only noted in patients <40 years old. [3] Given the relatively high LBR in all groups, prophylactic surgical intervention cannot be justified, but precycle hysteroscopy evaluation is recommended.


Subject(s)
Embryo Transfer , Endometrium/pathology , Fertilization in Vitro , Leiomyoma/complications , Pregnancy Outcome , Uterine Neoplasms/complications , Adult , Blastocyst/physiology , Case-Control Studies , Chorionic Gonadotropin/administration & dosage , Embryo Implantation , Estradiol/blood , Female , Follicle Stimulating Hormone/blood , Humans , Leiomyoma/pathology , Pregnancy , Pulsatile Flow , Regression Analysis , Retrospective Studies , Sperm Injections, Intracytoplasmic , Uterine Neoplasms/pathology , Uterus/blood supply
4.
Fertil Steril ; 73(4): 667-76, 2000 Apr.
Article in English | MEDLINE | ID: mdl-10731523

ABSTRACT

OBJECTIVE: To assess the efficacy of various controlled ovarian hyperstimulation (COH) regimens in the prior poor-responder patient preparing for assisted reproductive techniques. DESIGN: English-language literature review. PATIENT(S): Candidates for assisted reproductive techniques who had been defined as having a prior suboptimal response to standard COH regimens. INTERVENTION(S): A variety of regimes are reviewed, including increased gonadotropin doses, change of gonadotropins, adjunctive growth hormone (GH), luteal phase (long) GnRH agonist (GnRH-a) initiation, early follicular phase (flare) GnRH-a initiation, low-dose luteal phase (ultrashort) GnRH-a initiation, progestin pretreatment, and microdose flare GnRH-a initiation. MAIN OUTCOME MEASURE(S): Maximal serum E(2) levels, follicular development, dose, and duration of gonadotropin therapy, cycle cancellation rates, oocytes retrieved, embryos transferred, and clinical and ongoing pregnancy rates. RESULT(S): A lack of uniformity in definition of the poor responder and of prospective randomized trials make data interpretation somewhat difficult. Of the varied strategies proposed, those that seem to be more uniformly beneficial are microdose GnRH-a flare and late luteal phase initiation of a short course of low-dose GnRH-a discontinued before COH. CONCLUSION(S): No single regimen will benefit all poor responders. General acceptance of uniform definitions and performance of large-scale prospective randomized trials are critical. Development of a reliable precycle screen will allow effective differentiation among normal responders, poor responders, and those who will not conceive with their own oocytes.


Subject(s)
Gonadotropin-Releasing Hormone/agonists , Gonadotropins/therapeutic use , Ovary/physiology , Ovulation Induction/methods , Clinical Protocols , Dose-Response Relationship, Drug , Evaluation Studies as Topic , Female , Growth Hormone-Releasing Hormone/therapeutic use , Human Growth Hormone/therapeutic use , Humans , Ovary/drug effects , Predictive Value of Tests , Pregnancy
5.
J Reprod Med ; 45(2): 126-30, 2000 Feb.
Article in English | MEDLINE | ID: mdl-10710743

ABSTRACT

OBJECTIVE: To assess the response of proximal fallopian tube obstruction to a medically induced hypoestrogenic state after control for spasm at the uterotubal ostium. STUDY DESIGN: This was a prospective, randomized, placebo-controlled, pilot study in a tertiary care, university-affiliated infertility practice. Twenty-one infertile women with unilateral or bilateral proximal tubal obstruction previously diagnosed by standard hysterosalpingography or laparoscopic chromotubation were randomized into two groups in a 2:1 design. Group I, 14 patients (27 occluded tubes), was administered a depot preparation of the gonadotropin-releasing hormone (GnRH) agonist leuprolide acetate, 3.75 mg intramuscularly every 28 days. Group II, seven patients (11 occluded tubes), was administered a placebo. Follow-up hysterosalpingography was performed after administration of the antispasmodic glucagon within four weeks of completion of the protocol. RESULTS: Evidence of ovarian suppression was confirmed within four weeks in group I. A trend toward higher posttherapy patency rates was noted in group I (74.7% vs. 40%). The lack of statistical significance may have been a function of sample size. Similarly, spontaneous intrauterine pregnancy rates were also higher in GnRH agonist-treated patients (35.1% vs. 16.6%, P < .05). Tubal patency rates were significantly greater in patients with documented estrogen-sensitive disorders who received the agonist (75% vs. 20%, P < .05) CONCLUSION: Proximal tubal obstruction may be an estrogen-sensitive phenomenon in a subset of infertile patients. The administration of GnRH agonists may successfully overcome this state and result in enhanced conception rates.


Subject(s)
Fallopian Tube Diseases/drug therapy , Fertility Agents, Female/therapeutic use , Infertility, Female/drug therapy , Leuprolide/therapeutic use , Adult , Fallopian Tube Diseases/complications , Fallopian Tubes/pathology , Female , Gonadotropin-Releasing Hormone/agonists , Humans , Ovary/drug effects , Ovary/physiology , Pilot Projects , Pregnancy , Pregnancy Rate , Prospective Studies
7.
J Am Assoc Gynecol Laparosc ; 6(4): 383-9, 1999 Nov.
Article in English | MEDLINE | ID: mdl-10548697

ABSTRACT

Advances in fiberoptic technology make it possible to evaluate the tubal lumen endoscopically. Two basic procedures are salpingoscopy and falloposcopy. The former is a transfimbrial approach allowing visualization from the ampullary-isthmic junction to the fimbriae. The latter is a transcervical approach allowing assessment of the tubal lumen from the uterotubal ostium to the fimbriae. Both may be performed without general anesthesia. The procedures provide more sensitive information than laparoscopy with chromotubation or hysterosalpingography alone. Findings provide a strong correlation with conception. Technical shortcomings make falloposcopy more difficult than the more straightforward transfimbrial technique. With more widespread acceptance, endoscopic evaluation of the fallopian tube may become a standard component of the infertility evaluation.


Subject(s)
Endoscopy , Fallopian Tubes/pathology , Endoscopes , Endoscopy/methods , Fallopian Tube Diseases/complications , Fallopian Tube Diseases/diagnosis , Fallopian Tube Diseases/therapy , Female , Humans , Infertility, Female/etiology
8.
Obstet Gynecol Clin North Am ; 26(1): 53-62, vi, 1999 Mar.
Article in English | MEDLINE | ID: mdl-10083929

ABSTRACT

The role of the human fallopian tube in reproduction is more than a passive conduit. This organ is involved in oocyte pick-up, fertilization, and embryo transport. Metabolic substrates, cytokines, and immunoglobulins have been identified within the tubal lumen. Complex and coordinated endocrine secretions, neuromuscular activity, and cilial action are required for successful tubal function.


Subject(s)
Culdoscopy/methods , Fallopian Tubes/physiology , Cilia/physiology , Cytokines/immunology , Embryo, Mammalian/physiology , Endocrine Glands/metabolism , Fallopian Tube Diseases/diagnosis , Fallopian Tube Diseases/physiopathology , Fallopian Tube Diseases/therapy , Fallopian Tubes/anatomy & histology , Fallopian Tubes/immunology , Fallopian Tubes/metabolism , Female , Fertilization/physiology , Humans , Immunoglobulins/immunology , Neuromuscular Junction/physiology , Oocytes/physiology
9.
Fertil Steril ; 71(3): 420-4, 1999 Mar.
Article in English | MEDLINE | ID: mdl-10065775

ABSTRACT

OBJECTIVE: To reach a consensus on the role of add-back therapy for patients with endometriosis administered GnRH agonists (GnRH-a). DESIGN: Results of consensus conference reviewing MEDLINE search of English language abstracts of both prospective and retrospective series. SETTING: Consensus conference of 31 specialists in gynecologic surgery and reproductive endocrinology. PATIENT(S): Patients with symptomatic endometriosis who were candidates for GnRH-a therapy in treatment courses ranging in duration from 6 to 12 months. INTERVENTION(S): Oral steroidal and nonsteroidal add-back regimens. MAIN OUTCOME MEASURE(S): Alteration in painful symptoms, extent of disease, vasomotor symptoms, bone mineral density, and serum lipid profile. RESULT(S): When added to GnRH-a for 6 months, both 2.5 mg of norethindrone and 0.625 mg of conjugated equine estrogens with 5 mg/d of medroxyprogesterone acetate provide effective relief of vasomotor symptoms and decrease but do not eliminate bone mineral density loss. During 12 months of GnRH-a therapy, bone mineral density loss is eliminated effectively with an add-back of 5 mg of norethindrone acetate alone or in conjunction with low-dose conjugated equine estrogens. Organic bisphosphonates also may play a role. CONCLUSION(S): In patients with symptomatic endometriosis, the efficacy of GnRH agonists may be preserved and therapy prolonged while overcoming hypoestrogenic side effects with the use of appropriate add-back regimens.


Subject(s)
Endometriosis/drug therapy , Gonadotropin-Releasing Hormone/agonists , Hormones/therapeutic use , Bone Density/drug effects , Clinical Trials as Topic , Diphosphonates/therapeutic use , Estrogens, Conjugated (USP)/therapeutic use , Female , Humans , Medroxyprogesterone/therapeutic use , Norethindrone/therapeutic use
10.
J Assist Reprod Genet ; 16(2): 69-72, 1999 Feb.
Article in English | MEDLINE | ID: mdl-10079408

ABSTRACT

PURPOSE: Our purpose was to assess whether in vitro fertilization (IVF)-embryo transfer (ET) candidate couples with basically normal semen analyses but failing zona-free hamster egg penetration assay (HEPA) scores benefit from intracytoplasmic sperm injection (ICSI). METHODS: Twenty consecutive IVF candidate couples with normal-borderline semen analyses and failing HEPA scores were recruited. Mature oocytes obtained from each woman were randomly divided between ICSI (group I; n = 126 oocytes) and standard insemination techniques (group II; 138 oocytes). Fertilization (two pronuclei) and cleavage (2-4 cells) rates were assessed for both groups. RESULTS: There were no statistically significant differences between the two groups with respect to (mean +/- standard error of the mean) fertilization (group I, 63.1 +/- 7.75; group II, 77.8 +/- 4.7%) or cleavage (group I, 87.3 +/- 2.4%; group II, 91.2 +/- 3.5%) rates. CONCLUSIONS: ICSI is not beneficial for IVF-ET when sperm samples demonstrate a failing HEPA score but have normal or minimally compromised semen analysis parameters.


Subject(s)
Embryo Transfer , Fertilization in Vitro , Semen/cytology , Sperm-Ovum Interactions , Adult , Animals , Cricetinae , Cytoplasm , Female , Humans , Male , Microinjections , Prospective Studies , Reference Values
11.
Gynecol Obstet Invest ; 45 Suppl 1: 31-4; discussion 35, 1998.
Article in English | MEDLINE | ID: mdl-9628522

ABSTRACT

GnRH analogues have been demonstrated to be effective medical therapy for symptomatic endometriosis. The use of these agents has been limited to 6 months due to hypoestrogenic side effects. A variety of steroidal and nonsteroidal add-back regimens have been used in an effort to eliminate such side effects while maintaining efficacy in order to enhance compliance, safety and duration such side effects while maintaining efficacy in order to enhance compliance, safety and duration of administration of these agents. Only 3 regimens have been shown to be efficacious in prolonging analogue use beyond 6 months by reducing vasomotor symptoms as well as preventing significant bone mineral density loss. These include daily norethindrone acetate 5 mg alone or in conjunction with conjugated equine estrogens 0.625 mg daily, as well as norethindrone 2.5 mg daily in conjunction with an organic bisphosphonate. With further investigation, such regimens may allow safe prolongation of GnRH analogue use without sacrificing efficacy in those endometriosis patients with severe pelvic pain.


Subject(s)
Estrogens/deficiency , Genital Diseases, Female/drug therapy , Gonadotropin-Releasing Hormone/analogs & derivatives , Gonadotropin-Releasing Hormone/adverse effects , Endometriosis/drug therapy , Estrogens, Conjugated (USP)/administration & dosage , Estrogens, Conjugated (USP)/therapeutic use , Female , Humans , Norethindrone/administration & dosage , Norethindrone/analogs & derivatives , Norethindrone/therapeutic use , Norethindrone Acetate
12.
Fertil Steril ; 69(3): 419-24, 1998 Mar.
Article in English | MEDLINE | ID: mdl-9531870

ABSTRACT

OBJECTIVE: To assess the endocrine and clinical responses to microdose GnRH agonist (GnRH-a) that was administered in the early follicular phase before controlled ovarian hyperstimulation to poor responders who were candidates for IVF-ET. DESIGN: Prospective nonrandomized trial with historical controls. SETTING: Tertiary care university-affiliated infertility practice. PATIENT(S): Thirty-four IVF-ET candidates with a prior poor response to a standard long-protocol GnRH-a controlled ovarian hyperstimulation regimen (cycle A). Patients were divided into two groups based on their age at the initiation of cycle A (Group 1: < or = 39 years, n = 15; Group 2: > or = 40 years, n = 19). INTERVENTION(S): Low-dose oral contraceptive (x 21 d) followed by GnRH-a (leuprolide acetate; 40 micrograms s.c. b.i.d.) flare and urofollitropin initiated on day 3 of GnRH-a administration (cycle B). MAIN OUTCOME MEASURE(S): Comparative analysis of clinical responses (total urofollitropin dose used and number of oocytes retrieved as well as fertilization and clinical and ongoing pregnancy rates) and endocrine responses (serum E2, FSH, LH, T, and P levels) between cycles A and B in the two groups. Early follicular phase serum E2 and FSH changes in groups 1 and 2 were compared with changes in nine normal responder controls who were receiving a standard long-protocol GnRH-a/urofollitropin regimen (group 3). RESULT(S): Maximal E2 levels as well as clinical and ongoing pregnancy rates were higher in cycle B patients receiving microdose GnRH-a. Cancellation rates in cycle B were lower than in cycle A. Statistically significant increases in treatment day 6 serum FSH levels were noted during cycle B in both groups 1 and 2 but not in group 3 controls. No abnormal rises in LH, P, or T were noted in any of the groups. CONCLUSION(S): Microdose GnRH-a enhances urofollitropin response and clinical outcome in poor responders undergoing IVF-ET. This may be due to enhanced release of early follicular phase endogenous FSH without concomitant deleterious rises in androgen levels or corpus luteum rescue.


Subject(s)
Fertilization in Vitro , Leuprolide/administration & dosage , Adult , Embryo Transfer , Estradiol/blood , Female , Follicle Stimulating Hormone/blood , Humans , Luteinizing Hormone/blood , Menotropins/administration & dosage , Menotropins/therapeutic use , Pregnancy , Progesterone/blood , Prospective Studies , Testosterone/blood
13.
Obstet Gynecol ; 91(1): 16-24, 1998 Jan.
Article in English | MEDLINE | ID: mdl-9464714

ABSTRACT

OBJECTIVE: To evaluate the efficacy and safety of a GnRH agonist, leuprolide acetate depot, alone and in combination with three hormonal add-back regimens in the management of endometriosis-associated pelvic pain. METHODS: Two hundred and one patients were enrolled in this multicenter, randomized, double-blind, 1-year trial. All patients were given an intramuscular injection of leuprolide acetate depot 3.75 mg every 4 weeks. Patients were assigned to one of four treatment groups: Group A received placebos for progestin and estrogen, group B received norethindrone acetate 5 mg daily and placebo for estrogen, group C received norethindrone acetate 5 mg and conjugated equine estrogens 0.625 mg daily, and group D received norethindrone acetate 5 mg and conjugated equine estrogens 1.25 mg daily. Pelvic pain scores were assessed monthly, and bone density was measured after 24 and 52 weeks. RESULTS: By week 8, all four groups showed significant improvement in pelvic pain scores compared with baseline levels. A higher proportion of group D patients terminated the study prematurely due to a lack of improvement in symptoms. Group A experienced a 6.3 +/- 2.3% (P < or = .001) loss in bone density after 52 weeks of treatment, whereas bone density was preserved in all three add-back groups. CONCLUSION: The use of leuprolide acetate depot in combination with norethindrone acetate 5 mg alone, or with norethindrone acetate and conjugated equine estrogens 0.625 mg, provides effective suppression of pelvic pain symptoms associated with endometriosis while protecting against bone loss.


Subject(s)
Endometriosis/drug therapy , Gonadotropin-Releasing Hormone/agonists , Leuprolide/therapeutic use , Adult , Bone Density/drug effects , Bone Density/physiology , Cohort Studies , Delayed-Action Preparations , Double-Blind Method , Drug Therapy, Combination , Endometriosis/complications , Endometriosis/physiopathology , Equilin/administration & dosage , Estradiol/blood , Female , Humans , Injections, Intramuscular , Leuprolide/administration & dosage , Lipid Metabolism , Lipids/blood , Lumbar Vertebrae/drug effects , Lumbar Vertebrae/physiology , Norethindrone/administration & dosage , Pain Measurement/statistics & numerical data , Patient Dropouts/statistics & numerical data , Pelvic Pain/drug therapy , Pelvic Pain/etiology , Pelvic Pain/physiopathology , Progesterone Congeners/administration & dosage , Vasomotor System/drug effects , Vasomotor System/physiology
14.
J Assist Reprod Genet ; 14(9): 525-30, 1997 Oct.
Article in English | MEDLINE | ID: mdl-9401871

ABSTRACT

PURPOSE: We aimed to determine if midluteal GnRH agonist (GnRHa) use prior to controlled ovarian hyperstimulation (COH) results in uniform progesterone and androgen suppression and whether elevations of these hormones occurring early in follicular development may adversely effect the outcome of IVF-ET. METHODS: Forty-four COH cycles using midluteal GnRHa were evaluated. Serum gonadotropins (LH and FSH) and gonadal steroids (E2, A, P4, and T) were measured after 10 days of GnRHa administration [cycle day 31 (CD 31)] and again on the day of hCG administration, following COH. Cycle outcomes evaluated were the number of oocytes retrieved, morphologic grade, fertilization, implantation, pregnancy, and spontaneous abortion rates. RESULTS: Endogenous serum FSH was uniformly suppressed (6.32 +/- 0.47 IU/L) on CD 31, however, LH was not (23.76 +/- 0.76 IU/L). Five and four tenths percent of cycles demonstrated low-level P4 elevations (> or = 0.9 ng/ml), 24.4% demonstrated serum androstenedione levels > or = 600 pg/ml, and 39% of cycles were characterized by serum T levels > or = 200 pg/ml despite evidence of E2 suppression (< or = 30 pg/ml) and the absence of follicular growth by sonography. LH levels were not predictive of incomplete P4 or androgen suppression. Elevations of either P4, A, or T occurring early in the follicular phase were not found to correlate with an impairment in clinical cycle outcome. CONCLUSIONS: Midluteal GnRHa use prior to COH may result in incomplete suppression of circulating progresterone and androgens. However, these relative elevations, occurring early in the development of the follicular cohort, did not appear to affect IVF cycle outcome adversely.


Subject(s)
Androgens/blood , Fertilization in Vitro/methods , Gonadotropin-Releasing Hormone/agonists , Leuprolide/pharmacology , Luteal Phase/physiology , Progesterone/blood , Superovulation/drug effects , Abortion, Spontaneous/epidemiology , Adult , Chorionic Gonadotropin/pharmacology , Estradiol/blood , Female , Follicle Stimulating Hormone/blood , Gonadotropins/blood , Humans , Incidence , Luteinizing Hormone/blood , Pregnancy , Pregnancy Rate , Prospective Studies , Superovulation/physiology , Testosterone/blood
15.
J Am Assoc Gynecol Laparosc ; 4(4): 473-8, 1997 Aug.
Article in English | MEDLINE | ID: mdl-9224583

ABSTRACT

We compared falloposcopy employing a new coaxial system with traditional laparoscopic chromotubation and hysterosalpingography in a prospective, multicenter clinical trial at five tertiary infertility centers. Based on findings at hysterosalpingography or laparoscopic chromotubation, the 16 women (22 tubes) in group 1 had a presumed diagnosis of proximal tubal obstruction, and the 4 (7 tubes) in group 2 had unexplained infertility. Cannulation was successfully achieved in 83.3% of tubes. In group 1, 85% (17/20) of visualized tubes were patent and 35% (7/20) were normal. In group 2, 40% (2/5) of visualized tubes were abnormal. Management was changed in 52.4% of women as a result of falloposcopic findings. Falloposcopy with this new coaxial system allows improved visualization with less bulky and less traumatic instruments. The system provides valuable information regarding the fallopian tube lumen that correlates poorly with that obtained with more traditional techniques.


Subject(s)
Endoscopes , Fallopian Tubes/pathology , Adult , Constriction, Pathologic , Feasibility Studies , Female , Humans , Infertility, Female/etiology , Infertility, Female/pathology , Prospective Studies
16.
J Reprod Med ; 41(3): 207-10, 1996 Mar.
Article in English | MEDLINE | ID: mdl-8778425

ABSTRACT

BACKGROUND: Women with premature ovarian failure may conceive spontaneously or following different regimens of ovulation induction. CASE: A 29-year-old woman with eight years of hypergonadotropic hypogonadism following chemotherapy and radiotherapy for Hodgkin's disease conceived spontaneously and spontaneously aborted after discontinuation of estrogen replacement. Subsequently she underwent pituitary gonadotrope downregulation and attempted controlled ovarian hyperstimulation without an ovarian response or follicular development. Despite this failure, she conceived spontaneously on two occasions, resulting in a live-born infant and an ongoing pregnancy. CONCLUSION: Cases of hypergonadotropic hypogonadism may not be permanent or irreversible. Interventional regimens may fail to induce ovulation despite the presence of residual oocytes capable of recruitment and fertilization.


Subject(s)
Hodgkin Disease/drug therapy , Ovulation Induction , Pregnancy Outcome , Primary Ovarian Insufficiency/drug therapy , Adult , Drug Therapy, Combination , Estrogen Replacement Therapy , Female , Humans , Pregnancy , Primary Ovarian Insufficiency/chemically induced , Treatment Failure
17.
Fertil Steril ; 65(2): 267-71, 1996 Feb.
Article in English | MEDLINE | ID: mdl-8566246

ABSTRACT

OBJECTIVE: To correlate the severity and extent of intraluminal tubal abnormalities assessed by transfimbrial salpingoscopy with traditional criteria for evaluating distal tubal disease at laparoscopy. DESIGN: Prospective 2-year clinical trial with long-term follow-up. SETTING: University-affiliated tertiary care reproductive medicine and surgery practice. PATIENTS: Fifty-five infertile women with suspected distal tubal disease or unexplained infertility. INTERVENTIONS: Transfimbrial salpingoscopy was performed at the time of laparoscopy and terminal neosalpingostomy when appropriate. Salpingoscopic and laparoscopic findings of 91 fallopian tubes were scored independently. RESULTS: No correlation between laparoscopic and salpingoscopic findings was noted in group I tubes (n = 51) categorized as having minimal disease or no pathology by traditional staging. In contrast, a strong correlation was noted between findings obtained from these two techniques in group II tubes (n = 40) diagnosed as having moderate-to-severe tubal disease at laparoscopy. Intrauterine pregnancy was achieved in 38.9% (7/18) of patients with mean salpingoscopy scores < or = to 12 versus 3.8% (1/26) of patients with mean scores > 12. Life-table analyses of cumulative estimated pregnancy rates were significantly different between the groups. CONCLUSIONS: Fallopian tubes with minimal pathology appreciated at laparoscopy may have more significant intraluminal disease appreciated at salpingoscopy. In contrast, laparoscopic and salpingoscopic findings do correlate well in cases of more severe distal disease. Elevated mean salpingoscopy scores are associated with an extremely poor prognosis for conception.


Subject(s)
Fallopian Tubes , Infertility, Male/diagnosis , Laparoscopy , Adnexal Diseases/complications , Adnexal Diseases/diagnosis , Adult , Female , Follow-Up Studies , Humans , Infertility, Male/etiology , Male , Prospective Studies
18.
Fertil Steril ; 64(6): 1074-80, 1995 Dec.
Article in English | MEDLINE | ID: mdl-7589655

ABSTRACT

OBJECTIVE: To determine short-term pituitary and ovarian hormonal responses to GnRH agonist (GnRH-a) administered during various phases of the menstrual cycle, in the absence of controlled ovarian hyperstimulation (COH), to determine its independent effect on hormonal parameters previously demonstrated to influence assisted reproductive technology cycle outcome. DESIGN: Prospective, randomized, controlled crossover study of five regularly cycling women. The GnRH-a, leuprolide acetate (LA), was administered 1 mg SC daily for 5 days beginning on cycle day 3 (early follicular); 8 days post-LH surge (midluteal); or 13 days post-LH surge (late-luteal). SETTING: Clinical research unit at a tertiary care medical center. MAIN OUTCOME MEASURES: Serum gonadotropins (LH and FSH) and gonadal steroids (E2, estrone [E1], P, A, and T) measured daily during GnRH-a administration begun in the early follicular, midluteal, or late luteal phase of the menstrual cycle. Gonadotropin pulse amplitude and frequency were determined after frequent serum sampling on the 2nd day of GnRH-a administration in each treatment cycle. RESULTS: Serum LH elevations, 4- to 10-fold greater than observed for FSH, did not differ by cycle day of GnRH-a initiation. Initial increases in FSH did not differ by cycle day, however, early follicular initiation resulted in a more pronounced suppression of FSH. Mean LH pulse amplitude and frequency increased to a similar extent in all three groups, however, FSH pulse amplitude and frequency varied significantly by cycle day of GnRH-a initiation. Gonadotropin-releasing hormone agonist initiated in the early follicular phase resulted in significant increases in E2, E1, and P levels compared with both midluteal or late luteal. Increases in serum androgens were significantly greater after early follicular and late luteal initiation as compared with midluteal GnRH-a initiation. CONCLUSIONS: Relative FSH suppression and marked androgen elevations in both late luteal and early follicular groups, which may have potential detrimental effects on oocytes of the developing cohort, suggest little advantage of late luteal or early follicular over midluteal initiation of GnRH-a for COH.


Subject(s)
Follicular Phase/physiology , Hormones/blood , Leuprolide/pharmacology , Luteal Phase/physiology , Adult , Androstenedione/blood , Cross-Over Studies , Estradiol/blood , Estrone/blood , Female , Follicle Stimulating Hormone/blood , Humans , Luteinizing Hormone/blood , Progesterone/blood , Prospective Studies , Testosterone/blood
19.
Fertil Steril ; 64(4): 673-85, 1995 Oct.
Article in English | MEDLINE | ID: mdl-7672133

ABSTRACT

OBJECTIVE: To assess the efficacy of various steroidal and nonsteroidal add-back regimes in ameliorating hypoestrogenic side effects of long-term GnRH agonist (GnRH-a) therapy in gynecologic patients. DESIGN: English language literature review. PATIENTS: Gynecologic patients administered GnRH-a as therapy for ovarian hyperandrogenism, premenstrual syndrome, dysfunctional uterine bleeding, uterine leiomyomata, and symptomatic endometriosis. INTERVENTIONS: Steroidal and nonsteroidal add-back regimes including estrogens with progestins, progestins alone, and progestins with organic bisphosphonates in combination with various GnRH-a for > or = 6 months of therapy. MAIN OUTCOME MEASURES: Vasomotor symptoms, bone density changes, lipid profiles, alterations in presenting symptoms, and disease state. RESULTS: Estrogens in combination with progestins were efficacious as add-back in the management of ovarian hyperandrogenic states, dysfunctional uterine bleeding, premenstrual syndrome, and leiomyomata. Medroxyprogesterone acetate alone is ineffective as add-back for treatment of endometriosis or leiomyomata. Norethindrone is effective as add-back in the management of endometriosis but not leiomyomata, although high doses alter lipid profiles in an undesirable fashion. Organic bisphosphonates show great promise in preserving bone density without other untoward effects. CONCLUSIONS: No single add-back regime is appropriate for all gynecologic indications for GnRH-a. Ideal protocols preserve the efficacy of agonists while suppressing associated vasomotor symptoms and bone density loss.


Subject(s)
Diphosphonates/administration & dosage , Estrogens/administration & dosage , Genital Diseases, Female/drug therapy , Gonadotropin-Releasing Hormone/agonists , Progestins/administration & dosage , Diphosphonates/therapeutic use , Estrogens/therapeutic use , Female , Humans , Progestins/therapeutic use
20.
Fertil Steril ; 63(4): 747-55, 1995 Apr.
Article in English | MEDLINE | ID: mdl-7890057

ABSTRACT

OBJECTIVE: To examine the safety and efficacy of combining cyclic sodium etidronate and low-dose norethindrone with a long-acting GnRH agonist (GnRH-a) for prolonged therapy of symptomatic endometriosis. DESIGN: Prospective randomized open label study. SETTING: Tertiary care university-affiliated reproductive medicine program. PATIENTS: Nineteen regularly cycling women with laparoscopically diagnosed symptomatic endometriosis and 18 regularly cycling untreated controls without endometriosis. INTERVENTIONS: All patients received a depot preparation of the GnRH-a leuprolide acetate IM monthly for 48 weeks. Group I patients (n = 10) received supplemental sodium etidronate cycled with calcium carbonate as well as 2.5 mg norethindrone daily. Group II patients (n = 9) received only supplemental 10 mg norethindrone daily. Group III volunteers (n = 18) were untreated and followed for bone density changes. MAIN OUTCOME MEASURES: Disease extent at follow-up laparoscopy; pain, vasomotor, and vaginal symptom scores; bone mineral density (serial dual-energy roentgenogram absorptiometry scans); serum estrogens, lipids, and glucose and insulin response to glucose challenge. RESULTS: Painful symptoms and extent of endometriosis were reduced in both treatment groups. Despite maintenance of a chronically hypoestrogenic state for 48 weeks, no changes in bone density over time or in comparison to group III untreated controls were noted. Similarly, no evidence of significant vasomotor symptoms were reported in either treatment group. However, adverse changes over time in circulating low-density lipoprotein (LDL) cholesterol and apolipoprotein A1 levels as well as the ratio of high-density lipoprotein to LDL were noted only in group II. CONCLUSIONS: The combination of cyclic sodium etidronate and low-dose norethindrone with a long-acting GnRH-a served to safely prolong medical therapy of symptomatic endometriosis. Clinical efficacy was preserved while prophylaxis against significant hypoestrogenic side effects was achieved.


Subject(s)
Endometriosis/drug therapy , Etidronic Acid/administration & dosage , Gonadotropin-Releasing Hormone/agonists , Leuprolide/therapeutic use , Norethindrone/administration & dosage , Adult , Bone Density , Delayed-Action Preparations , Dose-Response Relationship, Drug , Drug Administration Schedule , Endometriosis/pathology , Endometriosis/physiopathology , Estradiol/blood , Etidronic Acid/therapeutic use , Female , Humans , Lipids/blood , Norethindrone/therapeutic use , Prospective Studies , Time Factors , Vasomotor System/physiopathology , Weight Gain
SELECTION OF CITATIONS
SEARCH DETAIL
...