Ileal endometriosis: radiographic findings in five cases.

PURPOSE: To determine the radiographic findings in five patients with ileal endometriosis. MATERIALS AND METHODS: A search of radiology files revealed five patients with surgically proved endometriotic implants in the ileum at enteroclysis (three patients), at small-bowel follow-through (one patient), and at double-contrast barium enema study (one patient). The radiographic findings were reviewed retrospectively. Clinical, surgical, and histopathologic findings were also reviewed. RESULTS: All five patients were nulliparous women (mean age, 34.4 years; age range, 28-41 years). Four patients presented with abdominal and/or pelvic pain, but only one of these four had cyclic pain that coincided with menstruation. Barium studies revealed endometriotic implants in the terminal ileum within 10 cm of the ileocecal valve in four patients and in the mid-ileum in one. The radiographic findings consisted of extrinsic mass effect with variable spiculation and tethering of folds in two patients, annular lesions with spiculated folds and abrupt or tapered borders in two, and a plaque-like lesion in one. In four patients who underwent double-contrast barium enema studies, associated endometriotic implants were found in the rectosigmoid colon. CONCLUSION: Ileal endometriosis usually involves the terminal ileum within 10 cm of the ileocecal valve and manifests as a spectrum of findings on barium studies. Ileal endometriosis should therefore be considered when these findings are present in young, nulliparous women with abdominal or pelvic pain.

Uterine leiomyomas: histopathologic features, MR imaging findings, differential diagnosis, and treatment.

Leiomyomas are the most common uterine neoplasm and are composed of smooth muscle with varying amounts of fibrous connective tissue. As leiomyomas enlarge, they may outgrow their blood supply, resulting in various types of degeneration: hyaline or myxoid degeneration, calcification, cystic degeneration, and red degeneration. Leiomyomas are classified as submucosal, intramural, or subserosal; the latter may become pedunculated and simulate ovarian neoplasms. Although most leiomyomas are asymptomatic, patients may present with abnormal uterine bleeding, pressure on adjacent organs, pain, infertility, or a palpable abdominalpelvic mass. Magnetic resonance (MR) imaging is the most accurate imaging technique for detection and localization of leiomyomas. On T2-weighted images, nondegenerated leiomyomas appear as well-circumscribed masses of decreased signal intensity; however, cellular leiomyomas can have relatively higher signal intensity on T2-weighted images and demonstrate enhancement on contrast material-enhanced images. Degenerated leiomyomas have variable appearances on T2-weighted images and contrast-enhanced images. The differential diagnosis of leiomyomas includes adenomyosis, solid adnexal mass, focal myometrial contraction, and uterine leiomyosarcoma. For patients with symptoms, medical or surgical treatment may be indicated. MR imaging also has a role in treatment of leiomyomas by assisting in surgical planning and monitoring the response to medical therapy.

Analysis of the human zona pellucida during culture: correlation with diagnosis and the preovulatory hormonal environment.

PURPOSE: The objective of this study was to analyze sequentially the human zona pellucida changes in an in vitro fertilization program as it relates to several variables. METHODS: The zona pellucida thickness was measured daily in zygotes and cleavage-stage embryos on a Nikon inverted microscope equipped with Hoffman modulation contrast optics, using an ocular micrometer. A total of 512 embryos from 96 patients was evaluated. RESULTS: There was a highly significant direct correlation between zona thickness and preovulatory estradiol and basal day 3 FSH levels (P < 0.02 and P < 0.0006, respectively). This relationship showed a rapid reversal following 48 hr of culture; embryos from patients with the highest FSH levels had thinner zonae prior to transfer (P < 0.0007). The zonae from patients with unexplained infertility were thicker (19.4 +/- 2.7 microns) than those from patients with endometriosis (17.7 +/- 2.2 microns), tubal (17.5 +/- 2.4 microns), or male-factor infertility (16.4 +/- 2.7 microns) (P < 0.0001) on the first day of culture. CONCLUSIONS: We hypothesize that the thickness of the human zona pellucida is influenced by the preovulatory hormonal environment and diagnosis. These factors should be considered as part of the embryo quality evaluation prior to transfer or when assessing the possibility of using assisted hatching. More studies are needed to understand the factors regulating the thickness of the human zona pellucida.

Sequential analysis of zona thickness during in vitro culture of human zygotes: correlation with embryo quality, age, and implantation.

Zona pellucida thickness was measured daily in zygotes and cleavage stage embryos. Measurements were performed on a Nikon inverted microscope equipped with Hoffman modulation optics, using an ocular micrometer. Zona thickness of each zygote/embryo was measured four times, the zygote/embryo was then "rolled over," and four more measurements were repeated for a total of eight. The zygotes/embryos were photographed daily and the measurements repeated on the prints. Subsequently, the mean zona thickness for each stage was calculated. A total of 81 patients (mean age 33.8 +/- 4.2) participated in the study. A total of 427 embryos were evaluated. Categorical data differences between groups were evaluated by ANOVA and multiple linear regression. For nominal data, the Kruskal-Wallis test was applied; when P < 0.05 the differences were considered to be significant. We found that the average zona thickness on day 1 of in vitro culture was 17.7 +/- 0.14 microns; 16.3 +/- 0.14 microns on day 2 and 14.9 +/- 0.14 microns on day 3 (P < .0001). When the zona thickness was analyzed in relation to the number of blastomeres on day 3 of culture, there was a highly significant correlation with blastomere number (P < .0001). Similarly, there was a highly significant correlation with embryo grade (P < .005) and fragmentation (P < .001). The data were also analyzed for embryos transferred that resulted in a successful pregnancy, revealing that embryos in a pregnancy cycle had significantly thinner zonae pellucidae (P < .0001), when compared to embryos that were not transferred or from nonconceptual cycles. The average zona thickness also decreased with age, and was most apparent after 35 years. Changes in zona thickness correlated with the number of blastomeres, grade, fragmentation, age and were more evident in embryos transferred from cycles resulting in successful pregnancies. Therefore, zona pellucida measurements should be included in the overall assessment of embryo quality, since this information may be useful in the selection of optimal embryos for transfer.

Markedly elevated cytokines in pleural effusion during the ovarian hyperstimulation syndrome: transudate or ascites?

OBJECTIVE: To study levels of proinflammatory cytokines in pleural fluid during the severe ovarian hyperstimulation syndrome (OHSS). DESIGN: Case report. SETTING: Tertiary academic medical center. PATIENT(S): A 35-year-old female with a 6-year history of unexplained infertility on menotropin therapy and 28 healthy normal controls. INTERVENTION(S): Thoracentesis for severe pleural effusion and venipunctures. MAIN OUTCOME MEASURE(S): Interleukin-1 beta (IL-beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) levels were measured by ELISA and compared between pleural effusion and serum from normal controls. RESULT(S): Pleural effusion IL-1 beta and IL-6 levels were higher than serum. Interleukin-6 levels were elevated particularly in pleural effusion (1,961.89 pg/mL) compared with serum (3.9 +/- 0.41 pg/mL). CONCLUSION(S): Our results confirm the high cytokine levels observed in OHSS. Cytokines have been implicated in capillary permeability, extravasation of fluid, oliguria, and shock. We have postulated that these mediators are released from the corpora lutea into the peritoneum and systemic circulation. Alternatively, the presence of high cytokine levels in pleural fluid maybe the result of diaphragmatic defects, which allow for the migration of ascites into the pleural space.

Uterine arteriovenous malformation in a patient with recurrent pregnancy loss and a bicornuate uterus. A case report.

BACKGROUND: Arteriovenous malformations (AVM) of the uterus are a rare but potential cause of recurrent pregnancy loss. Only four cases of uterine AVM have resulted in a live birth after conservative management. There is no previous report in which a combination of a müllerian anomaly and an AVM existed concomitantly. CASE: A 33-year-old woman with a history of recurrent pregnancy loss was found to have a coexistent uterine AVM and a bicornuate uterus. The patient underwent arterial embolization and Strassman metroplasty and subsequently had a term pregnancy with a live birth. CONCLUSION: Management of uterine AVM should be individualized, taking into account the patient's desire for future fertility and the stability of her health at presentation.

Can the immunobead assay for detecting sperm antibodies in fresh samples be reproduced in cryopreserved/thawed human spermatozoa?

PROBLEM: To evaluate the reproducibility of the Immunobead Assay (IBA) on sperm samples before and after cryopreservation. METHOD: Sperm samples (fresh and post-thaw) from known antibody negative donors (N = 20) were evaluated for percent immunobead binding by IBA following incubation with known antibody-positive serum. RESULTS: In both fresh and thawed negative samples, the mean sperm head binding was 0.5% +/- 0.5, the mean sperm tail binding was 2.0% +/- 2.0 and the mean sperm head-tail binding was 3.0% +/- 2.0 for IgG, IgA and IgM type antibodies, respectively. The same samples exposed to positive sera showed 40.0% +/- 10.0 mean head binding, 7.0% +/- 8.0 mean tail binding and 47.0% +/- 11.0 mean head-tail binding. CONCLUSIONS: IBA is highly reproducible for detecting sperm antibodies in both fresh and cryopreserved/thawed samples of human spermatozoa.

Effect of follicular size on oocyte retrieval, fertilization, cleavage, and embryo quality in in vitro fertilization cycles: a 6-year data collection.

OBJECTIVE: To determine the effect of follicular size, including the size of the leading follicle, on oocyte retrieval, fertilization, cleavage, and embryo quality in IVF cycles based on a large data collection. DESIGN: Retrospective analysis of 1,109 IVF cycles between 1987 and 1993 at the Hospital of the University of Pennsylvania including 606 patients ranging in age from 23 to 49 years. RESULTS: Follicles with a volume < or = 1 mL show a significantly lower oocyte recovery rate than follicles with a volume of > 1 mL. The highest recovery rate (83.5%) was found in follicles with a volume of 3 to 4 mL. Above a follicular volume of 7 mL, the oocyte recovery drops below that observed for follicles between 1 and 7 mL. Fertilization and cleavage rates were also higher in oocytes obtained from follicles > 1 mL compared with follicles < or = 1 mL. Although fertilization rates were fairly stable above volumes of 1 mL, cleavage rates continued to rise to a peak percentage of 92% with volumes between 6 and 7 mL. Leading follicle size did not have an effect on fertilization and cleavage rates of cohort oocytes. Embryo quality was not influenced significantly by follicular volume. CONCLUSION: Based on this evaluation of a large number of follicles, follicular size is a useful indicator of oocyte recovery, fertilization, and cleavage in IVF cycles. For optimal results, the follicular fluid volume in gonadotropin- and hCG-stimulated cycles should be > 1 mL, which corresponds to a follicle diameter of > 12 mm, and not larger than 7 mL (24 mm). For timing of hCG administration, the number of adequate size follicles appears to be more important than the size of the leading follicle(s).

Perioperative complications arising after transvaginal oocyte retrieval.

OBJECTIVE: To determine the incidence of perioperative morbidity in patients undergoing transvaginal oocyte retrieval and to identify those patients at greatest risk for complications. METHODS: A retrospective analysis was performed on 674 patients of reproductive age who underwent transvaginal retrieval of oocytes for assisted reproduction technologies during a 3-year period. All procedures were performed by surgeons with extensive experience with transvaginal retrieval. Patients were entered into the program with a primary diagnosis of unexplained infertility (16%), endometriosis (32%), pelvic adhesions and/or tubal occlusion (38%), or infertility from male or immunologic factors (14%). RESULTS: Of the 674 patients studied, ten (1.5%) required hospital admission because of perioperative complications. Nine of these patients needed intravenous antibiotics and one required admission and observation for an expanding broad-ligament hematoma. Six of nine women admitted for antibiotic therapy had a history of extensive pelvic adhesions with or without a history of salpingitis. Five of nine patients had a history of salpingitis. In addition, two patients experienced impressive vaginal arterial bleeding during the procedure. CONCLUSION: This study suggests that transvaginal retrieval may not be as innocuous as is often expressed and that the primary factor predisposing to perioperative morbidity is a history of previous pelvic inflammatory disease and/or adnexal adhesions.

Perceptions of infertility and treatment stress in females as compared with males entering in vitro fertilization treatment.

OBJECTIVE: To determine gender similarities and differences in perceptions of infertility and anticipated treatment stress in couples enrolling for in vitro fertilization (IVF) treatment. DESIGN: Both partners were evaluated at enrollment of IVF treatment. The evaluation was part of the screening procedure. SETTING: The Department of Obstetrics and Gynecology at a teaching hospital. PATIENTS, PARTICIPANTS: Two hundred consecutive couples who entered an IVF treatment program. MAIN OUTCOME MEASURES: Self-report questionnaire included items on the duration of infertility, degree of social support, effect of infertility on sexual relationship, expected likelihood of achieving pregnancy, anticipation of stress during treatment, and a self-rating scale of emotional reactions to infertility. RESULTS: The women anticipated more stress in IVF treatment but also rated greater degree of social support than the men. Both partners overestimated their chances of a successful treatment outcome. Factor analysis of the Infertility Scale produced three factors that were similar for both sexes. The first factor represented the desire to have a child as a major focus of life with inadequacy of the male role, social functioning and work efficiency, and pressure to have a child following. CONCLUSIONS: Women reported more stress, but the factors affecting stress of infertility were very similar for both partners. The intense focus on having a child was the predominant factor in anticipated stress of IVF treatment for both males and females.

Perinatal outcome of singleton pregnancies conceived by in vitro fertilization: a controlled study.

To determine whether conception by in vitro fertilization and embryo transfer (IVF) predisposes to perinatal complications, the obstetric records of 54 women delivered of singleton pregnancies after conception by IVF were examined. Control women were matched for age, parity, race, year of delivery, diethylstilbestrol exposure and medical problems; another group of women who conceived after infertility treatment was matched in similar fashion. IVF patients showed a longer first stage of labor than previously infertile women, experienced a greater intrapartum blood loss than control or previously infertile women, and showed a trend toward a higher cesarean delivery rate than control women. The differences noted probably do not arise from the physiology of IVF, and although some differences are statistically significant, they are of minimal clinical significance. Singleton pregnancies arising after IVF should not be considered as high risk in the absence of other predisposing factors.

Comparison of different regimens of a gonadotropin-releasing hormone analog during ovarian stimulation for in vitro fertilization.

Three treatment protocols were used in 156 in vitro fertilization cycles. Leuprolide acetate was begun on day 1 of the cycle in one group (n = 20), on day 3 in another (n = 48), and the third control group (n = 88) did not receive the gonadotropin-releasing hormone analog. Human menopausal gonadotropin was initiated on day 3 in all groups. Peak estradiol (E2) levels and the mean numbers of mature oocytes and embryos transferred per cycle were significantly greater in the day 3 group than in either the day 1 or control groups. Patients who received the day 3 protocol had significantly fewer cancelled cycles. A decline in E2 was observed on the third day of analog administration in certain patients, particularly those on the day 1 protocol. Follicle-stimulating hormone and luteinizing hormone (LH) levels increased two- to fivefold 24 hours after initiation of the analog. Thereafter the gonadotropin levels fell, but nevertheless remained above those of controls for most of the cycle. Hence, it appears that enhanced follicular growth attributed to the early transient rises in gonadotropins can be coupled to a suppression of endogenous LH surges in leuprolide-treated women. These beneficial effects seem to be more likely to occur if leuprolide is initiated on cycle day 3 rather than day 1.

Repetitive ovarian response to gonadotropin stimulation in an in vitro fertilization program.

The temporal changes of estradiol levels in 19 women undergoing ovulation induction for in vitro fertilization (IVF) and embryo replacement were described by a mathematical model. The model was analyzed for differences between treatment cycles of an individual woman and between cycles of different women. This model was also used to evaluate the results of IVF treatment. The variation between cycles within individuals was found to be less than that between different women. The parameters that describe this model were found to correlate with follicular growth but not with number of oocytes retrieved, fertilized or cleaved.

An increased initial follicle-stimulating hormone/luteinizing hormone ratio does not affect ovarian responses and the outcomes of in vitro fertilization.

The tenet that a combination of human follicle-stimulating hormone (hFSH)/human menopausal gonadotropin (hMG) improves follicular recruitment was assessed by randomly treating ovulatory women either with hFSH/hMG on days 3 and 4 of the cycle followed by two ampules of hMG daily or with a constant daily dose of 2 ampules of hMG. Estradiol (E2) levels on the day of human chorionic gonadotropin (hCG) and the mean number of mature, immature and atretic oocytes per cycle did not differ between the two groups. Likewise, fertilization, cleavage, and pregnancy rates were similar for the two treatments. When daily hormone levels were compared in 11 patients during two successive treatment cycles with both stimulation protocols, the temporal pattern of FSH accumulation was repeated in both cycles, but FSH levels were significantly higher when patients received hFSH/hMG. Nevertheless, during both cycles, E2 reached similar peak levels and the mean number of follicles per cycle on the day of hCG administration was not different. We conclude that routine use of hFSH/hMG does not improve the success of an in vitro fertilization (IVF) program and that higher FSH levels do not change the individuality of ovarian response in the same woman.

Ovarian response to human menopausal gonadotropin following suppression with oral contraceptives.

The main conclusion of this study is that a profound suppression of the pituitary and ovary can be associated with an inadequate response which may require a longer or different regimen of stimulation to achieve the desired outcome for IVF. We suggest that a pretreatment determination of E2 and gonadotropins can be of value to predict the nature of ovarian response in women with suppressed pituitary-ovarian function.

PIP: A profound suppression of the pituitary and the ovary is connected to an inadequate response to gonadotropin therapy. The therapy, used to produce multiple follicular development for in vitro fertilization (IVF), can cause a variety of responses including: premature luteinization, inadequate amount of preovulatory follicles and an asynchrony of follicular maturation. The aforementioned responses are related to lowered IVF success. IVF patients who received oral contraceptives as part of treatment had undesirable responses to human menopausal gonadotropin when the contraceptives were administered for only a short period. It is suggested that a different regimen be pursued to achieve adequate responses. A pretreatment determination of E and gonadotropins is a viable method of predicting ovarian response among women who have suppressed pituitary-ovarian function. It is further concluded that a favorable response to hMG was not found in IVF patients when treatments of oral contraceptives are administered for a short period.

Follicular aspiration and in vitro fertilization associated with pelvic reconstructive surgery.

Between August 1982 and May 1987, 103 patients underwent in vitro fertilization-embryo transfer (IVF-ET) in association with pelvic reconstructive surgery for infertility. Follicular stimulation was induced with clomiphene citrate and laparotomy scheduled day 12 to 15 of the menstrual cycle. Ultrasound measurements of follicular diameter and number of follicles were obtained on the day of human chorionic gonadotropin (hCG) administration, and laparotomy and ovum retrieval performed 36 hours later. Embryo transfer was performed 48 to 72 hours after insemination. Patients were treated postoperatively with intramuscular progesterone. In addition to evaluating the overall pregnancy rate, the outcome of patients having one or more follicles greater than or equal to 1.4 cm in mean diameter (group A) were compared to those in group B (no follicles greater than or equal to 1.4 cm in diameter). The number of oocytes obtained and the fertilization rate and polyspermic fertilization rate were not significantly different between groups; 10.1% of patients in group A conceived but no patient conceived in group B, yielding an overall pregnancy rate of 8.7%. These data suggest that physicians having IVF-ET at their disposal offer patients IVF during pelvic reconstructive surgery.

Incidence of abortion in pregnancies after in vitro fertilization and embryo transfer.

Our purpose was to assess factors that are associated with an increased rate of spontaneous abortion in pregnancies initiated by in vitro fertilization. Pregnancies were diagnosed by measurement of serum human chorionic gonadotropin (hCG) 15 days after embryo transfer. Of the 64 women who conceived, 47 delivered term infants, one patient delivered a stillborn at 22 weeks, 14 aborted in the first trimester, and two had pregnancies that implanted in the tube. Abortion rates were similar for women treated with human menopausal gonadotropin (24%; 12 of 54) and those who received clomiphene citrate (12.5%; one of eight). Two patients conceived after treatment with a combination of clomiphene citrate and human menopausal gonadotropin, neither of whom aborted. In 54 patients treated with human menopausal gonadotropin, there were no significant differences in mean maternal age, number of years of infertility before the pregnancy, history of previous pregnancies, amount of human menopausal gonadotropin used to induce ovulation, serum estradiol levels on the day of hCG administration, mean number of follicles, and the mean number of transferred embryos between the group who delivered and the group who aborted. We conclude that none of these factors are associated with increased tendency for fetal loss in our in vitro fertilization program. Beta-hCG levels on day 15 after embryo transfer were significantly lower in the group who aborted than in the group who delivered, and may be predictive of implantation failure.

Emotional and psychosocial factors in follow-up of women after IVF-ET treatment. A pilot investigation.

One hundred and fifty-six women who enrolled for treatment in an in vitro fertilization (IVF-ET) program were interviewed, 15 months (mean interval) after the last program contact. Perceptions of treatment stress, decisions about further treatment and the extent of resolution of the infertility crisis were investigated. Standard self-report instruments were used to assess emotional status, self-esteem and marital adjustment. The results showed that only about half the couples who did not achieve pregnancy had decided to terminate treatment. Resolution of infertility was significantly correlated with coping with infertility and with the decision to abandon treatment. Although most patients described treatment as extremely stressful, this did not itself result in emotional distress or dysfunction following treatment, and psychiatric syndromes were infrequent. A deeper understanding of the interactions of these identified factors would help all couples who confront unwanted infertility.