Full term delivery following cryopreservation of human embryos for 7. 5 years.

Successful pregnancy in a 44 year old woman is described following the transfer of embryos which were cryopreserved for 7.5 years. The embryos were obtained during a gamete intra-Fallopian transfer (GIFT) procedure in 1989. To our knowledge this is one of the longest published periods of cryopreservation of embryos which has resulted in a healthy baby. This report illustrates the previously presumed viability and normality of human embryos undergoing long-term cryopreservation. Additionally, it emphasizes the importance for advanced reproductive technique programmes and patients to review and update their embryo status.

A cohort study comparing laparoscopic-assisted vaginal hysterectomy and extrafascial hysterectomy.

STUDY OBJECTIVE: To compare extrafascial hysterectomy (TAH) and laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Consecutive women scheduled for hysterectomy, who entered one group or the other based on personal preference. SETTING: A university-affiliated women's hospital. PATIENTS: Thirty-seven women with benign gynecologic pathology. INTERVENTIONS: Eighteen underwent TAH and 19 had LAVH. All were followed for 6 months postoperatively. MEASUREMENTS AND MAIN RESULTS: The duration of LAVH was significantly longer than that of TAH; estimated blood loss was significantly higher for TAH; and the duration of use of narcotic analgesics, length of hospital stay, and length of time to resumption of routine working activity were significantly shorter after LAVH. No difference was found in the two groups with respect to Q-Tip test preoperatively and 6 months after surgery. CONCLUSIONS: We believe LAVH is a valid and safe alternative to TAH in selected patients. The two procedures do not alter the mobility of the bladder neck on short-term follow-up. Additional prospective studies are necessary to confirm our data.

The multicentre transcervical balloon tuboplasty study: conclusions and comparison to alternative technologies.

Transvaginal tubal catheterization procedures have been suggested as an alternative to microsurgery and in-vitro fertilization (IVF) in the treatment of women with proximal tubal occlusion. A transcervical balloon tuboplasty (TBT) catheter was specifically developed and tested in a prospective multicentre trial. A total of 151 women with confirmed bilateral or unilateral tubal occlusion were studied. The primary study population included 106 women who, after exclusion of patients for protocol violations, represented those females who were treated for complete tubal occlusion with TBT. TBT is an ambulatory, minimally invasive catheter procedure, performed under paracervical block or mild sedation, which utilizes a co-axial balloon catheter under fluoroscopic guidance. Re-canalization, pregnancy and reocclusion rates following the procedure were documented. A total of 28 patients demonstrating uni- or bilateral tubal patency after either hysterosalpingography and/or selective salpingography represented the control population. TBT established tubal patency of at least one Fallopian tube in 95/106 patients (90%) and in 167/205 obstructed oviducts (82%). Clinical pregnancies occurred in 37/106 females (35%), with a life table adjusted rate of 37%. Patients without distal disease had significantly higher pregnancy rates than those with bipolar tubal disease (49% versus 12%, life table adjusted rate; P = 0.0002) but pregnancy rates were independent of underlying aetiology for tubal disease. Pregnancy rates in control patients who did not reach TBT because of tubal patency after hysterosalpingography and/or selective salpingography were significantly lower than in those successful treated with TBT (P = 0.027), and occurred only for four cycles after hysterosalpingography and with approximately a 1 year delay after selective salpingography.(ABSTRACT TRUNCATED AT 250 WORDS)

Reproductive outcome after linear salpingostomy for ectopic gestation: a prospective 3-year follow-up.

The long-term reproductive outcome in patients treated with linear salpingostomy for ectopic gestation was similarly impacted by laparoscopy and laparotomy, further establishing laparoscopic salpingostomy as the preferable treatment modality. Patients with two consecutive ectopic gestations may not benefit from the conservative surgical approach because it may predispose them to a high risk of recurrence.

Effect of bromocriptine on sperm function in vitro and in vivo.

Vaginal bromocriptine is an effective method for the treatment of hyperprolactinemia, but it is unknown whether bromocriptine applied vaginally can interfere with sperm function. Thus, we sought to determine the effects in vitro and in vivo on sperm directly exposed to bromocriptine. Ten semen specimens from normal donors were diluted with Ham's F-10 medium and incubated with 0, 0.01, 0.1, and 1.0 mmol/L bromocriptine solution or diluent without bromocriptine. Computerized semen analysis revealed a 31% decrease in sperm motility, a 24% decrease in sperm average path velocity, and a 33% decrease in sperm average straight line velocity only using 1.0 mmol/L of bromocriptine (P less than .05). In addition, eight women with hyperprolactinemia and infertility who were receiving vaginal bromocriptine consented to a postcoital test. Five became pregnant and delivered normal infants. Four of the five women who had a postcoital test had six, eight, ten, and ten motile sperm per high-power field and one had one to two motile sperm per high-power field. Because sperm function was preserved enough to result in fertilization and term pregnancy, the clinical importance of the in vitro findings is probably minimal and it can be concluded that vaginal bromocriptine can be used in women with infertility due to hyperprolactinemia.

Ten-year follow-up of patients with secondary amenorrhea and normal prolactin.

A group of 46 patients with secondary amenorrhea without galactorrhea or hyperprolactinemia were studied retrospectively after being clinically categorized into four groups with the use of progesterone-induced uterine bleeding and measurement of serum gonadotropins and prolactin levels. The ability to have regular spontaneous menstrual cycles and to conceive was assessed after a follow-up period of 10 years. Patients who had been classified as having hypothalamic pituitary "failure" (hypoestrogenic amenorrhea) with low levels of circulating estradiol had a greater rate of recovery of spontaneous ovulation and menses when compared with patients who had been classified as having only hypothalamic pituitary dysfunction (euestrogenic amenorrhea). The patients with diagnosis of hyperandrogenic chronic anovulation or polycystic ovary syndrome generally required clomiphene citrate for induction of ovulation and almost all the patients with premature ovarian failure (hypergonadotropic amenorrhea) remained estrogen-deficient and unable to ovulate. Hyperprolactinemia or an identifiable pituitary adenoma has not developed in any of the patients to date.

Transcervical balloon tuboplasty. A multicenter study.

Transcervical balloon tuboplasty represents a noninvasive technique to treat proximal tubal occlusion. In a multicenter study, 77 women with confirmed bilateral proximal tubal occlusion underwent the procedure. In 71 patients (92%), at least one proximally obstructed fallopian tube was recanalized. Concomitant distal bilateral tubal occlusions were diagnosed after successful proximal tubal balloon recanalizations in 13 patients (17%). In the remaining 64 patients, 22 clinical pregnancies (34%) have been confirmed during a median follow-up period of 12 months. Among those, 17 (77%) resulted in normal deliveries and five (23%) resulted in a first-trimester miscarriage. One patient was diagnosed with an ectopic pregnancy. Among 25 patients who had not conceived within 6 months of the procedure, 17 (68%) demonstrated continuing tubal patency on repeated hysterosalpingogram. We conclude that transcervical balloon tuboplasty is a safe outpatient technique that may represent an alternative to in vitro fertilization or microsurgical reanastomosis of fallopian tubes.

Mifepristone (RU 486) failure in an ovarian heterotopic pregnancy.

A patient treated with mifepristone (RU 486), which successfully induced abortion of an intrauterine pregnancy, was discovered to have a heterotopic ovarian pregnancy resistant to this antiprogesterone. The ovarian pregnancy was removed with operative laparoscopy. This case demonstrates for the first time that an ovarian pregnancy may be resistant to treatment with RU 486 at a dose adequate to abort an intrauterine pregnancy.

Biochemical and biophysical indices of follicular development in spontaneous and stimulated ovulatory cycles.

This study was designed to evaluate the correlation between the follicular biophysical and biochemical indicators in spontaneous (N = 11) and stimulated (N = 110) ovulatory cycles. Ovulation was induced with clomiphene citrate in 14 cycles, gonadotropin-releasing hormone (GnRH) in 12 cycles, and human menopausal gonadotropins in 84 cycles. Patients were studied daily, starting on day 10, until sonographic verification of ovulation. Each woman had serum estradiol (E2) and LH measured daily and progesterone measured only 7 days after ovulation. In addition, the ovaries were imaged transvaginally daily and the two largest follicular diameters, volumes, cross-sectional areas, and circumferences were measured in all follicles 10 mm or larger in diameter. Ultrasonographic measurements of follicles from clomiphene-stimulated cycles were significantly larger than those from spontaneous, GnRH-, and human menopausal gonadotropins-stimulated cycles (P less than .05). Serum E2 and progesterone secretion in human menopausal gonadotropins- and clomiphene-stimulated cycles were significantly higher than in spontaneous and GnRH-stimulated cycles (P less than .01). Women treated with human menopausal gonadotropins developed significantly more follicles than with any other treatment (P less than .05). Correlation analysis indicated that biophysical variables alone (follicular diameter, volume, cross-sectional area, or circumference) were good indicators of normal follicular development and predicted the mid-cycle LH surge in spontaneous (r = 0.81, P less than .001), GnRH- (r = 0.78, P less than .001), and clomiphene citrate-stimulated cycles (r = 0.83, P less than .001). However, in human menopausal gonadotropins-stimulated cycles, both serum E2 levels and ultrasonographic evaluation were necessary to decide the best time for hCG administration (r = 0.55, P less than .001).

Reevaluation of the role of culdocentesis in the management of ectopic pregnancy.

Culdocentesis has been used routinely in the evaluation of ectopic pregnancy. To determine whether culdocentesis continues to play an important role, we reviewed the operative findings of 297 women undergoing an operative procedure because of ectopic pregnancy. Culdocentesis was performed before surgery in 252 cases. Of those, 210 (83%) had positive test results and 42 (17%) had negative results. Positive results accurately predicted a ruptured ectopic pregnancy in 50% of cases, whereas negative test results were predictive of an unruptured ectopic pregnancy in 58% of cases. Six patients without an ectopic pregnancy underwent unnecessary laparotomy because of positive culdocentesis test results, whereas 27 patients who were discharged from the emergency room after negative test results were obtained subsequently were found to have ectopic pregnancies. The results of this study imply that culdocentesis is of limited value in a clinical setting in which sensitive and rapid testing and pelvic ultrasonography are used.

Absence of direct effect of beta-endorphin and calcitonin on human sperm motility.

Beta-endorphin and calcitonin are found in the male reproductive tract. To elucidate the role of these hormones in reproduction, we studied their effect on sperm motility in vitro. Eight semen specimens were obtained from healthy donors, washed, and incubated with different concentrations of human beta-endorphin and human calcitonin. After 30 min of incubation, percentage of motile sperm (% motility), mean progressive velocity (MPV), and lateral head displacement (LHD) were assessed by a computerized semen analyzer. There were no significant differences in any of the sperm motility parameters between control and treated sperm. There was also no correlation between the concentration of beta-endorphin or calcitonin and any sperm motility parameters. It would appear that beta-endorphin and calcitonin may not directly affect sperm motility parameters in vitro.

Spontaneously resorbing ectopic pregnancy: preservation of human chorionic gonadotropin bioactivity despite declining steroid hormone levels.

We compared serum hormone profiles of patients with normal intrauterine pregnancies (n = 14), spontaneously resorbing ectopic pregnancies (n = 10), and viable ectopic pregnancies (n = 26). Hormone profiles were evaluated at 5 to 8 weeks' gestational age. Ectopic pregnancies were diagnosed by laparoscopy; intrauterine gestations were confirmed by ultrasonography. Immunoreactive beta-human chorionic gonadotropin, progesterone, estradiol, and 17-hydroxyprogesterone were measured by radioimmunoassay. Bioactive human chorionic gonadotropin was measured by a modified mouse Leydig cell bioassay. Diminished steroid production was noted in ectopic pregnancies; levels in serum of patients with resorbing ectopic pregnancies were lower than values expressed in viable ectopic pregnancies (p less than 0.01). Serum levels of human chorionic gonadotropin bioactivity correlated closely with immunoreactive human chorionic gonadotropin in all three groups (r = 0.81, p less than 0.01). Ratios of bioactive human chorionic gonadotropin to immunoreactive beta-human chorionic gonadotropin were similar (0.93 +/- 0.26 in resorbing ectopic pregnancies, 1.11 +/- 0.16 in viable ectopic pregnancies, and 0.90 +/- 0.10 in intrauterine pregnancies). We conclude that although reduced serum levels of steroids noted in ectopic pregnancy suggest an impairment in corpus luteum activity, diminished steroid production was not attributable to lower human chorionic gonadotropin bioactivity.

Presence of immunoreactive beta-endorphin and calcitonin in human seminal plasma, and their relation to sperm physiology.

Opioid peptides and calcitonin are found in high concentrations in the male reproductive tract. To further elucidate their role in sperm physiology, we studied semen samples from 49 infertile men and 25 men with proven fertility. beta-endorphin and calcitonin were measured in each sample by radioimmunoassay and then were correlated with seminal plasma testosterone (T) and dihydrotestosterone levels as well as sperm count, total motile sperm/milliliter, and percentage of penetrated hamster eggs. The levels of beta-endorphin (308 +/- 22 pg/ml) and calcitonin (331 +/- 32 pg/ml) in seminal plasma were 10 and 20 times higher than levels found in venous plasma (32 +/- 2 and 14.5 +/- 1.2 pg/ml, respectively) (P less than 0.001). There was no difference between the levels of beta-endorphin and calcitonin in seminal plasma of fertile and infertile men. However, seminal plasma T was significantly higher in fertile than infertile men (19.4 +/- 2 versus 11.5 +/- 1 ng/dl; P less than 0.05). No correlation could be demonstrated between either beta-endorphin or calcitonin and any of the parameters studied. In conclusion, beta-endorphin and calcitonin are produced locally in the male reproductive tract; however, their role in male reproduction remains to be elucidated.

Role of ultrasound in urinary incontinence evaluation.

Transrectal ultrasound was used to assess anatomic support of the urethrovesical junction (UVJ) in continent and stress incontinent women. UVJ drop on straining of less than 1 cm as assessed by transrectal ultrasound correlated well with good support to the UVJ. Drop of UVJ of more than 1 cm on straining correlated with poor support to bladder neck and stress urinary incontinence. The transrectal technique is quick and easy to perform and interpret.

Conservative management of ectopic gestation.

The management of ectopic gestation has become more challenging than ever before. The recent progress in diagnostic modalities, i.e., ultrasound and sensitive beta-hCG assays, has enabled early detection of ectopic gestation and a change in treatment goals. The traditional catastrophic presentation of a ruptured ectopic gestation and hemoperitoneum no longer is common. Today this condition is typically diagnosed before a rupture occurs, while the patient is only minimally symptomatic. Accordingly, treatment has shifted from an immediate life-saving intervention, into conservative methods of management, directed at preserving fertility and reducing morbidity. As experience is being gained rapidly in the various conservative treatment methods, their respective merits can be evaluated. Laparoscopic linear salpingostomy is the treatment of choice for small, unruptured, isthmic or ampullary gestations. Laparoscopic segmental resection is most suitable for ruptured tubal gestations. These procedures should be performed via laparotomy only if the patient is hemodynamically unstable. In selected cases, nonsurgical treatment methods, i.e., expectant management or methotrexate, may be considered. Serial serum beta-hCG measurements following a conservative treatment is mandatory to rule out persistence of trophoblastic tissue. Further prospective randomized studies are needed, to compare different conservative treatment methods in regard to their respective safety, reproductive outcome, and economic feasibility.

Predictive value of a single serum pregnancy associated plasma protein-A or progesterone in the diagnosis of abnormal pregnancy.

The value of a single measurement of serum levels of pregnancy associated plasma protein-A (PAPP-A) or progesterone (P4) in predicting abnormal gestations was assessed in 65 patients. P4 was greater than 20 ng/ml (mean +/- SEM 61.2 +/- 6.6 ng/ml, range 22.4-100.0 ng/ml) in all patients with normal intrauterine pregnancies (n = 21), and greater than 20 ng/ml (mean +/- SEM 8.5 +/- 3.9 ng/ml, range 0.1-68.8 ng/ml) in 16 out of 17 patients destined to abort spontaneously. Patients with ectopic gestations (n = 27) exhibited P4 values less than 20 ng/ml (mean +/- SEM 6.4 +/- 1.2 ng/ml, range 0.1-17.2 ng/ml). P4 levels in normal pregnancies were significantly higher (P = 0.001) than those of abnormal gestations. PAPP-A levels ranged from undetectable to 6448 mIU/ml in normal gestations. In 42 out of 44 abnormal pregnancies levels of PAPP-A were less than 100 mIU/ml, as were 7 out of 14 normal intrauterine pregnancies of less than 7 weeks gestational age. No ectopic demonstrated a value of PAPP-A greater than 50 mIU/ml and in 23 out of 27 ectopics, levels were undetectable. However, PAPP-A was less specific than P4 in correctly discriminating normal from abnormal gestations and exhibited lower positive and negative predictive values. It can be concluded therefore that a single PAPP-A measurement is of limited value in discerning normal from abnormal pregnancy prior to 8 weeks gestation. However, a single serum P4 is highly accurate and specific in detecting abnormal pregnancy, regardless of gestational age.

Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy.

This study was designed to compare prospectively the parameters of morbidity, cost, length of hospital stay, and fertility outcome after linear salpingostomy by laparoscopy versus laparotomy. Entry criteria included stable vital signs, hematocrit greater than 30%, age over 18 years, and desire for future fertility. All patients underwent diagnostic laparoscopy. Sixty patients with unruptured ectopic gestations of 5 cm or smaller were randomized to either laparoscopy (N = 30) or laparotomy (N = 30). Postoperative follow-up included serial measurements of serum beta-hCG titers at 3-day intervals and hysterosalpingography at 12 weeks. The laparoscopy and laparotomy groups were similar in age, height, weight, gravidity, gestational age, hematocrit, ectopic pregnancy size, and preoperative beta-hCG levels. The estimated blood loss was significantly (P less than .001) lower in patients undergoing laparoscopy, and was not affected by vasopressin injection. Two patients in the laparoscopy group required laparotomy for hemostasis, and two patients undergoing laparotomy had wound infection. One patient in each group had persistent trophoblastic activity. Baseline serum beta-hCG levels and the rate and magnitude of postoperative beta-hCG decline were similar in both groups. The length of hospital stay was significantly (P less than .001) shorter after laparoscopic salpingostomy (1.4 +/- 0.1 days) than after laparotomy (3.3 +/- 0.2 days). Postoperative hysterosalpingography showed patency of the involved tube in 16 of 20 (80%) and 17 of 19 (89%) of patients in the laparoscopy and laparotomy groups, respectively. Pregnancy rates were ten of 18 (56%) and 11 of 19 (58%) in these groups, respectively, and all pregnancies were conceived within 6 months of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Effectiveness of vaginal bromocriptine in treating women with hyperprolactinemia.

Treatment of hyperprolactinemia with oral bromocriptine has been associated with a high incidence of side effects. The authors recently demonstrated that, in normal women, the vaginal route of administration was an effective and safe alternative to oral bromocriptine. To evaluate the effectiveness of vaginal bromocriptine in treating women with hyperprolactinemia, the authors treated 15 hyperprolactinemic women with daily vaginal administration of 2.5 mg tablets of bromocriptine. Serum prolactin (PRL) levels and vital signs were measured daily for 6 days, then weekly for 4 weeks. Gastrointestinal side effects were limited to a single episode of mild nausea, and two cases of transient constipation. In all patients there was a dramatic initial reduction in PRL in response to a single 2.5 mg dose of bromocriptine. In 13 patients PRL levels were maintained within the normal range with daily administration of 2.5 mg, whereas in two patients, PRL levels remained higher than normal despite an increase in bromocriptine dose to 5 mg. These results suggest that short term use of vaginal bromocriptine is a safe and effective method of therapy for hyperprolactinemia.

Serum cancer antigen 125 in ectopic pregnancy.

Serum cancer antigen 125 was measured in subjects with intrauterine pregnancy (n = 44), ectopic pregnancy (n = 76) and in nonpregnant controls (n = 17). Values were appreciably elevated only in ruptured tubal gestations.

Rapid measurement of urinary pregnanediol glucuronide to diagnose ectopic pregnancy.

We investigated the ability of a single, random, urinary pregnanediol-3 alpha-glucuronide level to differentiate early intrauterine from ectopic pregnancy. Thirty-four patients with intrauterine gestations were compared with 60 patients with ectopic pregnancies. Urinary pregnanediol-3 alpha-glucuronide was measured by radioimmunoassay and enzyme immunoassay. Compared with intrauterine gestations, results demonstrate that urinary pregnanediol-3 alpha-glucuronide is significantly depressed in ectopic pregnancies: 24.5 +/- 2.2 versus 4.8 +/- 0.7 micrograms/ml (p = 0.0001). Urinary pregnanediol-3 alpha-glucuronide levels obtained by conventional radioimmunoassay correlated closely with values measured in minutes with enzyme immunoassay (r = 0.95, p = 0.0001), and with serum progesterone (r = 0.74, p = 0.0001). Urinary pregnanediol-3 alpha-glucuronide measured by enzyme immunoassay exhibited predictive values for detecting ectopic gestations comparable with random serum progesterone or serum beta-human chorionic gonadotropin values. We conclude that ectopic gestations demonstrate a reduced level of urinary pregnanediol-3 alpha-glucuronide (55/60 cases) detectable with a rapid enzyme immunoassay, which makes this assay a practical screening test in early pregnancy.