Contribution of diminished ovarian reserve to hypofertility associated with endometriosis.

OBJECTIVE: To determine if ovarian reserve, as measured by day 3 levels of E2 and FSH, was different in patients with endometriosis as compared to controls. STUDY DESIGN: Case-control study of 75 women with laparoscopically staged endometriosis and 75 age-matched controls undergoing in vitro fertilization/embryo transfer for male factor infertility. RESULTS: In women with stage III/IV endometriosis (revised American Fertility Society staging), day 3 E2 and FSH levels were significantly higher than control levels (51.9 pg/mL and 12.6 mIU/mL versus 34.7 pg/mL and 9.7 mIU/mL, P < .03). In contrast, women with stage I/II endometriosis did not differ significantly when compared to controls (36.8 pg/mL and 10.4 mIU/mL versus 34.0 pg/mL and 10.2 mIU/mL). The total group showed significantly higher E2 levels (41.8 pg/mL versus 34.1 pg/mL, P < .03), but no significant differences in FSH levels were observed. CONCLUSION: These data show that women with stage III/IV endometriosis have relatively diminished ovarian reserve, while this situation is not noted in women with stage I/II endometriosis. This observation is consistent with progressive loss of ovarian reserve in women with increasing stages of endometriosis independent of age.

New treatments of hyperandrogenism and hirsutism.

Approximately 5% to 8% of the female population demonstrates some form of hirsutism, the presence of prominent facial and body hair caused by excessive androgen effect. Treatment methods are classified into three categories: (1) hormonal suppression consisting of medical therapy to decrease androgen production, (2) the administration of antiandrogens to block the androgen effect at the hair follicle, and (3) physical methods of hair removal. Most patients require a combination of medical and physical therapy.

The use of propofol, nitrous oxide, or isoflurane does not affect the reproductive success rate following gamete intrafallopian transfer (GIFT): a multicenter pilot trial/survey.

BACKGROUND: Whether anesthetic agents administered during gamete intrafallopian transfer (GIFT) affect reproductive outcome is controversial. This multicenter pilot trial and survey had two purposes: to evaluate the effect of propofol, nitrous oxide, midazolam, and isoflurane on pregnancy outcome after GIFT, and to determine if a larger prospective, randomized study is warranted. METHODS: A written invitation was mailed to all 50 fertility programs in the United States that are members of the Society for Assisted Reproductive Technology and perform more than 30 GIFT procedures per year. They were invited to contribute information from the medical records of women who underwent GIFT during the calendar years 1993 and 1994. They were asked to document whether propofol, nitrous oxide, midazolam, a potent inhaled anesthetic agent was used during the GIFT procedure; if the woman became pregnant; and if she delivered at least one live neonate. RESULTS: Seven medical centers participated and contributed data from 455 women. The clinical pregnancy rate (number of pregnancies/total number of GIFT procedures) and the delivery rate (number of women who delivered at least one live baby/total number of GIFT procedures) were 35% and 32%, respectively. A statistically significant difference could not be found in the clinical pregnancy or delivery rates between those women who received propofol, nitrous oxide, midazolam, or isoflurane during GIFT and those who did not. CONCLUSIONS: No agent-related differences in pregnancy rates were found when propofol, nitrous oxide, isoflurane, or midazolam was used as part of the anesthetic technique for GIFT. Therefore, a more extensive prospective trial does not appear to be warranted.

The need to step up the gonadotropin dosage in the stimulation phase of IVF treatment predicts a poor outcome.

PURPOSE: It is a common practice to increase the gonadotropin dose during ovarian stimulation when the estradiol (E2) rise is found to be inadequate. The prognostic impact of the use of this step-up regimen on the outcome of the affected in vitro fertilization (IVF) cycle is the subject of this study. METHODS: This is a retrospective analysis of IVF cycles in a series of consecutive patients who required an increase in the gonadotropin dosage during the stimulation phase because of inadequate E2 rise. Controls consisted of patients in whom the dose was not increased. After 4 days of stimulation, the gonadotropin dosage was increased if E2 levels failed to rise by 70% every 2 days. Outcome was defined in terms of maximum E2 level, number of follicles at aspiration, number of oocytes obtained, fertility rate, and pregnancy rate and was compared in study and control patients. Pregnancy was defined by sonographic demonstration of cardiovascular activity. RESULTS: One hundred forty-five patients were analyzed. A step-up regimen was used in 35 patients (24.1%). Patients who required the step-up dosing had significantly lower peak E2 levels (1373 vs 1828 pg/ml; P < 0.005), fewer follicles measuring greater than 16 mm (7.2 vs 9.7; P < 0.003), and fewer oocytes recovered (8.3 vs 11.2; P < 0.009). The fertilization rate (67.6 vs 64.2%) was not significantly different. The pregnancy rate (8.5 vs 32.7%; P < 0.004) was significantly lower in the group requiring the step-up regimen. CONCLUSIONS: The utilization of a step-up regimen during an IVF treatment cycle is a predictor of a poor outcome for the specific IVF cycle. As this information is available before retrieval, consideration of cycle cancellation may be appropriate.

Leukocytosis in response to exogenous gonadotrophin stimulation.

Leukocytosis may develop in women undergoing ovulation induction. The production of blood leukocytes and their numbers in circulation are regulated by complex interactions involving endogenous haematopoietic cytokines, such as granulocyte-colony stimulating factor (G-CSF), monocyte-colony stimulating factor (M-CSF), and interleukins. The purpose of this prospective study was to explore the presence of leukocytosis in women who receive urinary menotrophins, and to determine whether haematopoietic cytokines are changed in the stimulation process. Controls were volunteers of the same age range, not taking any medication, who received daily saline injections. Subjects underwent phlebotomy at defined points for determination of complete blood counts, G-CSF, M-CSF, and interleukin-6 concentrations. Baseline white blood cell (WBC) counts were similar in patients and controls. In menotrophin-treated patients the WBC counts rose significantly (4.19 +/- 0.28 to 6.37 +/- 0.71) during the stimulation and peaked in the luteal phase (P = 0.037). In contrast, WBC counts decreased in controls. Other leukocytic lineages were not affected. In treated patients G-CSF concentrations rose significantly (P = 0.028 versus controls), while changes in M-CSF and interleukin-6 were not significant.

Sonographic assessment of endometrial pattern and thickness in patients treated with clomiphene citrate, human menopausal gonadotropins, and intrauterine insemination.

OBJECTIVE: To analyze the endometrium sonographically in patients undergoing controlled ovarian stimulation with clomiphene citrate (CC) in addition to menotropins to determine the significance of endometrial pattern and thickness on pregnancy rate (PR). DESIGN: A prospective study analyzing patients receiving sequential CC and hMG followed by hCG and IUI. Patients who exhibited homogeneous endometrial patterns were compared with those who had trilaminar patterns visualized by transvaginal sonography at the end of the follicular phase. Endometrial thickness was emphasized in this group of patients. SETTING: Tertiary infertility center. PATIENT(S): All patients receiving sequential CC and hMG therapy at a tertiary infertility center. INTERVENTION(S): All patients received individualized dosing of hMG after 5 days of CC. Transvaginal sonography was performed 15 hours before hCG administration. Intrauterine insemination was performed 36 hours after hCG injection. MAIN OUTCOME MEASURE(S): Occurrence of pregnancy as determined by serially rising beta-hCG titers and sonographic confirmation. RESULT(S): During the study period, 223 patients were analyzed. Fifty patients had a homogeneous endometrium, whereas 173 patients had a trilaminar pattern. In the homogeneous group, the PR was 8%, and in the trilaminar group it was 21%. There was no significant difference in age, parity, diagnosis, peak E2 level, and mature follicle number between the two groups. Although homogeneous patterns were associated with thinner endometrium, no difference in PRs could be discerned within the trilaminar group on the basis of endometrial thickness. CONCLUSION(S): In patients receiving sequential CC and hMG ovarian stimulation, a homogeneous endometrial pattern on the day of hCG administration predicts a significantly decreased PR compared with a trilaminar pattern.

Is the endometrial suction curette useful in the detection of chorionic villi during the first trimester?

OBJECTIVE: Early diagnosis of ectopic pregnancy is important for its medical management. Algorithms used for the diagnosis of ectopic pregnancy recommend obtaining a tissue diagnosis to rule out an intrauterine pregnancy when it is clear that a pregnancy is abnormal, but a stage of sonographic visualization has not been attained. The ability of an endometrial suction curette to identify products of conception early in pregnancy has not been documented. The purpose of this study was to determine the efficacy of an endometrial suction curette in detecting products of conception during the first trimester. METHODS: Twenty patients scheduled for termination of pregnancy via D&C agreed to endometrial sampling prior to dilatation of the cervix. All patients had transvaginal sonography which verified the gestational age. The specimen was evaluated microscopically after staining. RESULTS: Chorionic villi were identified in 14 of 20 (70 per cent) specimens as seen with light microscopy. CONCLUSION: An endometrial suction curette identifies chorionic villi from an intrauterine gestation in the first trimester with a sensitivity of 70 per cent. While most patients with an intrauterine gestation can be identified using an endometrial suction curette to obtain trophoblastic tissue, the absence of this tissue does not definitively identify an ectopic pregnancy. Therefore, the routine use of the endometrial biopsy in the algorithms for the diagnosis and treatment of ectopic pregnancy should be approached with caution.

Sonographic assessment of endometrial pattern and thickness in patients treated with human menopausal gonadotropins.

OBJECTIVE: To analyze sonographically the endometrium in patients undergoing controlled ovarian stimulation with menotropins in order to determine the significance of endometrial pattern and thickness on pregnancy rate. DESIGN: This is a prospective, nonrandomized study comparing pregnancy rates in patients with hyperechoic homogeneous patterns with those in patients with isoechoic or hypoechoic trilaminar patterns. SETTING: Tertiary infertility center. PATIENTS: All patients receiving menotropin therapy at a tertiary infertility center. INTERVENTIONS: All patients received individualized dosing of hMG starting on cycle day 3. Transvaginal sonography was performed 15 hours before hCG administration and the endometrium was assessed. MAIN OUTCOME MEASURE: Occurrence of pregnancy as determined by serially rising beta-hCG titers and sonographic confirmation. RESULTS: During the study period, 175 patients were evaluated. Thirty-four (19%) patients had a homogeneous endometrium, whereas 141 (81%) patients had a trilaminar pattern. There was 1 pregnancy (2.9%) among women with a homogeneous endometrial pattern and 33 pregnancies (23%) among those with a trilaminar pattern. No significant differences were found in mean E2 level, follicle numbers, parity, and diagnosis between the two groups. CONCLUSION: In patients receiving menotropins, a homogeneous pattern is a bad prognostic sign, regardless of endometrial thickness.