Reproductive outcome in patients with diminished ovarian reserve.

OBJECTIVE: To compare reproductive outcome between women with normal ovarian reserve and women with abnormal ovarian reserve. DESIGN: Retrospective. SETTING: Tertiary care center. PATIENT(S): Nine thousand eight hundred and two patients who had basal follicle-stimulating hormone (FSH) concentrations measured as part of an infertility evaluation. INTERVENTION(S): Monitoring of early pregnancy. MAIN OUTCOME MEASURE(S): Pregnancy loss rates, live birth rates. RESULT(S): Of 1,034 patients with diminished ovarian reserve (DOR) (FSH > or =14.2 IU/L), 28 (2.7%) conceived. Twenty of these pregnancies (20/28; 71.4%) were lost in the first trimester. Pregnancy loss rates in women with DOR were 57.1% in women <35 years old, 63.5% in women 35-40 years old, and 90.0% in women >40 years old. These rates of pregnancy loss were significantly higher compared to age-matched patients with normal ovarian reserve. CONCLUSIONS(S): Women with DOR have exceedingly high rates of pregnancy loss, regardless of age. Women with diminished ovarian reserve should be counseled that, in addition to a low probability of conception, live birth rates are poor.

Controlled ovarian hyperstimulation does not adversely affect endometrial receptivity in in vitro fertilization cycles.

OBJECTIVE: To determine whether exposure of developing endometrium to supraphysiologic E2 levels during controlled ovarian hyperstimulation (COH) in IVF cycles inhibits endometrial receptivity. DESIGN: Retrospective analysis of IVF-ET and ovum donation data. SETTING: Tertiary-care teaching hospital. PATIENT(S): Four hundred ten patients <33 years of age undergoing IVF-ET and 181 anonymous ovum donors (<33 years of age) and their associated ovum recipients. MAIN OUTCOME MEASURE(S): Implantation, pregnancy, and delivery rates. RESULT(S): Ovarian response to COH (duration of stimulation, peak E2 level, area under the curve for E2 exposure, and number of oocytes retrieved) was similar for IVF-ET patients and ovum donors. Donors were younger than IVF-ET patients (mean age, 27.5 +/- 0.2 years vs. 30.4 +/- 0.1 years). A similar number of embryos with similar number of blastomeres were transferred in IVF-ET patients and ovum recipients. The fragmentation rate at time of transfer differed slightly between groups (5.2 +/- 0.2% vs. 4.3 +/- 0.3%). Implantation, pregnancy, and delivery rates did not differ between IVF-ET patients and recipients of donor oocytes. CONCLUSION(S): Exposure of the developing endometrium to controlled ovarian hyperstimulation during IVF cycles does not inhibit embryo implantation or affect pregnancy and delivery rates.

Basal antral follicle number and mean ovarian diameter predict cycle cancellation and ovarian responsiveness in assisted reproductive technology cycles.

OBJECTIVE: To determine the predictive value and define threshold levels for basal antral follicle number and mean ovarian diameter in patients undergoing ART cycles. DESIGN: Retrospective. SETTING: Tertiary care center. PATIENTS: Two hundred seventy-eight patients who had ovarian measurements performed on cycle day 3 before beginning treatment with gonadotropins. INTERVENTION: Pretreatment ovarian ultrasound measurements. MAIN OUTCOME MEASURE: Number of oocytes retrieved, hormone levels, and cycle outcomes. RESULTS: A direct linear correlation was observed between mean ovarian diameter and basal follicle number. Both measures demonstrated a positive linear correlation with recovered oocytes, basal E(2), and peak E(2). Both demonstrated a negative linear correlation with ampules of gonadotropins administered, days of stimulation, patient age, cycle day 3 FSH, and FSH:LH ratio. An antral follicle count of

Evaluation of basal estradiol levels in assisted reproductive technology cycles.

OBJECTIVE: To determine if basal E(2) screening increases the diagnostic accuracy of basal FSH screening and to determine whether basal E(2) levels correlate with outcome in ART cycles. DESIGN: Retrospective. SETTING: Tertiary care center. PATIENT(S): Two thousand six hundred thirty-four infertility patients. INTERVENTION(S): Cycle outcome was evaluated after grouping patients by basal E(2) levels beginning at <20 pg/mL and extending to >100 pg/mL at 10 pg/mL increments. MAIN OUTCOME MEASURE(S): Retrieved oocytes, pregnancy rate, and cancellation rate. RESULT(S): Cancellation rates were significantly increased in patients with basal E(2) levels of <20 pg/mL or >/=80 pg/mL. Basal E(2) levels neither predicted pregnancy outcome nor correlated with ovarian response in those patients not canceled. CONCLUSION(S): Patients with basal E(2) levels of <20 pg/mL or >/=80 pg/mL had an increased risk for cancellation. Basal E(2) was predictive of stimulation parameters in patients 40 years or older. For those patients who proceeded to retrieval, there were no differences in pregnancy or delivery rates relative to basal E(2) levels. This suggests that irrespective of basal E(2) levels patients who produce more than three maturing follicles in response to stimulation have adequate ovarian reserve as evidenced by their pregnancy rates.

Women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B before a rise in day 3 follicle-stimulating hormone.

OBJECTIVE: To test the hypothesis that women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B levels before a rise in day 3 serum FSH levels. DESIGN: Case-control study. SETTING: Tertiary care fertility center. PATIENT(S): One hundred nine women with nonovarian infertility (tubal factor or male factor) and 47 women with declining ovarian reserve who underwent assisted reproductive techniques. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Serum inhibin B and FSH levels, number of ampules of gonadotropins administered, E2 levels on the day of hCG administration, number of oocytes retrieved, clinical pregnancy rate, and cycle cancellation rate. RESULT(S): Women who had declining ovarian reserve as demonstrated by an increased gonadotropin requirement, a decreased E2 response, fewer retrieved oocytes, a lower clinical pregnancy rate, and a higher cycle cancellation rate had lower day 3 serum inhibin B levels despite having nonelevated day 3 FSH levels similar to those of women with nonovarian infertility. CONCLUSION(S): Women with declining ovarian responsiveness and clinical outcomes consistent with declining ovarian reserve had decreased day 3 serum inhibin B levels despite having nonelevated day 3 serum FSH concentrations. Declining ovarian reserve may be demonstrated by a decrease in day 3 inhibin B levels before a rise in day 3 FSH levels.

Antiphospholipid antibodies and pregnancy rates and outcome in in vitro fertilization patients.

OBJECTIVE: To determine the relationship between antiphospholipid antibodies and pregnancy rates (PRs) and outcome among IVF patients. DESIGN: Prospective collection of all serum samples with assays for immunoglobulin G (IgG), IgA, and IgM antibodies for anticardiolipin, antiphosphatidyl serine, antiphosphatidyl ethanolamine, antiphosphatidyl choline, antiphosphatidyl inositol, antiphosphatidyl glycerol, and antiphosphatidic acid being done following completion of all treatment cycles. SETTING: A tertiary care teaching hospital. PATIENT(S): Seven hundred ninety-three patients attempting to conceive through IVF. MAIN OUTCOME MEASURE(S): Pregnancy rates (PRs) and pregnancy loss rates relative to each of the various antiphospholipid antibodies that were measured. RESULT(S): There were 528 pregnancies for an overall PR of 66%. Pregnancy rates were equal among patients with positive and negative antiphospholipid antibodies for each of the 21 measured antibodies. Use of receiver operator characteristic curves and logistic regression further confirmed that there was no relationship between PRs or outcome based on antiphospholipid antibodies for any definable threshold value. CONCLUSION(S): Elevated antiphospholipid antibody levels are not associated with any change in PRs or pregnancy loss rates in patients attempting to conceive through IVF.

Mature cystic teratoma: a clinicopathologic evaluation of 517 cases and review of the literature.

OBJECTIVE: To evaluate the clinical and pathologic presentation of mature cystic teratomas and the trends in management over a 14-year study period. METHODS: Tumor registry data and medical records between January 1, 1975 and December 31, 1989 were analyzed with respect to patient age, tumor size, bilaterality, malignant transformation, and treatment. RESULTS: Five hundred seventy-three tumors were removed from 517 patients. The median and mean (+/- standard deviation) age was found to be 30 and 32 +/- 11.3 years, respectively. Three hundred ten (60%) of the patients were asymptomatic. The mean tumor size was 6.4 +/- 3.5 cm. The bilaterality rate was 10.8%. The rate of torsion was 3.5%; larger tumors underwent torsion more frequently than smaller tumors (P = .029). The rate of malignant transformation was 0.17%. The mean cyst diameter for patients undergoing cystectomy was 5.7 +/- 2.4 cm; for oophorectomy, 8.0 +/- 4.1 cm; and for hysterectomy, 6.1 +/- 3.8 cm. Oophorectomies were performed for larger tumors when compared to cystectomies (P = .01). The number of hysterectomies was stable throughout the study period, whereas the number of oophorectomies decreased and the number of cystectomies increased markedly. Contralateral ovarian biopsy was common (48.5%) early in the study period. By 1989, the biopsy rate was less than 1%. CONCLUSIONS: We found the prevalence rates of symptomatic tumors, torsion, and malignant degeneration to be less than those previously reported by most other investigators. In addition, there has been an important change over the past 14 years in the management of these neoplasms, with an increased tendency for ovarian preservation, as evidenced by the more frequent use of cystectomy and a decrease in contralateral ovarian biopsy.

Age-related decline in female fertility is not due to diminished capacity of the uterus to sustain embryo implantation.

OBJECTIVE: To evaluate the contribution of the uterus to age-related reproductive failure in women. PATIENTS: Thirty-eight ovum donors (30.2 +/- 4.9 years [mean +/- SD]) donating oocytes throughout 102 ovum donations. Fifty-one cycles were documented in "younger" recipients (35.8 +/- 3.1 years) and 51 in "older" recipients (44.0 +/- 3.1 years). The study was prospectively designed; same-cohort oocytes obtained from one young donor during a specific cycle were evenly distributed between "young" and "old" ovum recipients. Use of oocytes from a single source and a unique ovulatory cohort provides strict control over oocyte quality. Uterine age is varied by design, according to the age of the recipient at the time of ET. The role of the aging uterus in the decline of female fertility can be thus isolated and scrutinized. RESULTS: No significant (NS) difference in the number of ova received (7.9 +/- 3.4 versus 7.0 +/- 3.5), ova fertilized (4.4 +/- 1.5 versus 4.5 +/- 2.3), or embryos transferred (4.1 +/- 1.5 versus 4.1 +/- 1.6) was observed between the < 40 and > or = 40 recipient age groups. A total of 23 pregnancies occurred among the 102 ETs (22.6%). Eleven clinical pregnancies (21.6%) resulting in 10 deliveries were observed in the < 40 recipient age group, and 12 clinical pregnancies (23.5%) leading to 10 deliveries occurred in the > or = 40 recipient age group (NS). The pregnancy loss rates were 9.1% (1 of 11) and 16.7% (2 of 12) for the two recipient age groups, respectively, (NS). CONCLUSION: The capacity to conceive and to gestate a conception to term when oocyte quality is controlled appears to be independent of uterine aging through the fifth decade of life.

Premature luteinization in controlled ovarian hyperstimulation has no adverse effect on oocyte and embryo quality.

OBJECTIVE: To determine if premature luteinization has an adverse effect on oocyte and, hence, embryo quality. DESIGN: Retrospective evaluation of anonymous ovum donors/oocyte recipients. SETTING: A large oocyte donation program. PATIENTS, PARTICIPANTS: Sixty-eight women undergoing controlled ovarian hyperstimulation (COH) as ovum donors were matched to 68 women with ovarian failure as ovum recipients who had endometrial maturation exogenously controlled by an identical hormone replacement protocol. INTERVENTIONS: Serum was collected for E2 and P in donors and recipients. MAIN OUTCOME MEASURES: The incidence of premature luteinization was determined in donors. Cycle characteristics were compared between donors with and without premature luteinization, with emphasis on oocyte and embryo quality. Implantation rates per embryo and delivery rates per transfer were measured in recipients. RESULTS: Twenty-one (31%) of the donors demonstrated premature luteinization. Serum P was higher on day before hCG, day of hCG, and day after hCG in women demonstrating premature luteinization. However, there were no differences between donor cycles with or without premature luteinization as determined by donor age, ampules of gonadotropins used, day of hCG administration, peak E2, total number of oocytes, and number of mature oocytes retrieved. Ovum recipients were of similar age and had similar E2 exposure (area under the E2 curve) before P administration. Similar fertilization rates, incidence of polyspermia, number of embryos transferred of similar embryo grade, and similar implantation rates and deliveries per transfer were observed in women receiving oocytes from donors with and without premature luteinization, respectively. CONCLUSIONS: Similar oocyte quality, fertilization, and polyspermia rates, embryo quality, implantation, and delivery rates suggest that any negative impact of premature luteinization on pregnancy rates in COH cycles from young women is not due to an adverse effect of PL on oocyte and hence embryo quality, but rather on the endometrial environment.

Premature luteinization is not eliminated by pituitary desensitization with leuprolide acetate in women undergoing gonadotrophin stimulation who demonstrated premature luteinization in a prior gonadotrophin-only cycle.

A total of 40 women who demonstrated premature luteinization (serum progesterone > or = 3.5 nmol/l (1.1 ng/ml) on or before the day of human chorionic gonadotrophin (HCG) administration) during ovarian stimulation with human menopausal gonadotrophins (HMG) were restimulated in 46 subsequent cycles after pituitary desensitization with the gonadotrophin-releasing hormone agonist (GnRHa, 1 mg), leuprolide acetate. Five women were treated with a double dose of agonist (2 mg) when premature luteinization was determined on the single dose protocol. In HMG-only cycles, a frank luteinizing hormone (LH) surge was detected in 30 cycles; 15 cycles were cancelled because of premature ovulation. In agonist cycles there were no cancellations, although 25 cycles demonstrated premature luteinization and in six cycles a frank LH surge was detected. Doubling the dose of the agonist did not prevent premature luteinization. Agonist cycles with and without premature luteinization did not differ in any in-vitro fertilization (IVF) outcome parameters (ampoules of gonadotrophins, day of HCG administration, peak oestradiol concentration, number of oocytes retrieved, fertilized, transferred or cryopreserved). We conclude that in patients who demonstrate premature luteinization in a gonadotrophin-only cycle, pituitary desensitization may not completely eliminate subtle luteinization or a frank LH surge.

The impact of embryonic development and endometrial maturity on the timing of implantation.

OBJECTIVE: To gain insight into the peri-implantation period in the human and to answer the question whether timing of nidation is dependent on the stage of embryonic development, endometrial maturation, or a possible dialogue between the two. DESIGN: Seventy-five women underwent embryo transfer (ET) throughout 93 cycles. Thirty-three ETs resulted in viable pregnancies and deliveries. These pregnancy cycles were used for embryonic signal detection. Embryos of identical age were transferred onto hormonally and histologically defined endometria of different maturational stages (days 15 to 19). Human chorionic gonadotropin (hCG) was measured by a hypersensitive chemiluminescence assay in maternal serum every 1 to 5 days to detect the first embryonic signal. RESULTS: Individual linear regressions of hCG versus embryonic age and endometrial maturation were performed on 33 viable pregnancy cycles (r2 = 90.5% to 99.9%, P less than 0.02 to 0.002). First signal detection was restricted to an embryonic age of 7.1 +/- 0.28 (mean +/- SD) days (range 6.6 to 7.4) irrespective of endometrial maturation. The pattern of hCG detection was triphasic, described by a sigmoidal curve with the maximal slope corresponding to an hCG doubling time of 15.9 hours. Embryo transfers on cycle day 19 had a steeper slope of hCG detection than days 15 and 16 (P less than 0.05). CONCLUSIONS: First embryonic signal detection (presumed window of implantation) extends between cycle days 20 and 24. Implantation is dependent on embryonic age and is independent of endometrial maturation within this window. The timing and sigmoidal pattern of hCG detection coincides with structural changes of the implantation bed. The steeper slope of late ETs may represent a compensatory mechanism for late maternal recognition of pregnancy for corpus luteum rescue.

Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment.

OBJECTIVE: To overview the world literature on ovarian hyperstimulation syndrome (OHSS) and modes of prevention and treatment of OHSS. STUDY SELECTION: All the pertinent literature on OHSS, its prevention, and strategies for treatment were reviewed. PREVENTION: Key to prevention is proper identification of the population at risk, which includes women with either the hormonal or the morphological signs of polycystic ovarian disease, high serum estradiol (E2) before human chorionic gonadotropin (hCG) administration (E2 greater than 4,000 pg/mL), multiple follicular response (greater than 35), younger age, and lean habitus. When a high risk situation is recognized, ovulatory dose of hCG may be reduced, avoided (with cycle cancellation), or substituted by gonadotropin-releasing hormone or its agonist. Luteal support with hCG is to be bypassed. To minimize risk of OHSS, endogenous pregnancy-drived hCG may be eluded by judicious cryopreservation of all embryos. Last, follicular aspiration will allow higher levels of E2 and larger number of follicles to be matured with lesser risk of OHSS than conventional ovulation induction without follicular aspiration. TREATMENT: In-house for the severe and intensive care for the critical form. Meticulous fluid and electrolyte balance using both crystalloids and colloids (albumin) until hemoconcentration abates. Paracentesis is indicated for tight ascites, deteriorating kidney functions, and symptomatic relief. Diuretics may be prudently used once hemodilution is achieved. Dopamine drip may be used as a renal rescue, whereas heparin is indicated for thromboembolic phenomena and surgery reserved for abdominal catastrophies. Therapeutic interruption of an early gestation may be lifesaving when all other measures have failed. CONCLUSIONS: Although severe and critical OHSS may not be completely avoided, early recognition of high-risk factors, judicious prevention schemes, and treatment strategies should reduce the complication and long-term sequelae of this iatrogenic syndrome.

Immunohistochemical localization of epidermal growth factor in human endometrium, decidua, and placenta.

Epidermal growth factor (EGF) was localized immunohistochemically in human endometrium throughout the menstrual cycle, in gestational decidua, and in first, second, and third trimester placenta using two polyclonal antihuman EGF antisera. In proliferative phase endometrium, moderate EGF immunostaining was localized to the cytoplasm of stromal cells, with absent to light staining of glandular epithelium. In the secretory phase, EGF immunostaining was intense and localized predominantly to stromal cells, particularly those surrounding spiral arterioles. There was absent to light EGF immunostaining within epithelial cells; however, there was no staining of subnuclear vacuoles. In addition, the luminal surface of exhausted secretory glands demonstrated moderate EGF immunostaining. In gestational decidua, EGF immunostaining was light to moderate in the stromal cells, but was intense in the surface epithelium. Intense EGF immunostaining was noted in the syncytiotrophoblast layer of first trimester placenta, with light to moderate staining of the cytotrophoblast. Immunostaining decreased in both layers of trophoblast as pregnancy progressed. Immunoreactive EGF is found in endometrium and trophoblast and may have a physiological role in endometrial and placental function.

High-resolution endovaginal ultrasonography of the endometrium: a noninvasive test for endometrial adequacy.

Endovaginal sonography of the endometrium demonstrates characteristic findings throughout the menstrual cycle. To correlate these findings with histologic criteria for normal endometrial development, we compared endometrial biopsies with ultrasonographic findings. Nineteen cycles were monitored in 18 women with ovarian failure whose endometrial cycles were induced exogenously by sequential transdermal 17 beta-estradiol (E2) and intramuscular progesterone. These subjects underwent ultrasonography of the endometrium prior to the day of progesterone initiation (luteal day +1) and continuing throughout the mid-secretory phase. On luteal day +1, ultrasonography characteristically demonstrated a multilayered endometrium consisting of a hyperechoic perimeter (endometrial-myometrial interface), a hypoechoic inner layer, and a hyperechoic midline (luminal interface). By luteal day +7, a gradual increase in echogenicity of the inner layer was detected, while the inner myometrium remained hypoechoic. Eleven of 19 cycles demonstrated a completely hyperechoic endometrium on luteal day +7 and also demonstrated normal stromal development on endometrial biopsies. Three patients who had endometrial biopsies consistent with their chronological development failed to demonstrate a hyperechoic endometrium by luteal day +7. All five biopsies that were histologically out of phase were detected by ultrasonography. Thus, ultrasonography demonstrated a sensitivity of 100% and a specificity of 62% for the detection of histologically normal endometrial development. Endometrial thickness could not be used to discriminate between biopsies that were normal (13 +/- 1.0 mm) and those out of phase (13.8 +/- 1.8 mm). Endometrial histology demonstrated asynchrony of glands and stroma in nine cases in which ultrasonography correlated with stromal, but not with glandular dating, suggesting that the increased echogenicity may reflect stromal edema.(ABSTRACT TRUNCATED AT 250 WORDS)

Poor oocyte quality rather than implantation failure as a cause of age-related decline in female fertility.

Female fertility declines with advancing age. To establish whether this age-related reproductive failure results from diminished oocyte quality or uterine/endometrial inadequacy we investigated ovum donation in 35 infertile women, aged 40 years or older (mean 42.7 [SE 0.3]) who had failed at attempts at conception with their own (self) oocytes. Oocytes were donated by 29 young individuals (mean age 33.4 [0.7]) undergoing in-vitro fertilisation (IVF). 8 (5.3%) pregnancies were achieved in 150 cycles of ovulation induction with self-oocytes and 2 (3.3%) in 60 such cycles by in-vitro fertilisation (IVF), but none attained viability. By contrast in 50 cycles with donated oocytes 28 (56%) pregnancies and 15 (30%) deliveries were realised (p less than 0.005). The rate of implantation per embryo transferred was higher (14.7%) with donated oocytes than that with self-oocytes (3.3%) (p less than 0.01). To further elucidate the contribution of age to reproductive outcome, pregnancy results were compared between the young donors and older recipients. Both donors and recipients shared oocytes from the same induced cohort. Rates for clinical pregnancy and delivery did not differ between donors (33% and 23%) and recipients (40% and 30%). Our data suggest that the age-related decline in female fertility is attributable to oocyte quality and is correctable by ovum donation. The uterus can adequately sustain pregnancies even when reproductive potential is artificially prolonged into the late 40s.

Immunohistochemical localization of gonadotropin-releasing hormone during implantation in the New Zealand white rabbit.

Gonadotropin-releasing hormone was localized immunohistochemically during implantation (gestational days 6 to 14) in the New Zealand White rabbit. During early implantation (days 7 to 9), intense gonadotropin-releasing hormone immunostaining was localized predominantly to the cytoplasm of the nonknob cytotrophoblast with light to moderate staining in the cytoplasm of the syncytiotrophoblast (knob). In later gestation, light to moderate staining of the cytoplasm of the trophoblast at the true placental site was detected. No appreciable change in staining was noted after day 10. Fetal membranes, identified after day 10, showed intense and unchanging immunostaining for gonadotropin-releasing hormone. Obplacental giant cells showed light to moderate nuclear and cytoplasmic gonadotropin-releasing hormone immunostaining. Light to moderate gonadotropin-releasing hormone immunostaining was also noted in the cytoplasm of uterine epithelium and glands. We conclude that immunoreactive gonadotropin-releasing hormone is present in the cytotrophoblast at the time of the earliest embryo-uterine interactions and may play a significant role in implantation and embryo survival.

An insight into early reproductive processes through the in vivo model of ovum donation.

To gain insight into early reproductive processes we have prospectively designed ovum donation protocols to elucidate several phenomena relating to embryo implantation and pregnancy sustenance. Artificial endometrial cycles with variable follicular phases were induced in 60 recipients by sequential estrogen and progesterone. A total of 964 oocytes were retrieved throughout 43 ovum donation attempts, for an average of 22.4 (range, 16-41) eggs/retrieval. The overall delivery rate per egg retrieval (donors and recipients combined) was 72.1% (31 of 43). The shortest estrogen stimulation (short follicular phase) resulting in ongoing pregnancies was 5 days in duration, while the longest (long follicular phase) was 35 days in duration before progesterone initiation. Utilization of variable length follicular phases, artificially extended the stage of endometrial receptivity to over 4 weeks. To assess the window of implantation, same age embryos were transferred onto endometrium of different maturational stages. Pregnancies were documented with embryo transfers between luteal day 1 (day 15) to luteal day 6 (day 20), extending the window of implantation in the human to at least 6 consecutive days. To evaluate the relative contribution of oocyte quality and endometrial receptivity to pregnancy outcome, common source ova were transferred onto endometrium with variable hormonal exposure. Despite the drastically different follicular phase estradiol levels and periods of exposure, similar delivery rates were attained in donor cycles (29.4%) and recipient cycles during short follicular phases (29.6%). Slightly higher delivery rates (39.4%) were observed with long follicular phases. The comparable pregnancy rates in donors and recipients are attributed to the common source oocytes regardless of endometrial stimulation.

Pregnancy after hemipelvectomy: a case report and review of the literature.

Hemipelvectomy is a most radical attempt at cure of malignant tumors of the pelvis and the upper portion of the femur. Pregnancy following this severely mutilating operation is rare. Despite the considerable loss of pelvic support patients do remarkably well. A case of pregnancy following hemipelvectomy is presented and represents the 16th report in the English literature. The anatomic consequences of hemipelvectomy are described and a review of the past 61 years experience with pregnancy following this operation is presented.

Mitral valve prolapse and thromboembolic disease in pregnancy: a case report.

Mitral valve prolapse is usually a benign condition, however, serious complications have been reported to be associated with it. A report of retinal artery occlusion associated with mitral valve prolapse and pregnancy is presented.