Use of Crinone vaginal progesterone gel for luteal support in in vitro fertilization cycles.

OBJECTIVE: To investigate the efficacy and safety of intravaginal Crinone 8% (Columbia Research Laboratories, Miami. FL) versus IM progesterone for luteal phase support after IVF-ET. DESIGN: Prospective open trial with comparison to historical controls. SETTING: University hospital. PATIENT(S): Two hundred six women undergoing IVF-ET. INTERVENTION(S): One hundred patients received Crinone vaginal progesterone gel (90 mg once daily) and 106 patients received IM progesterone (50 mg once daily) beginning on the evening of oocyte retrieval. MAIN OUTCOME MEASURE(S): Pregnancy and miscarriage rates, and midluteal serum progesterone levels. RESULT(S): Positive beta-hCG pregnancy rates, clinical pregnancy rates per transfer, and ongoing pregnancy rates were similar for the Crinone and IM progesterone groups. Women who received Crinone had higher rates of biochemical pregnancy loss but lower rates of clinical pregnancy loss (i.e., spontaneous abortion) than women who received IM progesterone. Midluteal serum progesterone concentrations were significantly higher in the IM progesterone group (94.3+/-8.8 ng/mL versus 57.7+/-7.4 ng/mL). Several women who received Crinone had vaginal bleeding 11-13 days after oocyte retrieval. CONCLUSION(S): For all age categories, positive beta-hCG and ongoing pregnancy rates were similar when Crinone or IM progesterone was given for luteal phase support in IVF-ET cycles, despite lower serum progesterone concentrations and higher rates of biochemical pregnancy loss with Crinone. Although the results of this study support the use of Crinone as an acceptable alternative for luteal support after IVF-ET, differences in bleeding patterns and rates of biochemical pregnancy loss demonstrate the need for a prospective randomized study.

Effect of antiphospholipid antibodies in women undergoing in-vitro fertilization: role of heparin and aspirin.

To describe the prevalence of antiphospholipid antibodies in women undergoing in-vitro fertilization (IVF) and to determine if heparin and aspirin affect implantation rates, 191 women with a history of infertility undergoing IVF were prospectively tested for antiphospholipid antibodies. This was a two-centre, non-randomized comparison of women with positive antiphospholipid antibodies receiving heparin and aspirin versus standard treatment. An enzyme-linked immunosorbent assay, with referenced standards and known positive and negative sera on each plate, was utilized to measure antibodies to cardiolipin, phosphatidylinositol, phosphatidylglycerol, phosphatidylserine and phosphatidylethanolamine. Statistical analyses of results included analysis of variance and Fisher's two-tailed exact test. Antiphospholipid antibodies were detected in 18.8% of patients undergoing IVF compared with only 5.5% in the 200 normal controls, 26% in 200 women with recurrent pregnancy loss, and 32% in 200 women with systemic lupus erythematosus. In conclusion, antiphospholipid antibodies were found more frequently in women undergoing IVF than in the normal control population. Although implantation rates appeared higher in the group of women treated with heparin and aspirin, no statistically significant differences were detected in implantation, pregnancy and ongoing pregnancy rates between those who received standard therapy and those treated with heparin and aspirin.

The effect of gonadotropin-releasing hormone agonist on thyroid-stimulating hormone and prolactin secretion in adult premenopausal women.

OBJECTIVE: To investigate the effects of chronic administration of GnRH agonists (GnRH-a) on pituitary TSH and PRL secretion in adult women. DESIGN: Prospective case-controlled study. SETTING: Academic division of Reproductive Endocrinology, Department of Obstetrics and Gynecology. PATIENTS: Ten ovulatory women and 10 women treated with monthly depot injections of leuprolide acetate (3.75 mg) were studied. INTERVENTIONS: All subjects underwent pituitary stimulation with human thyrotropin-releasing hormone (TRH), 500 micrograms IV. MAIN OUTCOME MEASURES: Basal and post-TRH-stimulated serum levels of TSH and PRL at 15, 30, 45, 60, 90, 120, and 180 minutes were compared among the two groups. Also, basal of T4, triiodothyronine, and triiodothyronine resin uptake studies were obtained and compared among the GnRH-a-treated and control groups. RESULTS: No statistically significant difference between baseline or TRH-stimulated serum TSH and PRL could be detected between control and GnRH-a-treated groups of women. Furthermore, these groups were similar with respect to routine thyroid function assays. CONCLUSION: Gonadotropin-releasing hormone agonist does not significantly affect baseline or TRH-stimulated TSH and PRL levels nor basal serum T4 and triiodothyronine levels or triiodothyronine resin uptake in adult women.

Steroid cell tumor associated with primary amenorrhea and virilization.

A 22-year-old woman sought medical advice because of primary amenorrhea and virilization that was manifested by facial hirsutism, temporal balding, and clitorimegaly. Plasma steroid levels were determined at the time of initial assessment; androstenedione and testosterone were increased in comparison with normal values. Vaginal ultrasonography revealed the presence of a mass localized to the right ovary. The patient underwent oophorectomy, and pathologic examination of the surgical specimen led to the identification of a steroid cell tumor associated with a polycystic ovary. Tumor steroid-metabolizing enzymes were evaluated in vitro: 17alpha-hydroxylase, 3beta-hydroxysteroid dehydrogenase/ delta5-->4-isomerase, 17beta-hydroxysteroid oxidoreductase, and 5a-reductase, which are required for androgen synthesis, were present in the tumor tissue. Postoperatively, plasma androstenedione and testosterone levels returned to normal. This study demonstrated that the tumor was the source of the increased levels of androgen precursor and androgen in this woman; excess tumor-derived androgen may have been the trigger in the development of the polycystic ovary.

Recognition of depression in obstetric/gynecology practices.

Depression is a common and serious health problem that occurs twice as often in women as in men. The lifetime prevalence of major depression in women is estimated to be as high as 21%. Although less severe and less common, mild depression and dysthymia (chronic mild depression) can cause functional disability and require treatment. Regardless of severity or duration, depression can be difficult to recognize because it frequently is masked by complaints that accompany other common obstetric and gynecologic illnesses and events. This article reviews the various depressive disorders in women with a focus on presentations that occur in obstetric and gynecologic practice.

Laparoscopic removal of gonads containing on occult seminoma in a woman with complete androgen resistance.

A 20-year-old woman with complete androgen resistance (AR; 46,XY), underwent prophylactic laparoscopic gonadectomy because of the known increased risk of gonadal malignancy. The procedure was performed with electrocoagulation using a four-puncture technique. Pelvic and abdominal inspection revealed no gonadal or metastatic tumor. The testes and attached structures were retracted medially, and the peritoneum and gonadal vessels were incised after electrocoagulation, thereby removing the gonads from the sidewalls. The gonads were individually placed into a specimen retrieval bag and removed through the suprapubic cannula site. Pathologic examination revealed an occult 8-mm seminoma in the let gonad, as well as bilateral Sertoli cell hamartomas, fallopian tube remnants, and smooth muscle tissue (mullerian remnants) adjacent to the gonads. Postoperatively, tumor markers were normal, and abdominal and pelvic computerized tomographic scans and chest radiographs were negative for possible metastatic disease. This case confirms that laparoscopic removal of testes in women with AR is effective, safe, and quick. Because of normal-appearing gonad may contain an occult tumor, we recommend using a retrieval bag, which may prevent dissemination of potentially malignant cells that may occur with unprotected morcellation.

Laparoscopic removal of gonads in women with abnormal karyotypes.

The objective of this study was to evaluate if laparoscopy can be an acceptable alternative to laparotomy for gonadectomy in women with gonadal dysgenesis (46,XY karyotype or 45,X karyotype with evidence of hyperandrogenism). We retrospectively analyzed five cases of gonadal dysgenesis that were managed by laparoscopic gonadectomy. All five patients underwent laparoscopic gonadectomy performed at a day surgery unit of a university medical center without any complications and were discharged the same day. The average operative time was 72 minutes (range, 35-95), the average blood loss was 20 mL, and the average cost was $4,380. We conclude that laparoscopic gonadectomy is a safe, effective and economical procedure to perform on patients with Y chromosomes or evidence of abnormal gonads. Laparoscopy should be accepted as the treatment of choice in these patients by physicians experienced in pelviscopic surgery.