Power Doppler ultrasound assessment of follicular vascularity in the early follicular phase and its relationship with outcome of in vitro fertilization.

OBJECTIVE: To determine whether ovarian perifollicular blood flow (PFBF) in the early follicular phase (EFP) was associated with treatment outcome. DESIGN: Retrospective longitudinal cohort study. SETTING: Tertiary referral centre/university hospital. PATIENTS: Thirty-four women underwent 37 IVF cycles, which resulted in 35 embryo transfers. INTERVENTIONS: Serial transvaginal scans using power Doppler ultrasound during the follicular phase. Ovarian PFBF of follicles > or =5 mm was subjectively assessed using a modified grading system (grades 0-4). MAIN OUTCOME MEASURES: Ovarian PFBF and pregnancy. RESULTS: Treatment cycles were retrospectively divided into two groups: Group 1 (n=20) had cycles with at least one small (5-10 mm) or medium (11-14 mm) size follicle(s) of high grade (2-4) PFBF on cycle day 5 or 6 or 7; and Group 2 (n=17), had cycles that did not. Group 1 had a significantly higher proportion of high grade large follicles in the late follicular phase (35% vs. 21%) (OR 2.0; 95% CI 1.1-3.7) and higher clinical pregnancy rate (47% vs. 12%) (OR 6.3; CI 1.1-35.7) compared to Group 2. CONCLUSION: High grade ovarian PFBF in the EFP during IVF is associated with both high grade PFBF in the late follicular phase and a higher clinical pregnancy rate.

A prospective, randomised, single-blinded, controlled trial comparing two topical anaesthetic modalities for the application of a tenaculum to the cervix.

The aim of this study was to compare the efficacy of equivalent doses of lignocaine spray vs lignocaine jelly in reducing pain during the application of a tenaculum to the cervix. A total of 58 women undergoing hysterosalpingography were prospectively randomised to receive either two doses of 10% lignocaine spray or 1 ml of 2% lignocaine jelly (both doses equivalent to 20 mg of lignocaine base) topically onto the cervix before tenaculum attachment. There was no difference in pain scores (measured by visual analogue scale and 4-point verbal descriptor scale) between lignocaine spray and lignocaine jelly during the attachment of the tenaculum to the cervix. In conclusion, there was no difference in pain during tenaculum attachment to the cervix following topical application of equivalent doses of either lignocaine jelly or spray.

Longitudinal assessment of ovarian perifollicular and endometrial vascularity by power Doppler ultrasound in pregnant and non-pregnant cycles in the IVF setting.

PURPOSE: This longitudinal study aimed to compare ovarian perifollicular and endometrial blood flow (PFBF and EBF, respectively) during the follicular phase in pregnant and non-pregnant IVF cycles. METHODS: Serial transvaginal scans were performed in 15 subjects undergoing IVF treatment. Both PFBF and EBF were subjectively graded (grades 0-4 for PFBF and grades 1-3 for EBF). After confirmation of clinical pregnancy, the treatment cycles were grouped into 'Pregnant' and 'Non-pregnant' cycles. Ovarian PFBF and EBF were retrospectively compared between the two groups. RESULTS: In pregnant cycles, the proportion of large (> or = 15 mm) follicles with high (24) grade PFBF increased with time throughout the follicular phase, and the proportion of large follicles with poor (0-1) grade PFBF decreased. In non-pregnant cycles these trends were reversed. There was no difference in EBF between the two groups. CONCLUSION: The pattern of ovarian PFBF but not EBF may be predictive of treatment outcome.

Prognostic value of baseline serum oestradiol in controlled ovarian hyperstimulation of women with unexplained infertility.

This study aimed to evaluate the prognostic value of the baseline serum oestradiol E2 level on the cycle pregnancy rate (PR) in women with unexplained infertility (UI) undergoing controlled ovarian hyperstimulation (COH). This study is unique in that it evaluates the effect of cycle day 1 (rather than day 3) E2 levels on cycle PR in a COH setting (without IVF) in women with UI (rather than multiple causes of infertility). Structured as a retrospective cohort study, the setting was the Ovulation Induction Clinic at an academic tertiary care hospital. One hundred and forty-five patients with UI underwent 374 cycles of COH with either human menopausal gonadotrophin (hMG) alone or hMG and clomiphene citrate. Outcome was measured as cycle pregnancy rate (PR) according to the cycle day 1 level of E2. Patients with an E2 level > 150 pmol/l on cycle day 1 of COH achieved a significantly lower PR (4%) compared with those with E2 levels < or = 150 pmol/l (13%). Logistic regression analysis demonstrated that women with day 1 E2 levels below 150 pmol/l were 3.2 times more likely to conceive than those with day 1 E2 levels above 150 pmol/l. Also, the impact of day 1 E2 levels on the chance of pregnancy was independent of day 1 serum FSH levels. Women with UI undergoing COH in our unit with an elevated baseline serum E2 > 150 pmol/l have a significantly lower PR and should be counselled regarding the decreased likelihood of pregnancy.

Choriocarcinoma co-existent with an intact pregnancy: case report and review of the literature.

A patient presenting with antepartum haemorrhage due to a vaginal metastasis of choriocarcinoma is reported. Following delivery she was successfully treated with chemotherapy and surgery. This report details this unusual presentation and reviews the literature on this rare condition.

The significance of pelvic ultrasound abnormalities detected on routine ultrasound scanning prior to assisted reproduction.

OBJECTIVE: To determine the benefit of screening patients with pelvic ultrasound before commencing treatment with in vitro fertilization or gamete intra-fallopian transfer, as well as before each subsequent treatment cycle was performed. SUBJECTS AND SETTING: Seven hundred and seventy-nine patients who were enrolled in the Royal Hospital for Women Fertility Group assisted reproduction program. METHOD: A retrospective analysis was performed. RESULTS: It was found that the majority of abnormalities were detected by the initial ultrasound. However, ultrasound contributed little to their diagnosis and management. CONCLUSION: As a result of this review of pelvic ultrasound examinations performed, the policy of screening prior to the initial cycle of treatment will be continued to exclude significant ovarian tumors and to identify patients with polycystic ovaries, who are more likely to be stimulated to levels at which there is a risk of ovarian hyperstimulation syndrome. The policy of screening before each subsequent treatment cycle has been discontinued, since few additional abnormalities were detected.

The influence of advanced age on the outcome of assisted reproduction.

PURPOSE: Our purpose was to determine the influence of age on the outcome of assisted reproduction, with particular interest in women aged 40 years or older. METHODS: A retrospective review of the 779 patients enrolled in the Royal Hospital for Women Fertility Group fertility program between 1987 and 1994 was performed. The results for women aged 40 years or older were compared with those for women between 36 and 39 years and those younger than 36 years. The main outcome measures were pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response. RESULTS: Compared with those in younger women, pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response to controlled ovarian stimulation were significantly worse in women aged 40 years or older. CONCLUSIONS: The outcome of assisted reproduction in women of 40 years of age or older was extremely poor. Compared with those in younger women, pregnancy outcome and ovarian response to controlled ovarian stimulation were significantly worse in women of 40 years or more.

A spontaneous luteinizing hormone surge is beneficial in women with unexplained infertility undergoing controlled ovarian hyperstimulation without in vitro fertilization.

OBJECTIVE: To determine whether a spontaneous luteinizing hormone (LH) surge influences the pregnancy and miscarriage rate in women with unexplained infertility undergoing controlled ovarian hyperstimulation (COH) without in vitro fertilization. DESIGN: Retrospective cohort study. SETTING: Ovulation Induction Clinic, Royal Hospital for Women, Sydney, Australia. PATIENTS: 145 patients with unexplained infertility who underwent 374 cycles of COH. METHODS: Two types of ovarian stimulation protocols were used: human menopausal gonadotrophin (hMG) alone or hMG and clomiphene citrate (CC). A spontaneous LH surge occurred in 54% of the total cycles. All patients received human chorionic gonadotrophin, whether or not a spontaneous LH surge occurred. All cycles were covered by natural intercourse. MAIN OUTCOME MEASURES: Cycle pregnancy rate and miscarriage rate in cycles with or without a spontaneous LH surge. RESULTS: The cycle pregnancy rate of the LH surge group was significantly higher than that of the no LH surge group for CC/hMG cycles (16.4% and 4.3% respectively, p = 0.02) but not for hMG alone cycles (12.8% and 10% respectively, P > .05). The miscarriage rate was not significantly different between the LH surge group and no LH surge group in either the CC/hMG cycles (30% and 75% respectively, P > .05) or the hMG alone cycles (22% and 38% respectively, P > .05). CONCLUSIONS: In women with unexplained infertility undergoing COH with CC/hMG, the occurrence of a spontaneous LH surge is a favorable event associated with a significantly increased pregnancy rate. The data showed a lower miscarriage rate, but there was insufficient power to confirm or refute this result.

Donor insemination: attitudes of parents towards disclosure.

OBJECTIVE: To determine attitudes of parents of children conceived by donor insemination to telling the children of their origin. DESIGN: Questionnaire survey, in 1992-1993, of parents who had had a child by donor insemination at four New South Wales clinics from 1979 to 1990. SETTING: Three hospital-based clinics (two public, one private) and a private clinic service. PARTICIPANTS: 276 families who altogether had had 420 children by donor insemination. MAIN OUTCOME MEASURES: Number of children told that they had been conceived by donor insemination; parents' intentions, before conceiving and after the birth, of informing the child; and whether other people were informed of the child's origin. RESULTS: Of 393 families who could be contacted, 353 agreed to participate and 276 (70%) replied to the questionnaire. Only 22 of the 420 children (5.2%) had been informed of their origin. Before conceiving, 18% of parents (49/273) planned to tell the child. Seventy-one per cent of families (182/257) had told others of the origin of the child, but 94% (241/257) had not told the child. Of the 29% of families (75/257) who had not told others of the child's origins, none had told the child. As the children grow older, more parents decide not to tell them of their origin. CONCLUSIONS: Most parents of children conceived by donor insemination do not plan to tell their child, but most of these parents have told others, creating the potential for accidental disclosure. Because of the small number of children who are told of their origin, there may not be a need for government-regulated donor registers, provided donor insemination units maintain a high standard of record-keeping.

Choriocarcinoma complicated by splenic rupture: an unusual presentation.

A patient with choriocarcinoma presenting with acute abdominal pain due to splenic rupture from secondary deposits is reported. This rare case exhibited several other unusual features including coexisting bilateral ovarian teratomas and the absence of any evidence of a primary lesion. Several hemangiomata in the liver initially confused the clinic picture.

Donor insemination: effects on parents.

OBJECTIVE: To examine the psychosocial effects of donor insemination on couples. DESIGN: Questionnaire survey of couples who had a child by donor insemination at four NSW clinics over a 15-year period. RESULTS: Forty-seven per cent of couples thought their marriage had improved, while 3% thought their marriage had deteriorated as a result of having a child by donor insemination. Seventy-six per cent felt it had a positive personal effect and almost all couples had no regrets about having a child this way. Over 90% of respondents felt very close to these children. In those who also had children not conceived by donor insemination (60 couples), men were significantly closer to their children by donor insemination than to their "other" children (P < 0.001). There was a significant sex difference in perceptions of the child's resemblance (P < 0.0001): 61% of women thought their child conceived by donor insemination resembled their partner, while 89% of men thought the child resembled their partner. Twenty-one per cent of couples were concerned about having to tell the child about donor insemination. CONCLUSION: Donor insemination can have positive psychosocial effects on couples and close relationships exist between the parents and their children conceived by donor insemination. The concern about the physical appearance of children conceived by donor insemination can be allayed by our finding that the majority of couples see a resemblance between the child and their partner.

EMACO in high risk gestational trophoblast disease--the Australian experience. Gestational Trophoblast Subcommittee, Clinical Oncological Society of Australia.

Sixty-five patients with high-risk trophoblast disease have been treated with the EMACO combination split regimen therapy in the 10 year period, 1981 to 1990. Four patients died but the remaining 61 (94%) remain free of disease up to 10 years later. Toxicity was manageable in most cases with minimal delay in treatment from myelosuppression. EMACO is a well tolerated regimen with a high cure rate in patients with high-risk gestational trophoblast disease (GTD).

Tuberous sclerosis: an unusual hysterosalpingographic appearance.

As part of the investigation of a 23-year-old nullipara with a history of tuberous sclerosis requesting inclusion on a donor oocyte programme, a hysterosalpingogram was performed and showed an unusual cavity pattern. The uterus appeared normal at hysteroscopy and laparoscopy. The cause for this unusual cavity pattern remains a matter of conjecture.

An unusual case of retrograde ejaculation.

Despite normal seminal analyses obtained for assay by masturbation, persistent negative postcoital tests led to the testing of postejaculatory urine following normal intercourse. This disclosed an unusual problem of retrograde ejaculation occurring only during intercourse. The mechanism for this selective form of retrograde ejaculation is unknown.

Screening for Neisseria gonorrhoeae and Chlamydia trachomatis in a donor insemination programme.

Cultures of all 4450 specimens of semen from 193 semen donors were negative for N. gonorrhoeae. A MicroTrak direct fluorescence microscopy test for the detection of Ch. trachomatis was used to screen 448 specimens from all 268 recipients of semen on an insemination programme for 3 1/2 years; all pre-insemination endocervical samples and all subsequent endocervical samples were negative. It is considered that the incidence of gonorrhoeae or chlamydia in our recipients or donors is very low. Fluorescence microscopy is a specific and cost-effective screening technique for Ch. trachomatis.

Torsion of the gravid uterus.

A case of 90 degrees dextrorotation of the uterus occurring in labour with successful outcome for mother and child is reported. Partial torsion may explain the occurrence of abnormal lie occurring during labour in the absence of detectable uterine pathology.

Are preoperative antibiotics helpful in abdominal hysterectomy?

An open, randomized study to compare the effectiveness of triple-dose cefoxitin with the effectiveness of cephradine-tinidazole and with the result of nontreatment in patients undergoing abdominal hysterectomy was conducted from July 1983 to July 1984. One hundred ninety-nine patients were enrolled: 66 untreated control patients, 69 patients in the cephradine-tinidazole--treated group, and 64 patients in the cefoxitin-treated group. No significant differences were present in relation to age, pathologic condition, length of operation, blood loss, or length of hospital stay. That patients in both treatment groups had a lower incidence of postoperative febrile morbidity was not statistically significant.

The outcome of artificial donor insemination compared to the husband's fertility status.

One thousand, three hundred and fifty-seven women were treated by artificial donor insemination (AID) using frozen semen at seven Australian centres. Eight hundred and forty-three of the husbands were azoospermic and five hundred and fifteen had pathological semen. The wives of azoospermic men had a significantly higher rate of success when the two groups were compared by life table analysis. It appears likely that the wives of oligospermic men who require AID are less fertile, and may be a contributory factor in the couple's subfertility.

Artificial insemination by frozen donor semen: results of multicentre Australian experience.

A total of 5461 insemination cycles with frozen donor semen has been analysed for 8 of the larger AID services in Australia. Cumulative pregnancy rate, calculated by life-table analysis, showed that 50% of all patients are pregnant after 6 cycles of insemination and 64% of all patients are pregnant after 12 cycles of insemination. Pregnancy rate was significantly higher in the first 3 cycles, declined in the next 3 cycles and was further reduced in the last 6 cycles of insemination. An average of 10% of all insemination cycle were anovular, but the proportion of anovular cycles was significantly lower in the first 2 cycles of insemination. There was no significant difference in cumulative pregnancy rates over the first 6 cycles of insemination in clinics using cervical mucus scoring or LH assay for detection of ovulation. An average of 12% of all pregnancies obtained by AID resulted in miscarriage.