Providing assisted reproductive care to male haemophiliacs infected with human immunodeficiency virus: preliminary experience.

Outlined is our experience with couples in whom the male was both human immunodeficiency virus (HIV) seropositive and a haemophiliac who underwent assisted reproductive technologies (ART) in order to attain family goals while minimizing the risk of HIV transmission. We report their demographics, attitudes towards assisted reproduction, and ART performance and outcomes. The study included HIV serodiscordant couples (n = 11) who underwent ART at a university-based infertility practice from August 1997 to May 2002. Prior to treatment, couples prospectively completed a survey regarding their demographics and attitudes towards assisted reproduction. All couples underwent ART and pregnancy outcomes were analysed. The majority of the patients were fully employed, college-educated, in good health, married and motivated to have a child while minimizing the risk of HIV transmission. Eleven couples underwent 25 cycles of ART [19 in vitro fertilization (IVF) cycles; five frozen embryo transfer cycles; and one oocyte donation cycle] resulting in nine successful pregnancies. The ongoing/delivered pregnancy rate per initiated IVF cycle was 42.1% per embryo transfer. Eight of 11 (72.7%) couples achieved a successful pregnancy. More than half (six of 11; 54.5%) the couples conceived during their initial attempt. Four of nine (44.4%) pregnancies were multiple gestations, including three sets of triplets. All female recipients tested seronegative for HIV at 3 and 6 months post-embryo transfer. All delivered babies (n = 8) tested seronegative for HIV at birth and 3 months postpartum. Four pregnancies are currently ongoing. ART should be considered for HIV serodiscordant couples with haemophilia who desire to have children in order to minimize the risk of viral infection.

Prostate-specific antigen and human glandular kallikrein 2 are markedly elevated in urine of patients with polycystic ovary syndrome.

Prostate-specific antigen (PSA) is a well-established tumor marker of prostatic adenocarcinoma. Human glandular kallikrein 2 (hK2), another serine protease closely related to PSA, is also gaining ground as a promising diagnostic tool in prostate cancer. The expression of these 2 proteases is known to be regulated by androgens and progestins in hormonally responsive tissues, such as the male prostate and the female breast. Previously, we have shown that serum PSA levels in normal women are very low but still detectable by ultrasensitive PSA immunoassays. We have also demonstrated that some women with hyperandrogenic syndromes have elevated serum PSA levels. In this study, we have measured urinary PSA and urinary hK2 levels in 35 polycystic ovary syndrome (PCOS) patients and compared them to those of 41 age-matched controls. We found that urinary PSA levels were significantly higher (P < 0.0001) in PCOS patients (mean +/- SE = 820 +/- 344 ng/L) than in the controls (mean +/- SE = 4.3 +/- 1.8 ng/L). Similarly, the difference between urinary hK2 of patients (mean +/- SE = 8.2 +/- 3.1 ng/L) and controls (0.5 +/- 0.3 ng/L) was also significant (P < 0.001). A weak correlation was observed between urinary PSA and serum 3 alpha-androstanediol glucuronide (r(s) = 0.42, P = 0.03) as well as between urinary PSA and serum testosterone (r(s) = 0.40, P = 0.04). The results of this study indicate that urinary PSA, and possibly urinary hK2, are promising markers of hyperandrogenism in females suffering from PCOS.

Immature oocyte retrieval: lessons from unstimulated IVF cycles.

OBJECTIVE: To describe retrieval of immature oocytes during unstimulated IVF and assess the in vitro maturation and fertilization rates. DESIGN: Retrospective analysis. SETTING: The USC program for assisted reproduction. PATIENT(S): Spontaneously ovulatory women with predominantly pelvic factor as their principal cause of infertility, under the age of 40, and no male factor. INTERVENTION(S): HCG administration in mid-cycle, aspiration of all visible follicles, in vitro maturation of immature oocytes in culture media versus 50% follicular fluid in media, IVF, and embryo transfer. MAIN OUTCOME MEASURE(S): Rates of in vitro maturation, fertilization, and implantation after embryo transfer. RESULT(S): A total of 101 immature oocytes were obtained during 59 follicle aspirations. Thirty percent of prophase I oocytes matured to metaphase II in vitro compared with 44% of metaphase I oocytes. Fertilization rates for matured prophase I oocytes were 62% for those cultured in standard culture media (controls) and 87% for follicular fluid culture media. Two pregnancies resulted from the transfer of embryos derived from immature oocytes when no other embryos were transferred. CONCLUSION(S): Immature oocytes may be retrieved successfully during the mid-cycle aspiration of the dominant follicle in unstimulated IVF cycles. Maturation of immature oocytes in vitro with follicular fluid results in similar maturation and fertilization rates as for control incubation. Immature oocytes thus retrieved contribute to the overall pregnancy success of unstimulated IVF cycles. It may be better to retrieve immature oocytes during unstimulated cycles than during the follicular phase of natural cycles.

Clinical evaluation of 0.5% ferric hyaluronate adhesion prevention gel for the reduction of adhesions following peritoneal cavity surgery: open-label pilot study.

The objective of this study was to assess the safety and to make a preliminary assessment of the efficacy of 0.5% ferric hyaluronate adhesion prevention gel in reducing adhesions in patients undergoing peritoneal cavity surgery by laparotomy, with a planned 'second-look' laparoscopy. The study was a randomized, open-label, placebo-controlled, parallel-group design in patients desirous of fertility at the Women's and Children's Hospital, Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, California. Female patients aged 24 to 41 years received 300 ml 0.5% ferric hyaluronate adhesion prevention gel or lactated Ringer's solution as an intraperitoneal instillate at the completion of the laparotomy procedure. At second-look laparoscopy 4-12 weeks after the laparotomy, the presence of adhesions was evaluated. Haematology and serum chemistry were determined throughout the study interval. All patients tolerated the procedures well and did not manifest any serious adverse events. At second-look laparoscopy, patients treated with 0.5% ferric hyaluronate adhesion prevention gel had significantly fewer adhesions than control patients. When adhesions did form, they were significantly less extensive and less severe in patients who received 0.5% ferric hyaluronate adhesion prevention gel. In conclusion, 0.5% ferric hyaluronate adhesion prevention gel was safe and highly efficacious in the reduction of the number, severity and extent of adhesions throughout the entire abdomen following peritoneal cavity surgery.

Successful pregnancy in a 63-year-old woman.

OBJECTIVE: To report the occurrence of an unusual case of successful pregnancy achieved by oocyte donation in a woman > 60 years of age. DESIGN: Case report. SETTING: University-based assisted reproductive technology program. PATIENT(S): Sixty-three-year old nulligravida, married for 16 years to her 60-year-old husband. Throughout her infertility treatment, the patient was believed to be 10 years younger, as she claimed. She revealed her true age of 63 only upon being referred for obstetric care at 13 weeks of gestational age. INTERVENTION(S): Oocyte donation, IVF, embryo cryopreservation, and ET. MAIN OUTCOME MEASURE(S): Attainment of pregnancy and subsequent delivery. RESULT(S): The patient underwent two cycles of oocyte donation. During the second attempt, the fresh transfer resulted in a clinical miscarriage at approximately 8 weeks of gestational age. A subsequent transfer of three frozen-thawed embryos resulted in an ongoing singleton gestation. The pregnancy was complicated by gestational diabetes (controlled by diet) and mild pregnancy-induced hypertension. Delivery by cesarean section at 38 weeks of gestational age resulted in the birth of a healthy female infant weighing 2,844 g with Apgar scores of 9 and 9. CONCLUSION(S): This case demonstrates that the uterus is capable of supporting nidation and subsequent gestation for many years beyond natural menopause. It shows that other aspects of human physiology are capable of adapting to the stresses and changes of pregnancy sufficiently well to achieve a normal birth at the age of 63 years. This case also exemplifies the difficulty in attempting to regulate the age of recipients in oocyte donation. As in other aspects of human life, when age limits are applied to the provision of certain services, human beings whose age falls outside of these limits become motivated to deceive the providers of those services to avail themselves of the services.

The significance of polycystic-appearing ovaries versus normal-appearing ovaries in patients with polycystic ovary syndrome.

OBJECTIVE: To evaluate what hormonal or biochemical parameters are most highly associated with the finding of polycystic-appearing ovaries as compared with normal-appearing ovaries in women with polycystic ovary syndrome (PCOS). DESIGN: Prospective randomized study. SETTING: Academic medical center. PATIENTS: Ten women with PCOS-five with normal-appearing ovaries and five with polycystic-appearing ovaries-were matched for age and body mass index. All had serum T levels between 80 and 150 ng/dL (conversion factor to SI unit, 3.467). INTERVENTION(S): Insulin infusion for the purpose of performing insulin tolerance testing to evaluate insulin resistance or sensitivity. MAIN OUTCOME MEASURE(S): We measured serum T, DHEAS, androstenedione, sex-hormone binding globulin, 5 alpha-androstane-3 alpha-17 beta-androstenediol glucuronide, FSH, LH, insulin-like growth factor-I, insulin-like growth factor binding protein-1, and insulin-like growth factor binding protein-3. Insulin resistance, measured by insulin tolerance testing, also was done on the same day after the patient had fasted for at least 8 hours. RESULT(S): Serum androgens and binding proteins were not significantly different in both groups. Insulin tolerance testing demonstrated a slower glucose disappearance in the polycystic appearing ovary group (Kitt glucose was 4.58% +/- 1.4%/min in the normal-appearing ovaries group versus 2.07% +/- 1.07%/min in the polycystic-appearing ovaries group). CONCLUSION(S): Women with PCOS and polycystic-appearing ovaries do not demonstrate any definitive serum hormonal differences compared with women with PCOS and normal-appearing ovaries. The presence of polycystic-appearing ovaries correlates significantly with the presence of insulin resistance.

Follicle aspiration, sperm injection, and assisted rupture (FASIAR): a simple new assisted reproductive technique.

OBJECTIVE: To describe the first successful application of a new fertility-enhancing technique. DESIGN: Case report. SETTING: Academic fertility program. PATIENT(S): A 36-year-old nulligravid woman undergoing inseminations with frozen-thawed donor sperm. INTERVENTION(S): Ovarian superovulation, follicle aspiration, sperm injection, and assisted follicular rupture. MAIN OUTCOME MEASURE(S): Assessment of feasibility of technique and pregnancy outcome. RESULT(S): After failing to conceive during 16 cycles of IUI, the patient successfully achieved an ongoing pregnancy during the second follicle aspiration, sperm injection, and assisted rupture (FASIAR) attempt. CONCLUSION(S): Follicle aspiration, sperm injection, and assisted rupture combines the concepts of superovulation, IUI, and peritoneal oocyte and sperm transfer to obviate the possibility of luteinized unruptured follicle syndrome, assist oocyte release, and ensure gamete intermixing. It also can be used to reduce the number of ovulating oocytes and thus to reduce the risk of multiple gestations. Follicle aspiration, sperm injection, and assisted rupture is a new, simple, office-based procedure that does not require embryologic expertise beyond sperm preparation as for IUI, yet promises to be more successful than IUI.

Histopathologic findings in 107 uterine leiomyomas treated with leuprolide acetate compared with 126 controls.

The reported histopathologic findings in leiomyomas treated with leuprolide acetate (LA) differ. We examined 233 myomectomy specimens, including 107 myomas from 30 patients (mean age, 34.7 +/- 4.6 years) treated with LA. Their histopathologic findings were compared with those from a control group of 126 myomas from 30 untreated patients (mean age 32.7 +/- 5.3 years). The LA-treated leiomyomas had myxoid change (n = 2; 1.9%), total necrosis (n=4; 3.7%), focal necrosis (n = 5; 4.7%), calcifications (n = 5; 4.7%), hemorrhage (n = 8, 7.5%), vascular changes (n = 12; 11.2%), hydropic degeneration (n = 22; 20.5%), and hyalinization (n = 61; 57.0%). None of these changes differed significantly from the untreated controls. None of the LA-treated leiomyomas had nuclear atypia, whereas nuclear atypia occurred in four (3.2%) of the untreated leiomyomas; this difference was also not significant. Mitotic figures were present in 8.4% of the LA-treated myomas and 8.5% of untreated controls. The number of mitotic figures per 10 high-power fields was slightly higher in the untreated myomas, but the difference was not statistically significant (range, 0-3 for treated, 0-5 for controls). The degree of cellularity did not differ between the two groups. In conclusion, (a) LA-treated myomas do not significantly differ from untreated myomas with respect to nuclear atypia, calcification, total coagulative necrosis, focal coagulative necrosis, hemorrhage, vascular changes, myxoid change, hydropic degeneration, hyalinization, mitotic activity, or cellularity; and (b) the mechanism leading to a reduction in the size of myomas treated with LA is not apparent from routine histologic examination.