Successful treatment of immunologic abortion with low-dose intravenous immunoglobulin.

OBJECTIVE: To evaluate the efficacy of low-dose intravenous immunoglobulin (IVIG) treatment in older women with immunologic abnormalities and recurrent spontaneous abortion (RSA), a condition referred to as immunologic abortion. DESIGN: Prospective clinical trial. SETTING: Outpatient referral practice. PATIENT(S): Forty-seven women were enrolled in the study. The mean age of the women was 37 years (range, 28-45 years), and the mean number of prior miscarriages was 3.7. Immunologic abnormalities included antiphospholipid antibodies (32%), antithyroid antibodies (53%), antinuclear antibodies (28%), antiovarian antibodies (2%), increased natural killer cells (40%), increased immunoglobulin (Ig)M level (28%), and increased CD4/CD8 T-cell ratio (15%). One patient had IgA deficiency, and three women had endometriosis. Thirty-one of the 47 patients (66%) had more than one immunologic abnormality. INTERVENTION(S): Treatment with IVIG at a dose of 0.2 g/kg within 2 weeks of attempted conception. Once conception was achieved, IVIG treatment was continued on a monthly basis at the same dose through 26-30 weeks of gestation. MAIN OUTCOME MEASURE(S): Successful pregnancy or recurrent abortion. RESULT(S): Of the 47 women, 36 received initial IVIG treatment, and 24 subsequently became pregnant. Of these women, 20 continued IVIG treatment through 26-30 weeks of gestation, and 19 (95%) had a successful term pregnancy. Four women discontinued IVIG therapy after 10-12 weeks of gestation, and 3 (75%) had a successful pregnancy outcome. Of the 11 women who refused IVIG therapy, 7 became pregnant, and all 7 miscarried. The difference in pregnancy success rate between the IVIG-treated and untreated groups was significant (P=.001). Three women had adverse reactions during the low-dose IVIG infusion, and these reactions resolved when the IVIG brand was changed. Fetal abnormalities were not observed. CONCLUSION(S): Low-dose IVIG therapy is beneficial for older women with immunologic abortion. The optimum duration of IVIG treatment in these women requires further study.

Reduction of cannula-related laparoscopic complications using a radially expanding access device.

STUDY OBJECTIVE: To determine the safety of a new radially expanding access device compared with complication rates associated with sharp laparoscopic cannulas. DESIGN: Prospective, multicenter study (Canadian Task Force classification II-1). SETTING: Free-standing and hospital-based ambulatory surgery centers. PATIENTS: Two hundred twelve women undergoing various laparoscopic procedures and followed over 44 months. INTERVENTION: Five hundred forty-one radially dilating access devices were used exclusively for laparoscopic abdominal wall access. MEASUREMENTS AND MAIN RESULTS: No major vascular injury, abdominal wall bleeding, intestinal injury, bladder or ureteral injury, liver trauma, or postoperative incisional hernia occurred. One patient developed a postoperative mesenteric hematoma probably caused by a venous injury from the Veress needle. Of the 541 radially expanding access cannulas placed, only 6 (1%) slipped, despite absence of fascial anchoring devices. CONCLUSION: Radially dilating abdominal access devices may reduce laparoscopic complications, lessen a surgeon's exposure to liability, and improve patient outcomes while reducing facility costs. (J Am Assoc Gynecol Laparosc 6(1):79-84, 1999)

Low-dose aspirin for oocyte donation recipients with a thin endometrium: prospective, randomized study.

OBJECTIVE: To evaluate the effect of low-dose aspirin use in oocyte donation recipients with an endometrial thickness of < 8 mm. DESIGN: A prospective, randomized study. SETTING: An oocyte donation program in a private infertility practice. PATIENT(S): Twenty-eight recipients undergoing oocyte donation who failed to develop an endometrial thickness of at least 8 mm in a previous evaluation cycle. INTERVENTION(S): Fifteen recipients received low-dose aspirin (81 mg/d) in addition to standard hormone replacement for an oocyte donation cycle. The remaining 13 recipients did not receive aspirin. MAIN OUTCOME MEASURE(S): Clinical pregnancy rates, delivery rates, implantation rates, and change in endometrial thickness were compared in the aspirin and nonaspirin groups. RESULT(S): There was no demonstrable increase in endometrial thickness in the aspirin-treated group. However, there was a statistically significant increase in implantation rates in the aspirin-treated group (24% versus 9%) and in implantation rates and clinical pregnancy rates in the aspirin-treated group when the final endometrial thickness was < 8 mm. CONCLUSION(S): Low-dose aspirin therapy improves implantation rates in oocyte donation recipients with a thin endometrium.

Outpatient laparoscopic-assisted vaginal hysterectomy.

STUDY OBJECTIVE: To compare laparoscopic-assisted hysterectomy (LAVH) with conventional abdominal hysterectomy. DESIGN: First 50 consecutive LAVH procedures. SETTING: An outpatient facility at a major medical center (35 procedures) and a nonhospital free-standing surgicenter (15). PATIENTS: Sequential sample of 50 women requiring hysterectomy. INTERVENTIONS: LAVH in 46 women, converted to open laparotomy in 4. MEASUREMENTS AND MAIN RESULTS: Outpatient LAVH was performed successfully in the majority of women. Most patients had significant uterine enlargement, pelvic adhesions, or endometriosis. Only six required replacement of autologous blood postoperatively. Other complications were cystotomy and postoperative pelvic hematoma in one patient each. CONCLUSIONS: LAVH can be performed safely in free-standing surgicenters. It offers several advantages to patients, and is considered cost effective by third-party payers.

Argon beam coagulation rescue to correct bleeding during pelviscopy.

A new technique of unipolar laparoscopic coagulation is particularly useful for the treatment of pelvic or abdominal bleeding during laparoscopic procedures. Blood present at the coagulation site is blown clear with a stream of argon gas prior to tissue coagulation. Of particular importance is the virtual absence of smoke, and because the procedure involves a nontouch technique, eschar is not removed inadvertently. The speed of tissue coagulation is faster than that of conventional bipolar and unipolar techniques.

A survey of parental attitudes toward oocyte donation.

A questionnaire was sent to couples who had successfully completed oocyte donation cycles to survey their experiences and make suggestions to others considering this option. A majority of couples were successful in their first cycle, despite advanced maternal age or length of time attempting conception. A preference for non-anonymous arrangements was highlighted, despite the unknown long-term impact, and the importance of finding support was stressed. Respondents indicated no confusion about their role as parents of children conceived through oocyte donation.

Improvement of pregnancy rates with oocyte donation in older recipients with the addition of progesterone vaginal suppositories.

Pregnancy rates and implantation rates with oocyte donation in recipients 40 years of age and older were significantly lower than those obtained in recipients under the age of 40. This difference was eliminated when P vaginal suppositories were added to the luteal regimen in older recipients. Our experience suggests that uterine aging may play a role in the successful initiation of a pregnancy, but this may be overcome with the preparation of the uterus with P vaginal suppositories.

Cumulative pregnancy rate from one gamete intra-fallopian transfer (GIFT) cycle with cryopreservation of embryos: a practical mathematical calculation.

We evaluated the cumulative pregnancy rate from one gamete intra-Fallopian transfer (GIFT) cycle plus subsequent cycles in which embryos cryopreserved at the time of the original GIFT cycle were transferred. All patients who had their first GIFT cycle in our centre between January, 1989 and March, 1991 were included. Ovarian stimulation was accomplished with leuprolide acetate (luteal phase protocol) and a combination of follicle stimulating hormone and human menopausal gonadotrophin. GIFT was performed with three to five oocytes. Excess oocytes were inseminated and good quality embryos were cryopreserved at the 2- to 4-cell stage with 1-2 propanediol. When the GIFT cycle did not result in a pregnancy, uterine transfer of cryopreserved embryos was carried out in subsequent unstimulated cycles. A total of 97 patients had GIFT and 46 pregnancies were achieved (47.4%). A total of 51 patients (52.5%) had embryos frozen; of these, 21 were from the non-pregnant group (41.1%) and 30 from the pregnant group (65.2%) (P < 0.05). Up to now, 22 of them have undergone a frozen-thawed embryo transfer cycle, and two of them achieved a pregnancy. Based on these data, patients having a GIFT could theoretically expect a cumulative pregnancy rate of 52.2%.

Severe ovarian hyperstimulation syndrome in assisted reproductive technology: definition of high risk groups.

In a retrospective analysis of 637 cycles of ovarian stimulation and transvaginal follicular aspiration for various assisted reproductive technologies, severe ovarian hyperstimulation syndrome (SOH) occurred in six (0.94%) cycles. The patients at a high risk of developing SOH in cycles of assisted reproduction were those who had excessive serum oestradiol levels on the day of human chorionic gonadotrophin (HCG) administration (oestradiol greater than 6000 pg/ml; 38% SOH) and a high number of oocytes obtained (greater than 30 oocytes; 23% SOH). In those patients with both oestradiol greater than 6000 pg/ml on the day of HCG administration and greater than 30 eggs retrieved, the chance of developing SOH was 80%. The higher the serum oestradiol levels and the more eggs retrieved, the higher the pregnancy rates observed. High oestradiol level did not appear to have a detrimental effect on pregnancy rates and outcome. Furthermore, our results are not consistent with suggestions that the addition of gonadotrophin-releasing hormone agonist to ovarian stimulation protocols, follicular aspiration and/or luteal support with progesterone may reduce the incidence of ovarian hyperstimulation syndrome.

Human leukocyte antigen compatibility and failure to achieve a viable pregnancy with assisted reproductive technology.

Many couples fail to achieve a viable pregnancy with multiple attempts of Assisted Reproductive Technology (ART). Immunologic rejection of the embryo may be a factor in these couples. We evaluated shared human leukocyte antigen (HLA) antigenicity in 10 couples who failed multiple ART cycles and compared them with 10 couples who achieved a viable pregnancy with their first ART attempt. Study couples shared a statistically significant greater number of HLA antigens than control couples. Leukocyte immunotherapy is discussed. We conclude that couples who share multiple HLA antigens may have an immunologic basis for failing to achieve a viable pregnancy with multiple ART cycles.

Results of tubal embryo transfer in premature ovarian failure.

The transfer of embryos generated in vitro to the fallopian tubes in 11 cases of premature ovarian failure resulted in 9 clinical pregnancies. This approach may have theoretical advantages over GIFT and IVF-ET in agonadal patients.

Non-surgical expulsion of non-viable early pregnancy: a new application of RU 486.

PIP: As an alternative to dilatation and curettage or expectant management, a single oral dose of 600 mg RU 486 was given to 3 women after failure of early pregnancy after in vitro fertilization and embryo transfer (IVF- ET) or gamete intra-Fallopian transfer (GIFT). In these women when early pregnancies are lost, missed abortions may endure because of continued progesterone release by the corpus luteum causing sustained hCG production by remaining trophoblast tissue. These 3 cases experienced fetal demise at 40, 38 and 28 days gestation. RU-486 was given orally on Days 53, 55 and 45, respectively, resulting in passage of the gestational sac within 2-3 days in all cases. The women experienced light spotting for 2 days, or bleeding for 1 week. Their menses reappeared within 1 month. This non-invasive approach was welcomed by the patients as a psychological relief.^ieng

Placenta accreta: a problem of increasing clinical significance.

Placenta accreta in association with placenta previa and previous cesarean delivery is a condition of increasing clinical significance. A case report of a woman with placenta percreta is presented. Risk factors, incidence, and management are discussed. Recommendations for preoperative and intraoperative management are presented.

Clinical diagnosis of ectopic pregnancy.

PIP: The difficult problem of differentiating ectopic pregnancy from other gynecologic disorders presenting with pain, bleeding, and amenorrhea is discussed by evaluating available diagnostic tests, singly and in combination. The first essential is to take a thorough history and clinical exam. Pain may be diffuse, bilateral, contralateral, vague or sharp. Amenorrhea, present in 75-95%, may be obscured by associated bleeding. Few cases exhibit pregnancy symptoms. The uterus is soft, but not always as large as expected. Adnexal mass may be palpable in 50%. Other disorders to consider include salpingitis, ruptured corpus luteum cyst, threatened or incomplete abortion, appendicitis, dysfunctional uterine bleeding, adnexal torsion, degenerating fibroid and endometriosis. It is important to use a monoclonal antibody pregnancy test, with a sensitivity of 50 mIU/ml, to detect the lower levels of hCG. In some cases doing quantitative hCG assays 48 hours apart to estimate doubling time will rule out normal pregnancy. Ultrasound is invaluable to identify an intrauterine pregnancy. Culdocentesis, a painful, invasive procedure, is rarely useful, often misleading, and should be used only if ultrasound and a sensitive hCG assay cannot be obtained without dangerous delay. After the patient is under anesthesia, do dilatation and curettage to rule out missed abortion, laparoscopy if findings are still confusing, and laparotomy if the previous tests indicate ectopic gregnancy. The most reliable combination of diagnostic tests is a serum radioimmunoassay pregnancy test and ultrasound. A diagnostic algorithm is presented in flow chart format.^ieng

Ultrasound: a technique useful in determining the side of ovulation.

It is often assumed that ovulation commonly occurs from alternating sides each month, but it is unknown whether it can occur repeatedly from the same side. In an effort to answer this question, we selected 39 women from our infertility clinic who had six consecutive courses of ultrasound (US) to monitor ovulation and in whom the side of ovulation was recorded. Nine patients (23.1%) ovulated from the same side for six consecutive cycles, whereas no patient alternated side of ovulation in the same period of time. Stimulation with clomiphene citrate and/or human menopausal gonadotropin that results in single ovulation did not affect this pattern. The data were analyzed statistically with the use of a Markov Chain Model and the chi-square goodness-of-fit; the occurrence of persistent same-side ovulation was significant to P less than or equal to 0.001.

Accurate diagnosis of early ectopic pregnancy.

Commonly used preoperative diagnostic procedures were analyzed for their ability to predict the presence of early ectopic pregnancy. Patients presenting to the emergency room with acute onset of pelvic pain were evaluated with culdocentesis, pelvic ultrasonography, and qualitative serum and urine pregnancy testing. Clinical examination and urine pregnancy testing were found to be poor predictors of either the presence or absence of an early ectopic pregnancy. The combination of a sensitive serum human chorionic gonadotropin (hCG) determination and pelvic ultrasonography accurately predicted ectopic pregnancy in 93% of proved cases. This predicted accuracy was superior to that of culdocentesis alone or in combinations of culdocentesis and ultrasound or qualitative serum pregnancy testing.