Influence of the conclusion of a recent large cooperative study in changing standard protocol of inducing menses in anovulatory women with oligomenorrhea prior to initiating ovulation induction with anti-estrogens and outcome

PURPOSE

To compare pregnancy rates following ovulation induction in anovulatory women with clomiphene citrate vs. letrozole and to determine the relative confounding effect of inducing menses or not. The study also evaluated whether starting these anti-estrogen drugs later in the menstrual cycle has-less adverse effect on endometrial thickness.

MATERIALS AND METHODS

Prospective series with choice by physician of inducing menses or not or choosing clomiphene citrate or letrozole for ovulation induction. Peak endometrial thickness was compared between drugs and between those conceiving or not.

RESULTS

There were 21 first cycles using letrozole and 42 using clomiphene. Menses were not induced in 18/21 (86%) letrozole cycles and 24/42 (57%) clomiphene cycles. Clinical pregnancies occurred in four (22.2%) letrozole cycles without induced menses with one miscarriage vs. 4/24 (16.6%) clomiphene cycles, no mis- carriage. One of three (33.3%) letrozole cycles with menses induced achieved a clinical pregnancy vs. only 1/18 (5.5%) of clomiphene cycles. There were no miscarriages.

CONCLUSIONS

Though the endometrial thickness was higher with clomiphene without induced menses vs. menses induced (11 mm vs. 9.5 mm), one cannot explain the trend for lower pregnancy rates in women with induced menses because of thinner endometria since the thickness was 10.3 mm for clomiphene and 10.0 with letrozole.

Sympathetic neural hyperalgesia edema syndrome as a cause of autoimmune hearing loss

PURPOSE

To describe another previous unreported manifestation of the sympathetic neural hyperalgesia edema syndrome - autoimmune hearing loss.

MATERIALS AND METHODS

Dextroamphetamine sulfate 30 mg extended release capsules was given to a woman to try to help her conceive since, with her pelvic pain, chronic fatigue syndrome, and diarrhea, it was thought that an inflammatory condition related to permeation of unwanted chemicals into endometrial tissue related to the sympathetic neural hyperalgesia edema syndrome could be inhibiting her failure from conceiving despite three cycles of embryo transfer.

RESULTS

Not only did the symptoms mentioned above disappear, but she also noted marked improvement of hearing loss that had been present for several years. The improvement in hearing was documented by audiology tests and had not responded to many months of 15 mg/day prednisone.

CONCLUSIONS

Autoimmune hearing loss (diagnosis established by her ear nose and throat specialist) should be added to the long list of manifestation of the sympathetic neural hyperalgesia edema syndrome.

The correlation of the degree of abnormal sperm morphology using strict criteria and pregnancy rates following intrauterine insemination (IUI)

OBJECTIVE

To determine the effect of extremely low sperm morphology on pregnancy rates following intrauterine insemination (IUI) where all other semen parameters were normal.

MATERIALS AND METHODS

Retrospective review of all IUI cycles over a two-year period on infertile women age ≤ 35 where all parameters, but morphology had to be normal. The data were evaluated according to seven levels of percentage of normal morphology (NM): 0, 1, 2, 3, 4, 5, and ≥ 6%.

RESULTS

The percent live delivery was 9.5, 16.7, 8.8, 16.1, 11.4, 12.3, and 10.9%.

CONCLUSIONS

Morphology of 0% or 1% did not seem to impair pregnancy rates following IUI. More studies are needed but should include determining the confounding effect of the type of morphologic abnormality.

Serum levels of the immunomodulatory protein, the progesterone induced blocking factor (PIBF) which is found in high levels during pregnancy is not higher in women with progesterone (P) receptor (R) positive vs. negative breast cancer

PURPOSE

To determine if serum levels of the immunomodulatory protein, the progesterone induced blocking factor (PIBF), which is present in high levels during normal pregnancy, is present in higher levels in women with breast cancer positive for progesterone receptors. The study would also determine whether the presence or absence of the estrogen receptor in any way modifies PIBF expression.

MATERIALS AND METHODS

PIBF using a research ELISA was evaluated in the follicular phase in 21 women with receptor status as follows: seven with estrogen receptor (ER)+ and progesterone receptor (PR)+, seven with ER- and PR+, and seven with ER+ and PR.

RESULTS

The results showed no differences in serum PIBF in the three groups. The serum PIBF levels were no different than historical controls in the follicular phase.

CONCLUSIONS

Measurement of serum PIBF does not seem to be an important marker to use to either detect women with breast cancer or to help determine tumor virulence or potential specific therapies. If PIBF plays a role in helping cancer cells to escape immune surveillance, it seems that the intracytoplasmic PIBF would be the form most likely operative.

Dextroamphetamine sulfate provided quick relief of severe post-partum depression that was recalcitrant to standard antidepressants and psychotherapy

PURPOSE

To determine if dextroamphetamine sulfate could improve symptoms of post-partum depression.

MATERIALS AND METHODS

A woman with severe post-partum depression that was resistant to standard antidepressant therapy and psychotherapy was treated with dextroamphetamine sulfate extended release capsules 15 mg/day.

RESULTS

A quick and complete abrogation of the depression ensued along with improvement of migraine headaches, insomnia, and chronic fatigue.

CONCLUSIONS

Dextr6amphetamine sulfate should be considered as a treatment modality for post-partum depression.

A normal baby is possible despite twins following a single embryo transfer even if one twin is genetically defective

PURPOSE

To demonstrate that it is important to consider all possibilities when confronted with a decision to terminate a pregnancy because it is likely to be chromosomally abnormal.

MATERIALS AND METHODS

A cell free DNA test was performed on a woman with dichorionic diamniotic twins that followed the transfer of a single embryo.

RESULTS

The cell free DNA test was consistent with trisomy 21. Two perinatologists favored identical twins and thus suggested termination since both twins would be trisomy 21 and the couple did not want to raise a child with Down's syndrome. Our group suggested the possibility that these were fraternal twins with one occurring from natural conception. We suggested to forego termination by D&E but to undergo an amniocentesis at 16 weeks. One twin had obvious cardiac abnormalities by ultrasound and this one was reduced while amniocentesis with karyotype was performed on fetus 2. The results showed a normal male.

CONCLUSIONS

One should consider all possibilities before suggesting termination of a very desired pregnancy. This woman had also been advised by other specialists in reproductive endocrinology that conception with her own oocytes (as did occur here) was not possible and she should consider donor oocytes based on her marked diminished oocyte reserve.

Mid-luteal phase injection of subcutaneous leuprolide acetate improves live delivered pregnancy and implantation rates in younger women undergoing in vitro fertilization-embryo transfer (IVF-ET)

PURPOSE

To determine if a single injection of one-mg leuprolide acetate three days after embryo transfer (ET) in younger women causes an increase in pregnancy rates, and if so, is it associated with a higher initial serum hCG level?

MATERIALS AND METHODS

A prospective study was initiated where women aged ≤ 35 years were offered the option of taking the leuprolide or not.

RESULTS

Though a significant difference was not found, there was a trend for higher live delivered pregnancy rates in those taking the leuprolide supplement (47.8%) vs. those not taking it (38.6%). There was no difference in the first serum beta hCG level.

CONCLUSIONS

The trends is interesting enough to continue with a higher powered study.

Sperm with an abnormal hypo-osmotic swelling test--normal fertilization, normal embryo development, but implantation failure

PURPOSE

To review the clinical importance of including the hypo-osmotic swelling (HOS) test in routine male fertility testing which in general is not evaluated by most physicians dealing with infertility.

MATERIALS AND METHODS

Pregnancy rates were evaluated in patients with low HOS test scores. A low HOS test was specifically defined as having less than 50% of sperm exhibiting the normal physiologic response of tail swelling, when subjected to a hypo-osmolar solution. Pregnancy rates of patients with low HOS test were examined after intercourse, intrauterine insemination (IUI), conventional oocyte insemination, and in vitro fertilization (IVF). Patients with a low HOS test were also treated with a protein digestive enzyme chymotrypsin. Patients receiving intervention then underwent IUI, IVF with conventional oocyte insemination, or IVF with intracytoplasmic sperm injection (ICSI). Pregnancy rates of the cohort receiving intervention were then examined for comparison.

RESULTS

The HOS test abnormality leads to normal fertilization but almost invariably negatively effects embryo implantation. Treatment with chymotrypsin, or performing IVF with ICSI, can overcome the toxic protein causing the embryo implantation defect. This toxic protein may be cryolabile and freezing sperm or embryos may prove to be another mode of therapy.

CONCLUSIONS

The HOS abnormality may be the most reliable semen abnormality predicting failure to conceive even with IVF unless the defect is negated. Therapy is very effective. Unfortunately this test is rarely evaluated by most infertility specialists but it should be. The frequency increases with age.

The use of granulocyte colony stimulating factor to enhance oocyte release in women with the luteinized unruptured follicle syndrome

PURPOSE

To determine if an injection of granulocyte colony stimulating factor (G-CSF) prevoulatory can enable oocyte release from the follicle in women who have failed to release in natural cycles despite an endogenous luteinizing hormone (LH) surge, and also despite treatment with human chorionic gonadotropin (hCG) or a gonadotropin releasing hormone agonist (GnRHa).

MATERIALS AND METHODS

A single injection of 100 mg G-CSF was given in the late follicular phase followed by hCG 10,000 units at peak follicular maturation in women with at least three consecutive cycles of luteinization without oocyte release.

RESULTS

Six women had ten cycles with G-CSF and hCG. Definite release occurred in four, inconclusive in four, and definitely the luteinized unruptured follicle in two. Biochemical pregnancies occurred in two of the cycles where oocyte release occurred and a live delivered pregnancy in another cycle of release.

CONCLUSIONS

Without controls one cannot state with certainty that G-CSF enabled oocyte release when hCG and leuprolide failed. Nevertheless, the data do support a trial with G-CSF before proceeding to IVF-ET.

Failure to increase the thickness of thin endometria with intrauterine infusion of granulocyte colony stimulating factor (G-CSF)

PURPOSE

To corroborate or refute a previous study suggesting that intrauterine infusion of granulocyte colony stimulating factor (G-CSF) could significantly improve endometrial thickness into more fertile levels when the endometrial thickness was ≤ five mm.

MATERIALS AND METHODS

Three women whose endometrial thickness never exceeded five mm on the in vitro fertilization-embryo transfer (IVF-ET) cycle or subsequent attempted frozen ETs using graduated estradiol had intrauterine infusion of G-CSF to the estradiol regimen.

RESULTS

Not one of the three women improved the endometrial thickness beyond five mm and none conceived on the G-CSF cycle. One woman had a subsequent pregnancy following a frozen ET with only a four-mm thickness with no infusion of G-CSF.

CONCLUSIONS

These data do not confirm the efficacy of intrauterine infusion of G-CSF for poor endometrial thickness. Perhaps only certain cases will respond. A larger series could take time to accumulate since other studies have shown that only 0.3% of women with ≤ five mm endometrial thickness in the late proliferative phase during an IVF-ET cycle will not improve the endometrial thickness > five mm using graduated estradiol protocols.

An Editor's opinion of the recent committee opinion of the American Society for Reproductive Medicine that the luteal phase deficiency as a clinical entity causing infertility has not been proven

PURPOSE

To present an opposing view to the recent conclusions reached by the Practice Committee of the American Society for Reproductive Medicine and a recent review of the role of progesterone in subfertility by Sonntag and Ludwig that there is no evidence to support using progesterone in the luteal phase as exclusive therapy.

MATERIALS AND METHODS

A large quasi randomized study not mentioned by either review is presented.

RESULTS

In this study published in 1989 when women with luteal phase deficiencies and subfertil- ity were evaluated for follicular maturation, the majority seemed to form mature follicles. This majority group found far better with pregnancy outcome by taking exclusive progesterone in the luteal phase than follicle maturing drugs. A recent prospective series confirmed its beneficial effect.

CONCLUSIONS

Physicians should not empirically treat with follicle maturing drugs but should use progesterone in the luteal phase, preferably in those women who seemingly create a mature follicle.

Chronic unremitting lower abdominal pain quickly abrogated following treatment with amphetamine

PURPOSE

To describe a cause and treatment for chronic unremitting lower abdominal pain of long duration with unknown origin.

MATERIALS AND METHODS

A 50-year-old woman with 30 years of unexplained right lower quadrant pain was treated with dextroamphetamine sulfate.

RESULTS

Dramatic complete abrogation of the pain occurred within two weeks. The complete relief persisted for two years while she remains on therapy.

CONCLUSIONS

Symphathetic neural hyperalgesia edema syndrome should be considered whenever there is refractory pelvic or abdominal pain.

Dextroamphetamine sulfate treatment eradicates long-term chronic severe headaches from temporomandibular joint syndrome--a case that emphasizes the role of the gynecologist in treating headaches in women

PURPOSE

To test sympathomimetic amine therapy on another type of chronic headache syndrome--headaches from temporal mandibular joint (TMJ) syndrome.

MATERIALS AND METHODS

A woman with 20 years of severe daily pain from TMJ refractory to all therapies was treated with dextroamphetamine sulfate.

RESULTS

The woman showed immediate 100% relief from sympathomimetic amine treatment saving her from an expensive jaw breaking operation that was only given a slight chance of helping.

CONCLUSIONS

Unfortunately most treating physicians are unaware of this defect of sympathetic nervous system hypofunction leading to the absorption of toxins, which when it involves brain tissue, leads to severe headaches. Thus, the gynecologist who is aware of this syndrome because sympathetic nervous system hypofunction is the most common cause of pelvic pain, may need to intervene in women with chronic headaches, even TMJ.

The progesterone receptor antagonist mifepristone does not lower serum progesterone induced blocking factor (PIBF) in the presence of progesterone

PURPOSE

To determine if mifepristone can lower serum levels of a progesterone (P) induced immunomodulatory protein believed to be needed for the fetus to escape immune surveillance.

MATERIALS AND METHODS

A female volunteer had her serum P induced blocking factor (PIBF) increased by ingestion of oral micronized P. While remaining on P mifepristone, 200 mg/day was given for six days when another serum PIBF level was obtained.

RESULTS

The serum PIBF was 273 ng/ml after five days of oral micronized P. It increased further to 737 ng/ml despite taking six days of 200 mg mifepristone.

CONCLUSIONS

The mechanism for inducing abortion by mifepristone does not seem to be related to decreasing serum levels of PIBF. This does not eliminate the possibility that the mechanism involves reducing the intracytoplasmic PIBF levels.

Very unusual symptoms consistent with a possible migraine immediately following the injection of recombinant follitropin beta

PURPOSE

To present a new side effect of follitropin beta not shared with highly purified urinary follicle stimulating honnone (FSH).

MATERIALS AND METHODS

Follitropin beta was administered for preparation of in vitro fertilization-embryo transfer (IVF-ET).

RESULTS

Within a few minutes of injection of subcutaneously of follitropin beta, a 27-year-old woman developed a feeling of fever, headache, nausea, vomiting dizziness, and a visual aura consistent with migraine syndrome. These side effects did not occur when switched to highly purified urinary FSH.

CONCLUSIONS

Since this reaction did not occur when injected with FSH not made with recombinant DNA technology, it is concluded that recombinant FSH (at least with follitropin beta) can produce an immediate migraine-like syndrome.

Improving the chance of successful implantation - part I - embryo attachment to the endometrium and adequate trophoblast invasion

The first in a series on improving embryo implantation is presented with emphasis on embryo attachment and trophoblast invasion.

PURPOSE

To present knowledge of events needed for embryo attachment to the endometrium and subsequent trophoblast invasion and uterine remodeling leading to successful pregnancy.

MATERIALS AND METHODS

Based on normal events, some practical suggestions are proposed as to possible means of improving pregnancy rates by enhancing possible embryo attachment and trophoblast invasion.

RESULTS

Potential benefits of achieving adequate serum estradiol levels at peak follicular maturation, and the benefits of progesterone in the luteal phase are discussed. Also the potential benefits of purposeful endometrial injury is considered.

CONCLUSIONS

Knowledge of the events leading to embryo attachment and trophoblast invasion could lead to novel research ideas helping to improve pregnancy rates in addition to proper hormone supplementation and endometrial biopsy.

Efficacy of a single injection of human chorionic gonadotropin at peak follicular maturation in natural cycles on pregnancy rate and mid-luteal hormonal and sonographic parameters

PURPOSE

To discover if infertile women with presumed luteal phase deficiency would improve pregnancy rates, mid-luteal sera estradiol (E2) and progesterone (P), and increase the percentage of women achieving a mid-luteal sonographic homogeneous hyperechogenic endometrial texture by the addition of a single injection of human chorionic gonadotropin (hCG).

MATERIALS AND METHODS

Women with over one year of infertility with regular menses and with no other known infertility factor were presumed to have the need for extra P in the luteal phase based on previous studies. Women aged ≥ 30 years were selected along with women < 30 years who had pelvic pain or dysmenorrhea. Women aged 40-45 were evaluated separately. They were treated with either vaginal micronized P 8% twice daily alone or 10,000 units of hCG at the time of peak follicular maturation was also given. Women were eliminated if they did not achieve an 18-24 average diameter follicle with a serum E2 of > 200 pg/ml. Seven days after ovulation, sera E2 and P were measured along with endometrial thickness and echo patterns.

RESULTS

The only significant difference between groups was an increased mid-luteal serum E2 in the group receiving additional hCG. However, this did not result in an increased pregnancy rate.

CONCLUSIONS

In general, adding a single injection of hCG to P luteal support does not improve pregnancy rates in natural cycles where women were treated with supplemental P.

In vitro fertilization (IVF) outcome in women in overt menopause attempting to induce follicular maturation by follicle stimulating hormone (FSH) receptor down-regulation

PURPOSE

To determine the frequency of ovulation induction, obtaining oocytes leading to embryos, and pregnancy rates per embryo transfer in women with premature menopause.

MATERIALS AND METHODS

Prospective observational study of women hoping to have in vitro fertilization-embryo transfer (IVF-ET) with their own oocytes despite being in menopause. Ethinyl estradiol was used to lower follicle stimulation hormone (FSH) and restore sensitivity of follicles to mild FSH stimulation.

RESULTS

Three of five women had a live baby. Only one woman failed to induce ovulation and thus failed to have an embryo to transfer. One woman conceived two times and delivered a live healthy baby twice. The live delivered pregnancy rate per transfer was 20% (4/20) with generally one or occasionally two embryos transferred. The pregnancy rate per retrieval was 9.3% (4/43).

CONCLUSIONS

These data can help other women in this circumstance to decide on IVF with their own eggs or switch to donor eggs.

The effect of clomiphene citrate vs. letrozole on post-coital tests

PURPOSE

To determine if letrozole is less likely to create a hostile cervical mucus than clomiphene citrate.

MATERIALS AND METHODS

Post-coital testing compared at time of peak follicular maturation in women attaining mature follicles in first or second cycle of these two drugs. The study was randomized. Intercourse occurred at least 8-16 hours before.

RESULTS

Poor post-coital tests were found in twice the frequency in letrozole cycles than clomiphene citrate cycles.

CONCLUSIONS

Despite its shorter half-life, letrozole seems to be as least as likely, if not more, to adversely affect cervical mucus.

Increased tissue permeability and sympathetic nervous system hypofunction may be the common link between dysmenorrhea, chronic pelvic pain, Mittelschmerz, and Crohn's disease

PURPOSE

To determine if severe periovulatory diarrhea in a woman with Crohn's disease for just one day may be related to increased permeability of the large bowel related to hormonal changes that occur at this time of menstrual cycle.

MATERIALS AND METHODS

Dextroamphetamine sulfate was given to a woman whose Crohn's disease was markedly improved by adalimumab but who still had one day of severe diarrhea at mid-cycle.

RESULTS

She did not have any diarrhea or frequent defecation for the first two periovulatory times before she achieved pregnancy. Previously for two years there had not been one month where she did not have the severe periovulatory diarrhea.

CONCLUSIONS

This case helps support the concept that the classic symptoms of Mittelschmerz in women with endometriosis may be related to periovulatory events which either cause increased permeability of an already compromised tissue, whether it be pelvic or bowel or other tissues, or these periovulatory events impair sympathetic nervous system function, which is already impaired.

Intravenous intralipid therapy is not beneficial in having a live delivery in women aged 40-42 years with a previous history of miscarriage or failure to conceive despite embryo transfer undergoing in vitro fertilization-embryo transfer

PURPOSE

To evaluate the efficacy of intralipid intravenous infusion in achieving a live pregnancy following IVF--embryo transfer in women of advanced reproductive age (40-42 years).

MATERIALS AND METHODS

A matched control was performed. Women aged 40-42 with a previous history of miscarriage or who failed to conceive despite previous embryo transfer who entered an IVF program were offered intravenous intralipid therapy (four ml of 20% liposyn II in 100 ml normal saline over one hour) during the mid-follicular phase. Clinical pregnancy rates (eight weeks with viable gestation) and live delivered pregnancy rates were then determined and compared.

RESULTS

The results were evaluated after ten matched cycles. There were no clinical pregnancies in those receiving intralipid vs. a 40% clinical and a 30% live delivered pregnancy rate in the untreated controls (p = 0.087, Fisher's exact test). The study was terminated because of these preliminary data.

CONCLUSIONS

In the test tube, adding intralipid to natural killer cells can inhibit their cytolytic action. However, the use of intravenous intralipid to suppress natural killer cell activity does not seem to improve the chance of a live delivery in women aged 40-42 years with a previous history of miscarriage. In fact this therapy may actually be detrimental in this age group. Since efficacy of this therapy was not found in a group of advanced reproductive age, it is not clear why this should be effective for a younger population. A controlled study for the younger group is needed. Perhaps such a study could be limited to only those with miscarriage rather than also concluding failure to conceive despite embryo transfer. Intralipid failed to improve live delivered pregnancy rates in women with prior miscarriage or previous failure with embryo transfer.

A prospective comparison of outcome following cryopreservation using vitrification vs. a modified slow-freeze protocol of 2 pronuclear (2PN) and day 3 multi-cell embryos

PURPOSE

To compare the efficacy of vitrification of 2 pronuclear and day 3 cleavage stage embryo vs. a modified slow freeze protocol that historically has achieved good survival and pregnancy rates at these stages.

MATERIALS AND METHODS

Embryos were randomly assigned by day to freezing at the 2 proncular stage or day 3 cleavage stage embryos by either vitrification or a modified slow freeze protocol. Comparisons were made for survival rate, cleaveage rate, and pregnancy rate.

RESULTS

The results were comparable with a slight edge to vitrification. Only the implantation rates of day 3 cleavage staged embryos (75% vs. 30.4%) showed a significant difference.

CONCLUSIONS

Vitrification seems to be equally or possibly slightly superior to freezing embryos at the 2 pronuclear or day 3 cleavage stage vs. a modified slow freeze protocol that had been previously found to be superior to the slow freeze method of LaSalle-Testart.

Failed fertilization with conventional oocyte insemination can be overcome with the ability of ICSI according to binding or failing to bind to the zona pellucida

PURPOSE

To determine the frequency of failed fertilization with conventional oocyte insemination and to determine the ability of intracytoplasmic sperm injection (ICSI) to overcome the failed fertilization according to binding or failing to bind to the zona pellucida.

MATERIALS AND METHODS

Retrospective review of 12,448 in vitro fertilization (IVF) cycle to identify cycles where failed fertilization occurred following conventional oocyte insemination with seemingly normal sperm. A number of three oocytes retrieved was required.

RESULTS

There were only 12 cases of failed fertilization (0.1%). Six were related to failure of any or few sperm attaching to the zona pellucida These six had high fertilization rates with ICSI. Six had normal attachment and five attempted another cycle, this time with ICSI. Only 60% had good fertilization.

CONCLUSIONS

When there is failed fertilization with normal sperm oocyte binding following conventional oocyte insemination, ICSI may still be effective in 60% of the cases, but it would be probably recommended to combine ICSI with artificial oocyte activation by calcium ionophore.

Correlation of ImmunoBead® and ImmunoSphere™ Immunoglobulin G (IGG) tests on detecting antisperm antibody (ASA) on sperm

PURPOSE

To determine the correlation with detection of antibody on sperm by a new ImmunoSphere™ Immunoglobulin test vs. ImmunoBeads®.

MATERIALS AND METHODS

A sampling of sperm tested for antisperm antibody (ASA) tested by direct Immunobead? assay with levels varying from zero to 100% were compared to the percentage of sperm positive for ASA by a new test using immunospheres.

RESULTS

The correlation was not perfect but, in general, there was good correlation.

CONCLUSION

Now that the manufacturer is curtailing the manufacture of immunobeads, it is comforting to see a good correlation with immunospheres.

Detection of a microgonadotropinoma by magnetic resonance imaging performed because of excellent response to controlled ovarian hyperstimulation despite elevated day 3 FSH

PURPOSE

To determine if a better response than anticipated to controlled ovarian stimulation in a woman assumed to have diminished oocyte reserve based on an increased day 3 serum follicle stimulating hormone (FSH) level, could be related to a gonadotropinoma.

MATERIALS AND METHODS

Magnetic resonance imaging (MRI) with and without gadolinium contrast was used in a woman who made 21 mature oocytes despite a history of day 3 serum FSH as high as 20 mIU/mL.

RESULTS

A pituitary microgonadotropinoma was detected.

CONCLUSIONS

The presence of a better response than anticipated to controlled ovarian hyperstimulation (COH) with exogenous gonadotropins despite an increase in day 3 serum FSH should prompt a search for a possible gonadotropinoma.

Mid-luteal phase injection of subcutaneous leuprolide acetate improves live delivered pregnancy and implantation rates in younger women undergoing in vitro fertilization-embryo transfer (IVF-ET)

PURPOSE

To see if the single injection of one mg of the gonadotropin releasing hormone agonist (GnRHa) leuprolide acetate given in the mid-luteal phase can increase live delivered pregnancy and implantation rates. Furthermore the purpose was to determine if improvement was found, did the mechanism involve increased secretion of human chorionic gonadotropin (hCG).

MATERIALS AND METHODS

A prospective study was conducted in women aged 35 who were undergoing in vitro fertilization-embryo transfer (IVF-ET). They were advised of data from Tesarik et al. and a previous pilot study conducted in the present IVF center showing improved pregnancy rates with the injection of a GnRHa three days after embryo transfer. They were offered the option of returning for a one-mg injection s.c. of leuprolide acetate or not. Clinical and live delivered pregnancy rates were compared according to those taking or not the leuprolide acetate one-mg injection. Chi-square analysis was used for statistical comparisons. Serum beta-hCG levels were compared between those conceiving with or without the extra injection of leuprolide.

RESULTS

There was a non-significant trend for higher live delivered pregnancy rates in those taking leuprolide (47.8%, 64/134) vs. those not taking it (38.6%, 76/197). For those pregnant there was no difference in hCG levels according to taking the GnRHa or not.

CONCLUSIONS

The 25% increased live delivered pregnancy rate per transfer was insufficiently powered to detect a significant difference. The results do justify continuing the study. Perhaps the difference could be wider using a slightly older age group whose embryos are frequently less hearty.

The effect of oocyte reserve on pregnancy rates per oocyte harvest in women aged 36-39

PURPOSE

To determine the relative effect of diminished oocyte reserve on clinical viable and live delivered pregnancy rates per transfer and live delivery pregnancy rate per oocyte harvest in women aged 36-39.

MATERIALS AND METHODS

A retrospective comparison of pregnancy outcome was performed over a ten-year time period in women with normal oocyte reserve (day 3 serum FSH ≤ 11 mIU/mL) vs. diminished reserve (day 3 serum FSH ≥ 12 mIU/mL). Pregnancy rate per oocyte harvest equals the odds of conceiving with fresh or frozen embryos from a given retrieval before proceeding to another oocyte retrieval.

RESULTS

The clinical and viable (at end of first trimester) pregnancy rate per transfer was only 20% lower for the group with diminished oocyte reserve, but was 50% lower for the pregnancy rate per oocyte harvest.

CONCLUSIONS

Mild stimulation for women with diminished oocyte reserve allows a higher percentage of chromosomally normal embryos in women with diminished oocyte reserve, leading to only a 20% lower clinical and viable pregnancy rate per transfer. However, overall, there are less normal total number of normal embryos leading to a pregnancy rate per oocyte harvest only half as good in the group with lower reserve vs. normal.

Improved implantation and live delivered pregnancy rates following transfer of embryos derived from donor oocytes by single injection of leuprolide in mid-luteal phase

PURPOSE

To determine if the use of a single injection of one-mg leuprolide acetate in mid-luteal phase can increase pregnancy rates in donor oocyte recipients.

MATERIALS AND METHODS

Prospective study where couples were made aware of a study using the gonadotropin releasing hormone agonist (GnRHa) triptorelin that in the mid-luteal phase found improved pregnancy rates following embryo transfer in donor oocyte recipients. They were given the option of a single one-mg injection of the GnRHa leuprolide acetate. Pregnancy outcome was compared according to whether leuprolide was given or not. Also compared were the average first serum beta-hCG level in those who conceived according to taking leuprolide or not.

RESULTS

Chi-square analysis showed a significantly higher clinical and live delivered pregnancy rate (63.9% and 52.8%) in those supplementing with leuprolide than those who did not (39.5% and 32.9%). Similarly implantation rates were significantly higher (44.2% vs. 25.2%). The average first serum beta-hCG level for those conceiving and taking leuprolide was 294 mIU/mL vs. 325 mIU/mL for those who did not.

CONCLUSIONS

Similar to triptorelin the mid-luteal injection of leuprolide acetate improves pregnancy outcome in donor oocyte recipients.

A practical approach to diagnosing and treating infertility by the generalist in obstetrics and gynecology

PURPOSE

To present a diagnostic and treatment paradigm for infertility designed for the obstetrician gynecologist generalist.

MATERIALS AND METHODS

Simple methods of tubal evaluation, e.g., the hysterosalpingogram (HSG) and post-coital test to evaluate both male and cervical factor are discussed. Treating paradigms will be discussed for ovulatory disorders and luteal phase defects. The role of the OB/GYN generalist on performing surgery in the modem era will be mentioned.

RESULTS

If an HSG shows a unilateral hydrosalpinx the generalist should consider performing the unilateral salpingectomy since the advent of in vitro fertilization-embryo transfer (IVF-ET) with a de-emphasis on surgery has made the reproductive endocrinologist/infertility specialist (REI) less skillful in laparoscopic surgery. The REI rarely performs tuboplasty today. Not only does the exclusive treatment in the luteal phase with progesterone save the women money and side effects (including multiple births), but may actually improve pregnancy rates compared to the usual technique of follicle stimulating drugs plus intrauterine insemination.

CONCLUSIONS

Because the generalist will not be tempted to suggest therapies, e.g., IVF-ET because this effective therapy is the best option for the financial success of the REI, but at the expense of financial depletion of the patient, there is plenty of room for generalists taking over as the first line physicians for infertility rather than just a referral service. Reproductive endocrinologists/infertility will almost invariably perform IUI each month even if not doing IVF which is also profitable to the REI, but costly in time and money to the patient. In contrast, the generalist, aimed with the knowledge that IUI does not improve pregnancy rates if the post-coital test is normal, will save the patient and/or the insurance money if the woman conceives. Obviously certain circumstances, e.g., bilateral blocked fallopian tubes or very severe oligoasthenozoospermia (but not teratozoospermia) will prompt an immediate referral to an REI.

Failed surgical therapy for chronic back pain and sciatica may be due to hypofunction of the sympathetic nervous system

PURPOSE

To describe a distinctive pharmacological treatment for chronic pelvic pain and sciatica after spinal surgery with a laminectomy and spinal fusion failed to provide relief.

MATERIALS AND METHODS

Dextroamphetamine suflate was prescribed to a woman with a history of chronic back pain which was attributed to a ruptured disc. The pain was still unbearable after surgery.

RESULTS

After adjusting dosage, within three months of the correct dose, 25 mg twice a day, relief was provided and has persisted for ten months.

CONCLUSIONS

Chronic pelvic pain and sciatica both may be symptoms of hypofunction of the sympathetic nervous system. In addition, with other pain symptoms, this can be effectively treated with sympathomimetic amines.

Complete resolution of frozen shoulder syndrome in a woman treated with dextroamphetamine sulfate for chronic urinary urgency

PURPOSE

To evaluate the efficacy of dextroamphetamine sulfate for idiopathic frozen shoulder in a woman being treated for blad- der urgency and inability to lose weight despite dieting.

MATERIALS AND METHODS

Dextroamphetamine sulfate was initiated at 15 mg extended release capsules increasing to 25 mg extended release capsules to a 47-year-old woman.

RESULTS

She lost 19 pounds in four months, her bladder urgency disappeared, and she had complete resolution of the idiopathic frozen shoulder problem.

CONCLUSIONS

Idiopathic frozen shoulder syndrome can be added to the long list of conditions that are related to hypofunction of the sympathetic nervous system and all respond to dextroamphetamine sulfate therapy. They gynecologist is more familial with this syndrome be- cause of it being the main cause of pelvic pain. Thus the gynecologist may become the physician who subsequently treats orthopedic or rheumatological problems or other health issues.