Effects of Renal Denervation vs Sham in Resistant Hypertension After Medication Escalation: Prespecified Analysis at 6 Months of the RADIANCE-HTN TRIO Randomized Clinical Trial

Importance

Although early trials of endovascular renal denervation (RDN) for patients with resistant hypertension (RHTN) reported inconsistent results, ultrasound RDN (uRDN) was found to decrease blood pressure (BP) vs sham at 2 months in patients with RHTN taking stable background medications in the Study of the ReCor Medical Paradise System in Clinical Hypertension (RADIANCE-HTN TRIO) trial.

Objectives

To report the prespecified analysis of the persistence of the BP effects and safety of uRDN vs sham at 6 months in conjunction with escalating antihypertensive medications.

Design, Setting, and Participants

This randomized, sham-controlled, clinical trial with outcome assessors and patients blinded to treatment assignment, enrolled patients from March 11, 2016, to March 13, 2020. This was an international, multicenter study conducted in the US and Europe. Participants with daytime ambulatory BP of 135/85 mm Hg or higher after 4 weeks of single-pill triple-combination treatment (angiotensin-receptor blocker, calcium channel blocker, and thiazide diuretic) with estimated glomerular filtration rate (eGFR) of 40 mL/min/1.73 m2 or greater were randomly assigned to uRDN or sham with medications unchanged through 2 months. From 2 to 5 months, if monthly home BP was 135/85 mm Hg or higher, standardized stepped-care antihypertensive treatment starting with aldosterone antagonists was initiated under blinding to treatment assignment.

Interventions

uRDN vs sham procedure in conjunction with added medications to target BP control.

Main Outcomes and Measures

Six-month change in medications, change in daytime ambulatory systolic BP, change in home systolic BP adjusted for baseline BP and medications, and safety.

Results

A total of 65 of 69 participants in the uRDN group and 64 of 67 participants in the sham group (mean [SD] age, 52.4 [8.3] years; 104 male [80.6%]) with a mean (SD) eGFR of 81.5 (22.8) mL/min/1.73 m2 had 6-month daytime ambulatory BP measurements. Fewer medications were added in the uRDN group (mean [SD], 0.7 [1.0] medications) vs sham (mean [SD], 1.1 [1.1] medications; P = .045) and fewer patients in the uRDN group received aldosterone antagonists at 6 months (26 of 65 [40.0%] vs 39 of 64 [60.9%]; P = .02). Despite less intensive standardized stepped-care antihypertensive treatment, mean (SD) daytime ambulatory BP at 6 months was 138.3 (15.1) mm Hg with uRDN vs 139.0 (14.3) mm Hg with sham (additional decreases of -2.4 [16.6] vs -7.0 [16.7] mm Hg from month 2, respectively), whereas home SBP was lowered to a greater extent with uRDN by 4.3 mm Hg (95% CI, 0.5-8.1 mm Hg; P = .03) in a mixed model adjusting for baseline and number of medications. Adverse events were infrequent and similar between groups.

Conclusions and Relevance

In this study, in patients with RHTN initially randomly assigned to uRDN or a sham procedure and who had persistent elevation of BP at 2 months after the procedure, standardized stepped-care antihypertensive treatment escalation resulted in similar BP reduction in both groups at 6 months, with fewer additional medications required in the uRDN group.

Trial Registration

ClinicalTrials.gov Identifier: NCT02649426.

A longitudinal study of ego identity development at a liberal arts college

Ego identity development in the areas of occupational choice, religion, and political ideology was studied using Marcia's categorization system. The results indicated a significant increase in the frequency of the identity achiever status for occupational choice and corresponding decreases in the frequency of the moratorium and identity diffusion statuses. A significant decrease in the frequency of foreclosures on religion was also found. In those instances where students underwent an identity crisis, the probability of resolving it successfully was very high. High scores on the Cultural Sophistication scale of the College Student Questionnaire-Part 1 were found to be associated with presence in the identity achievement status. For students not in the achiever status as freshmen, an interest in various literary and art forms was predictive of becoming an achiever while in college.

Evaluation of a modified ACR20 scoring system in patients with rheumatoid arthritis receiving treatment with etanercept

OBJECTIVE

To evaluate a modified American College of Rheumatology 20 (mACR20) scoring system for patients with rheumatoid arthritis.

METHODS

The data were evaluated from one study on patients with methotrexate (MTX)-naive early rheumatoid arthritis (ERA) and another study on patients with DMARD-refractory late rheumatoid arthritis (LRA). For mACR20 scoring, acute-phase reactant measurements were excluded, and 20% improvement from baseline was determined by 2 or 3 of the 4 remaining ACR components.

RESULTS

For full joint counts with data from patients with ERA, marked differences favoured 25 mg etanercept (ETN) over 10 mg ETN by using the unmodified ACR20 (69% v 55%), the mACR20(3 of 4) (63% v 49%) and the mACR20(2 of 4) (72% v 58%). An assessment of 28 joints showed similar findings. In the trial on patients with LRA, considerably more patients in both ETN groups achieved a clinical response compared with placebo by using the ACR20, the mACR20(3 of 4) and the mACR20(2 of 4), whether using full or 28 joint counts. The mACR20(3 of 4) and full joint counts with data on patients with ERA showed a marked difference between the MTX and 10 mg ETN groups (63% v 49%), which was not observed with the ACR20.

CONCLUSION

Patterns of improvement indicated by mACR20 scores were consistent with standard ACR20 scores.

Two sniffing strategies in palinurid lobsters

Most studies of lobster chemoreception have focused on the model systems of Panulirus argus (Palinuridae) and Homarus americanus(Nephropidae). We compare antennule morphology across lobsters and conduct the first kinematic study of antennule flicking in a palinurid species other than P. argus. High-speed video analysis shows that Palinurus elephas flicks at a rate more than an order of magnitude higher than in P. argus. However, both species flick their antennular flagella at a Reynolds number (Re) of approximately one, such that an asymmetry in the speed of the flick phases causes both species to have a leaky closing flick phase and a non-leaky opening phase. The antennular flagella of P. argus are nearly seven times longer than those of P. elephas,and, when compared across palinurid genera, Panulirus species sample far greater areas of water over greater spatial and time scales than do any other palinurid genera. Palinurid lobsters appear to have two sniffing strategies: low flick rates over a large area of water (e.g. P. argus) or high flick rates over a small area of water (e.g. P. elephas). P. argus is a highly informative model system in which to study aquatic chemoreception; however, its antennule anatomy and kinematics suggest a separate strategy, unique to Panulirus species, for sensing chemical plumes in fluid environments.

Fluid dynamic design of lobster olfactory organs: high speed kinematic analysis of antennule flicking by Panulirus argus

Many organisms use olfactory appendages bearing arrays of microscopic hairs to pick up chemical signals from the surrounding water or air. We report a morphometric and high speed kinematic analysis of the olfactory organs (lateral flagella of the antennules, which bear chemosensory aesthetasc hairs) of the spiny lobster, Panulirus argus. Panulirus argus sample specific locations by executing a rapid series of antennule flicks at one position, moving the antennule to a different spot and then performing another series of flicks. Odorant delivery to an aesthetasc depends on the water motion near it, which depends on its Reynolds number (Re, proportional to both the diameter and speed of the hair). High speed video enabled us to resolve that during a series of flicks, an antennule moves down rapidly (aesthetasc Re = 2) and up more slowly (Re = 0.5), pausing briefly ( approximately 0.54 s) before the next downstroke. The antennules of P. argus operate in a range of Re values and inter-aesthetasc spacings in which penetration of fluid between the hairs in an array is especially sensitive to changes in speed. Therefore, when antennules flick 'old' water is flushed out of the aesthetasc array during the leaky downstroke and is not picked up again during the less leaky upstroke, hence the antennules can take discrete samples. Thus, by operating in this critical Re range these antennules should be particularly effective at sniffing.

Cooperative assembly of an hnRNP complex induced by a tissue-specific homolog of polypyrimidine tract binding protein

Splicing of the c-src N1 exon in neuronal cells depends in part on an intronic cluster of RNA regulatory elements called the downstream control sequence (DCS). Using site-specific cross-linking, RNA gel shift, and DCS RNA affinity chromatography assays, we characterized the binding of several proteins to specific sites along the DCS RNA. Heterogeneous nuclear ribonucleoprotein (hnRNP) H, polypyrimidine tract binding protein (PTB), and KH-type splicing-regulatory protein (KSRP) each bind to distinct elements within this sequence. We also identified a new 60-kDa tissue-specific protein that binds to the CUCUCU splicing repressor element of the DCS RNA. This protein was purified, partially sequenced, and cloned. The new protein (neurally enriched homolog of PTB [nPTB]) is highly homologous to PTB. Unlike PTB, nPTB is enriched in the brain and in some neural cell lines. Although similar in sequence, nPTB and PTB show significant differences in their properties. nPTB binds more stably to the DCS RNA than PTB does but is a weaker repressor of splicing in vitro. nPTB also greatly enhances the binding of two other proteins, hnRNP H and KSRP, to the DCS RNA. These experiments identify specific cooperative interactions between the proteins that assemble onto an intricate splicing-regulatory sequence and show how this hnRNP assembly is altered in different cell types by incorporating different but highly related proteins.

Fibromyalgia, hypermobility, and breast implants

OBJECTIVE

To examine possible relationships among fibromyalgia (FM, American College of Rheumatology 1990 criteria), hypermobility, and breast implants.

METHODS

The medical records of 2,500 female patients (ages 25-65) who had been seen for the first time in a rheumatology practice in Atlanta, GA, during 1986-92 were abstracted and analyzed. In each analysis, patients whose records indicated that the patient met the full case criteria were compared with patients whose records had no indication of the disease. Patients whose medical records indicated the clinical onset of FM prior to breast implantation were identified.

RESULTS

Univariate and multivariate regression analyses were performed, adjusting for age, income, and the presence of connective tissue disease or rheumatoid arthritis. Significant associations were found between hypermobility and FM (adjusted OR 2.20, 95% CI 1.73, 2.80) and between hypermobility and breast implantation (adjusted OR 1.80, 95% CI 1.19, 2.69). No association was found between breast implantation and subsequent FM (adjusted OR 0.74, 95% CI 0.42, 1.32).

CONCLUSION

Hypermobility was found to be independently associated with both FM and with breast implantation, but FM and breast implantation were not found to be independently associated with each other.

Term domain distribution analysis: a data mining tool for text databases

In this paper, we give a case history illustrating the real-world application of a useful technique for data mining of text databases. The technique, which we call Term Domain Distribution Analysis (TDDA), consists of keeping track of term frequencies for specific finite domains and announcing significant differences from standard frequency distributions over these domains as a hypothesis. TDDA is part of a larger framework, the Digital Filter Model, for data mining of text documents. In the case study presented, the domain of terms was the pair {right, left}, over which we expected a uniform distribution. In analyzing term frequencies in a thoracic lung cancer database, the TDDA technique led to the surprising discovery that primary thoracic lung cancer tumors appear in the right lung more often than the left lung, with a ratio of 3:2. Treating the text discovery as a hypothesis, we verified this relationship against the medical literature in which primary lung tumor sites were reported, using a standard chi 2 statistic. We subsequently developed a working theoretical model of lung cancer that may explain the discovery. This discovery and our model may change how oncologists view the mechanisms of primary lung tumor location.

Connective tissue disease in people exposed to organic chemical solvents: systemic sclerosis (scleroderma) in dry cleaning plant and aircraft industry workers

The etiology of connective tissue disease appears to be multifactorial and includes genetic factors, autoimmune responsiveness and environmental elements. This survery in a clinical rheumatology practice has investigated the relationship of environmental occupational organic solvent exposure and the presence of connective tissue disease. Two hundred and seventynine consecutive patients with various connective tissue diseases were classified according to the American College of Rheumatology criteria for systemic lupus erythematosus, systemic sclerosis (scleroderma), and rheumatoid arthritis and clinically as dermatomyositis/polymyositis, mixed connective tissue disease, and Sjogren's syndrome. Comprehensive questionnaires were used regarding diagnosis, occupational history and chemical and other substance exposure.There was a striking increase in exposure to organic chemical solvents in the population of people with systemic sclerosis. Twelve of 33 people with scleroderma gave a history of organic chemical exposure versus 22 of the other 246 people (p = .00001); 3 of 33 with systemic sclerosis were exposed to perchloroethylene versus 2 of the other 246 (p = .00076), 2 scleroderma patients to trichloroethane versus 1 of the other 246 (p = .0031), and 2 scleroderma patients each to petroleum solvent and fluorocarbon solvent versus 0 of the other 246 (p = .00011) for each. Four of these 33 scleroderma patients worked in dry cleaning plants versus one of the other 246 (p < .00001), and 2 scleroderma subjects had been cleaning airplane parts versus 2 of the other 246 (p = .00076).These observations support a hypothesis for a role of occupational exposure in some patients with scleroderma. Prospective epidemiologic studies are needed. Clinicians should question new patients about such exposures and may wish to counsel them about avoiding exposures. However, no data have yet suggested that stopping the exposures made patients healthier.

Breast implants, rheumatoid arthritis, and connective tissue diseases in a clinical practice

This study was designed to assess the relationship between breast implants and certain rheumatologic diseases (rheumatoid arthritis and diffuse connective tissue diseases). The study base was a rheumatological practice in Atlanta, Georgia that started in 1982 and began computerizing its records in 1985. The computerized records through May 1992 included 4229 women patients, 150 with breast implants and 721 with a diagnosis of rheumatoid arthritis (RA) and/or one of the connective tissue diseases (CTDs). Of the 721 patients who had been diagnosed as having rheumatoid arthritis (RA) and/or one of the connective tissue diseases (CTDs), 392 had rheumatoid arthritis, 344 had connective tissue disease, 15 had both rheumatoid arthritis and a connective tissue disease, and 33 had more than one connective tissue disease. Of the patients with connective tissue disease, 179 had systemic lupus erythematosus, 64 had scleroderma, 49 had Sjögren's syndrome, 36 had dermatomyositis or polymyositis, and 49 had mixed connective tissue disease. Data were analyzed by univariate and multivariate techniques including logistic regression. Significant variables included age at first visit, income strata, and period of first visit. Analyses were performed for each clinical diagnosis, for all connective tissue diseases together (CTDs), and for those with rheumatoid arthritis and/or connective tissue disease (RA/CTD). Analyses were performed on the total data base and on the records of new patients (1986-1992). The adjusted odds ratio for breast implants among women who entered the practice in 1986-1992 and were diagnosed as having rheumatoid arthritis and/or one of the connective tissue diseases (RA/CTDs) was 0.45 (0.22-0.90), for those with rheumatoid arthritis was 0.61 (0.28-1.49), for those with any of these specific diffuse connective tissue diseases was 0.34 (0.11-1.06) compared to those without the disease. For systemic lupus erythematosus, the odds ratio of 0.24 (0.03-1.75) was based on a single case who had the disease 5 yr before the implant. For Sjögren's syndrome, the odds ratio was 1.67 (0.39-7.13) based on two cases, one of whom had the disease 5 yr before the implant. The calculated odds ratios for scleroderma, dermatomyositis/polymyositis, and mixed connective tissue disease were zero since no cases were diagnosed among the patients with breast implants. This study found no evidence that women with breast implants are at an increased risk for having rheumatoid arthritis or other diffuse connective tissue disease.

An acoustic basis for maternal recognition in timber wolves (Canis lupus)?

An in-den recording system was used to monitor the vocalizations and behavior of adult wolves tending to a litter of pups during the first five postnatal weeks. Two female adults, one of them the mother, tended to the pups on nonoverlapping schedules. The distributions of the fundamental frequencies of the adults' squeak vocalizations were largely nonoverlapping, suggesting that this feature may be available as an acoustic cue to individual recognition. Squeaks emitted outside the den, and which were associated with pup exit responses, had fundamental frequencies wholly within the range of the mother's, raising the possibility that the pups used this as a cue for maternal recognition.

Cognitive rehabilitation of adults with severe and persistent mental illness: a group model

The authors report on a group treatment approach developed for adults with schizophrenia who live in a Community Mental Health Center supported group home. The goals of the group intervention included cognitive rehabilitation and the development of effective communication and social skills. A variety of outcome measures used to evaluate the effectiveness of treatment revealed that the group modality promoted improved functioning in cognitive processing, social skills, and verbal communication. Although the results of the study can only be viewed as suggestive due to a small sample size and lack of a control group, the authors present a detailed group treatment format that can be utilized and further developed by people working with a severe and persistent mentally ill population.

A prospective randomized comparison of two gonadotrophin-releasing hormone agonists, nafarelin acetate and buserelin acetate, in in-vitro fertilization-embryo transfer

We tested the efficacy of a new gonadotrophin-releasing hormone agonist (GnRHa), nafarelin acetate, in in-vitro fertilization (IVF), and compared the results with those of another widely used GnRHa, buserelin acetate; both were in the form of nasal spray. Therapy was used in a long protocol in the luteal phase in two groups of women with similar aetiology of infertility. There was no significant difference in patient response, measured by cycle cancellation, number of oocytes retrieved, fertilization rate and cleavage rate. Pregnancy rates were similar in nafarelin acetate and buserelin acetate treated women, namely 22% and 24% pregnancies per cycle, and 28.8% and 32.1% pregnancies per transfer, respectively. Side-effects were few and comparable in both groups. The only difference noted was that women receiving nafarelin acetate required significantly fewer ampoules of human menopausal gonadotrophin, making a significant difference in the expense involved. We conclude that on the basis of our experience, nafarelin acetate is an efficient and safe gonadotrophin-releasing hormone agonist, effective in IVF therapy.

Self-perception variables that mediate AIDS-preventive behavior in college students

Three psychological variables--self-efficacy, control and meaning, and perceived risk--were tested in a structural model predicting AIDS-preventive behavior. Results revealed a good model fit, indicating that these psychological variables did play a role in mediating AIDS-preventive behavior in college students. A multivariate analysis of variance and individual analyses of variance conducted for men and women also revealed gender differences on individual items of self-efficacy, perceived risk, and AIDS-preventive behavior. This study underscores the importance of identifying and assessing the psychological determinants of AIDS-preventive behavior.

The impact of long-term gonadotropin-releasing hormone analogue treatment on preclinical abortions in patients with severe endometriosis undergoing in vitro fertilization-embryo transfer

OBJECTIVE

To examine the relationship between endometriosis and preclinical abortions and to evaluate the effect of gonadotropin-releasing hormone analogue (GnRH-a) therapy on these pregnancies.

DESIGN AND PATIENTS

Of 67 women with severe endometriosis referred to us for in vitro fertilization-embryo transfer (IVF-ET), 32 underwent ovarian stimulation for oocyte retrieval with menotropins (protocol A), whereas the other 35 were admitted for the procedure after a 6-month period of hormonal suppression with a GnRH agonist (protocol B). The clinical impact of the preclinical and clinical pregnancies in both treatment protocols were evaluated on the basis of oocyte classification and embryo quality score.

SETTING

All patients were treated in our IVF Unit.

MAIN OUTCOME MEASURE

Clinical pregnancy was used as our main outcome measure of success.

RESULTS

A significantly higher number of preclinical pregnancies (P less than 0.0001) occurred in patients treated by protocol A. After GnRH-a treatment, the preclinical pregnancy rate declined significantly (P less than 0.0001), whereas the clinical pregnancy rate per cycle and per transfer rose significantly (P less than 0.0001 and P less than 0.0001, respectively). Furthermore, clinical pregnancies had a significantly better mean embryo quality score in comparison with preclinical pregnancies (P less than 0.0001).

CONCLUSIONS

It is concluded that combining GnRH-a therapy before IVF-ET provides an improved treatment modality for preclinical abortions and infertility associated with severe endometriosis.

Fresh versus frozen thawed semen for initial and late insemination in IVF cycles

Frozen thawed semen has been associated with reduced semen quality and as a result diminished pregnancy rates. In vitro fertilization (IVF) can supply the true measure of the functional fertilizing capacity of fresh versus frozen-thawed semen. One hundred and six patients in an IVF program who underwent donor insemination were divided into two groups. Group I included 51 women in whom initial insemination with donor fresh or frozen semen was performed. They were compared to 65 group II women in whom late insemination with donor fresh or frozen semen was performed after initial insemination with husband semen had failed to fertilize the eggs. There was no statistically significant difference between groups I and II on initial insemination; however, statistically significant difference in fertilization (P less than 0.006) and pregnancy rates (P less than 0.001) between the two groups were achieved when late insemination was carried out. Consequently, we prefer initial insemination with frozen-thawed donor semen in cases indicated.

Transvaginal ultrasonic needle-guided aspiration of endometriotic cysts before ovulation induction for in vitro fertilization

Controversy still exists concerning the optimal treatment of endometriomata in endometriosis and its related infertility. Forty-one women with endometriomata who failed to conceive during previous in vitro fertilization and embryo transfer (IVF-ET) cycles (protocol A) were readmitted for ovum pickup following transvaginal ultrasonic needle-guided aspiration of the endometriomata (protocol B). Following aspiration a significantly higher number of oocytes was recovered (P less than 0.0006); subsequently, more embryos were transferred, and significantly higher clinical pregnancy rates per cycle (P less than 0.0001) were achieved. This difference may be directly related to the reduction of extensive ectopic endometrial tissue (endometriomata) with improved ovarian response, follicular accessibility, and, most probably, improved oocyte quality.

Hypermobility and deconditioning: important links to fibromyalgia/fibrositis

In this study 210 patients who were identified as having fibromyalgia/fibrositis were evaluated for hypermobility of joints. The patients were then instructed to perform an exercise program, and thereafter their compliance with the program and its effect on their symptoms were evaluated. The data were then analyzed using the Student's t test and Pearson's correlation coefficient. Patients who exercised during the study had improvement. Because the hypermobile patients as a group exercised more than the nonhypermobile group, they showed greater improvement than the nonhypermobile group (58% versus 30%). Patients with fibromyalgia/fibrositis who have articular hypermobility are more likely to exercise, which will improve their symptoms. The ability to show the objective findings of hypermobility to a person with fibromyalgia/fibrositis, a diagnosis based on subjective symptoms and signs, facilitates management of the patient. These tangible signs help the patient accept and adjust to the diagnosis of fibromyalgia/fibrositis.

Very early pregnancy wastage in in vitro fertilization and embryo transfer (IVF-ET)

The occurrence and incidence of early pregnancy wastage in an in vitro fertilization and embryo transfer (IVF-ET) program have been studied in 750 patients. In 297 (39.6%) a pregnancy was diagnosed; of these, 14.8% were biochemical and 24.8% clinical pregnancies. In the latter group 23.6% aborted, while 75.8% had clinical ongoing pregnancies. The mean embryo quality score of the biochemical pregnancy group was similar to that of the clinical ongoing pregnancy group but statistically different from that of the clinical abortion group (P less than 0.005). Furthermore, the clinical ongoing pregnancy rate in women with previous biochemical pregnancy was 24.7%, a significantly higher percentage compared to clinical ongoing pregnancies achieved in IVF-ET cycles (P less than 0.05). It is possible that biochemical pregnancy does not represent an index for infertility but rather an intact stage of reproduction leading toward implantation. The high clinical pregnancy rate in subsequent cycles may probably serve as an encouraging sign or a marker for future clinical pregnancy.

Giant diverticulum of the bladder simulating ovarian cyst

A patient was admitted for investigation of a giant ovarian cyst, confirmed by physical examination. At laparotomy the genital organs appeared normal. Ultrasonic reexamination affirmed the preliminary findings of a pelvic cystic mass. A urinary bladder diverticulum was suspected and confirmed by cystography and found to be nonobstructive in nature. Although extremely rare, bladder diverticulum should be considered in the differential diagnosis of a cystic pelvic mass.

The prognostic value and significance of preclinical abortions in in vitro fertilization-embryo transfer programs

Preclinical abortions occur in natural conceptions as well as in in vitro fertilization-embryo transfer (IVF-ET) cycles. Nevertheless, although known, this entity is ill defined.

OBJECTIVE

The purpose of this study was to propose a classification of these pregnancies on the basis of pathophysiological evidence and to evaluate their future clinical impact.

DESIGN

Of 970 IVF-ET cycles, 114 cycles (11.7%) terminated in preclinical abortions. Abortions were divided according to peak beta human chorionic gonadotropin (beta-hCG) values into chemical abortions (52%) occurring 2 weeks after ET with beta-hCG values not higher than 21 mIU/mL and peri-implantation abortions (47%) terminating spontaneously 4 weeks after ET; the latter had higher beta-hCG values for a longer period of time but without any sonographic evidence of gestational sac. No woman in the two groups needed curettage.

RESULTS

After a chemical abortion, the pregnancy outcome had better ongoing pregnancy rates (24.7%) in comparison with the 17% achieved in the total IVF-ET cycles.

CONCLUSIONS

It is concluded that these two groups most probably have different pathophysiological backgrounds and concomitantly different future clinical impacts.

Age and pregnancy rates in in vitro fertilization

The influence of women's age on the results of in vitro fertilization (IVF) was analyzed in 1801 women undergoing the procedure. Advancing age was found to be related to significant reduced success rates from an average of 30.1% per transfer below the age of 36 years to 15.9% per transfer at 37 years or more (P less than 0.001). The decrease was related to a reduction in oocyte production (five at 25 years or less, four below the age of 40 years, three at 40 years or more, and two in the 43 to 47-year group) and probably due to reduced implantation. It is concluded that a woman's age must be considered an important prognostic factor when IVF is suggested.

GnRH agonist increases pregnancy potential of retrieved oocytes given adequate preincubation before insemination: a comparative study

Preincubation of oocytes aspirated from follicles in IVF-ET programs is a controversial approach. While some investigators recommend this technique others doubt its necessity. We have studied the embryo quality in 100 women, undergoing IVF-ET, in whom ovulation was induced by the combination of GnRH agonists (GnRHa) and menotropins and compared to a control group in whom ovulation was induced with menotropins alone. No statistically significant difference was noted with regard to the fertilization and cleavage rates as well as to the preincubation period. Significantly higher pregnancy rates (P less than 0.001) were encountered in the first group in comparison with the control group.

The impact of the refractory period to gonadotropin therapy in IVF-ET cycles post longacting gonadotropin-releasing hormone (GNRH) analogue

Sixty-nine women were treated with a long-acting gonadotropin-releasing hormone analogue (GnRHa), D-Trp-6-LH-RH (DTRP6) 3.2 mg (Decapeptyl, Ferring, Kiel, F.R.G.) prior to induction of ovulation for in vitro fertilization (IVF) with human menopausal gonadotropin (hMG; Pergonal; Serono Laboratories, Inc., Randolph MA). Three types of response were noted: Group I (18 patients) responded between days 1-3 of the treatment; Group II (30 patients) responded between days 4-6 of the therapy, and Group III (21 patients) responded after 7 days of treatment. Although a higher number of oocytes were encountered in Group I than in the latter two groups fertilization and clinical pregnancy rates were lower than in Group II (P less than 0.05), respectively, but higher than in Group III (P less than 0.07 and P less than 0.01), respectively. The best results were achieved by Group II patients, while Group III seemed to represent low responders as the number of embryos and pregnancy rate were significantly lower than in the other two groups. It seems that the level of ovarian suppression achieved by GnRH analogue results in a period of refraction of the ovary, and its duration has most probably an effect upon the results of the IVF cycles.

Combination of long and short term GnRH analogue protocols: a new therapeutic approach to persistent high progesterone levels in IVF cycles

Thirty-four patients who had had persistently high progesterone (P) levels during menotrophin therapy in previous in-vitro fertilization (IVF) cycles, despite pretreatment with a long acting gonadotrophin-releasing hormone analogue (GnRHa), were randomly divided into two groups according to the mode of ovulation induction used. In 16 women (group 1), induction of ovulation was performed with decapeptyl (DTRP6)/pure follicle-stimulating hormone (PFSH)/human menopausal gonadotrophin (HMG)/human chorionic gonadotrophin (HCG). In 18 patients (group II), the protocol was identical to the former group, except for the addition of a short-acting GnRHa (buserelin) that was started when P levels were persistently high. The combination of long and short acting GnRH analogues (group II) resulted in an improved follicular phase with significantly lower P levels on the day of HCG administration (P less than 0.001). Furthermore, a significantly higher number of oocytes was retrieved, fertilized and cleaved (P less than 0.005; P less than 0.001; P less than 0.005, respectively) and, as a consequence, significantly higher pregnancy rates were achieved (22.2 versus 12.5%; P less than 0.005). These results indicate that a combination of long- and short-acting GnRH agonists may be of value in cases of persistent high P levels during menotrophin therapy in IVF cycles. Further larger studies must be performed before the true efficacy of this mode of treatment can be determined.

The value of hysteroscopy in elderly women prior to in vitro fertilization-embryo transfer (IVF-ET): a comparative study

Two hundred eighty-four hysteroscopies were performed in 312 (91%) candidates for in vitro fertilization and embryo transfer (IVF-ET) who were divided into two groups. Group I consisted of elderly women over 40 years, and group II of women below this age. Although visualization revealed uterine abnormalities in 29.9% of all patients, abnormal findings were significantly increased in the former group in comparison to the latter (P less than 0.001). This difference was attributed mainly to uterine rather than cervical pathology. Furthermore, in elderly women age-related uterine pathology such as submucous myomata, endometrial hyperplasia, and polyps were more prominent, while in younger patients other uterine lesions such as adhesions and tubal ostia occlusion were more common. Moreover, treatment prior to IVF-ET resulted in 7 clinical pregnancies (8.9%) in group I and in 41 clinical pregnancies (19.9%) in group II, all of which failed in one to three cycles previously. It seems that hysteroscopic evaluation may reduce the IVF-ET failure rate due to intrauterine abnormalities in elderly as well as young patients, thus it becomes an absolute prerequisite for all patients scheduled for an IVF program.

The impact of embryo quality on pregnancy outcome in elderly women undergoing in vitro fertilization-embryo transfer (IVF-ET)

Most IVF-ET units limit the procedure to women below age 38. Nevertheless, demands for infertility treatment, including IVF therapy, are more frequent nowadays. We compared 46 cycles for ovulation induction for IVF in 46 women aged 40 or more (Group I) to 51 induced cycles for this procedure in younger women of mean age 30.2 years (Group II). Cancellation rates due to early luteinization or ovulation were significantly higher in group I than in group II (28.2 and 17.6%, respectively) (P less than 0.001). Also, significantly higher abortion rates were observed in older women (62.5%), in comparison to the younger control group, (25%), (P less than 0.001). It is suggested that the high abortion rate considered to be due to genetic factors in older women, may possibly also be due to the aging uterine environment. Furthermore, while embryos with fragmentations may often produce clinical pregnancies in the young, the aging uterus in the elderly woman does not encourage the development of clinical pregnancies in such embryos. Consequently the higher abortion rate in the elderly woman.

The value of pre-treatment with gonadotrophin releasing hormone (GnRH) analogue in IVF-ET therapy of severe endometriosis

Controversy concerning the optimal treatment of endometriosis and its related infertility still exists. Thirty-one women with moderate and severe endometriosis, who failed to conceive during previous in-vitro fertilization and embryo transfer (IVF-ET) cycles (protocol A), were re-admitted for the procedure following a period of hormonal suppression with a gonadotrophin releasing-hormone (GnRH) agonist (protocol B). Following GnRH analogue treatment, a significantly higher number of oocytes were recovered (P less than 0.0006); consequently more embryos were transferred and significantly higher clinical pregnancy rates per cycle (P less than 0.0001) were achieved. This difference may be directly related to the beneficial effect of the GnRH analogue on pelvic endometriosis, converting severe cases into mild ones with improved ovarian accessibility and probably oocyte quality.

Umbilical artery velocimetry in insulin dependent diabetes mellitus (IDDM) pregnancies

Seven hundred and sixty seven Doppler umbilical artery velocity waveform analyses were performed in 108 pregnant insulin-dependent diabetes mellitus (IDDM) women. No significant correlation between mean third trimester systolic to diastolic (S/D) ratio and either mean blood glucose (r = 0.19) or glycosylated hemoglobin levels (r = 0.28) was found. Mean second and third trimester S/D ratios differed significantly in patients with or without vascular disease (P less than 0.05). Furthermore, women without vasculopathy who demonstrated an elevated S/D developed preeclampsia and delivered appropriate for gestational age infants while patients with vascular disease or chronic hypertension and elevated third trimester S/D (greater than 3) delivered intra uterine growth retarded (IUGR) infants. Moreover, in most of the latter group elevated S/D ratios were recorded in the second trimester prior to ultrasound documentation of IUGR. Our data suggest that in the absence of vasculopathy normal fetal placental resistance can be expected in most pregnancies complicated by diabetes. Patients with vasculopathy are at higher risk for fetal IUGR, which may be identified by early umbilical artery velocimetry.

The value of GnRH agonists in the treatment of failed cycles in an IVF-ET program: a comparative study

Occasionally, menotropins fail to induce ovulation for IVF-ET, due to early luteinization resulting in high cancellation rates of 15-40% of cycles. The efficacy of GnRH agonists in reducing these problems was prospectively studied in 91 women undergoing repeated IVF-ET, after desensitization with GnRH agonists. In all patients, the cycles that had been induced by menotropins alone failed due to early luteinization. By comparing these patients to a control group with significantly lower cancellation rates as well as significantly higher fertilization, the cleavage and pregnancy rates were achieved for the former group (p less than 0.001 in all parameters). Pituitary down-regulation by means of GnRH agonists prior to the induction of ovulation seems to be an effective and rewarding method for minimizing cancellation rates, and for achieving improved results in IVF-ET therapy.

Reinsemination in human IVF with fresh versus initial semen: a comparative study

In the event of non-fertilization of oocytes at the first insemination, repeat insemination is often successful in the IVF procedure. Nevertheless, the value of reinsemination is still controversial. In 56 out of 132 (42%) women treated in our IVF-ET Unit for mechanical infertility by identical induction and aspiration protocols, reinsemination of one or more ova was required. They were divided into two groups. Group I: 79 oocytes from 32 women who were reinseminated with initial semen 24 hours following primary insemination. Group II: 57 oocytes from 24 patients who were reinseminated with fresh semen 24 hours following primary insemination. Fertilization, cleavage and pregnancy rates differed significantly in group I as compared to group II (21.2%, 37.3%, p less than 0.005; 18.6%, 31.9%, p less than 0.001; 18.4%, 29.1%, p less than 0.001). We conclude that reinsemination is a beneficial procedure in cases of non-fertilization of oocytes at the first insemination. Furthermore, the use of fresh semen is preferred to achieve higher fertilization, cleavage and pregnancy rates.

The vaginal contraceptive diaphragm and the condom--a reevaluation and comparison of two barrier methods with the rhythm method

The use-effectiveness and continuation rates of two barrier methods of contraception, the diaphragm and condom, were studied during a two-year follow-up in a group of 85 and 98 women, respectively. All were highly motivated. Results were compared to a group of 64 women using the periodic abstinence or rhythm method, i.e. not using any contraceptive. The patients selected the method of contraception they preferred and were instructed in their proper use. Results showed good continuation rates in the groups using a diaphragm and the condom for 2 years, for a total follow-up of 5570 cycles. Pregnancy rate after 24 months of use, as calculated by Pearl's formula, was 2.48 for the diaphragm, 3.21 for the condom, and 5.19 in the rhythm group. No serious side effects or complications occurred in either group. The study demonstrated a fair acceptability and use-effectiveness for barrier contraceptive. We suggest that these harmless and complication-free methods may still be reasonable alternatives for the "modern" methods, the pill and the IUD.

Anticentromere antibody in patients without CREST and scleroderma: association with active digital vasculitis, rheumatic and connective tissue disease

This paper looks at the problem confronting a doctor evaluating a patient with anticentromere antibody who does not have evidence of disease along the spectrum from CREST (calcinosis, Raynaud's phenomenon, oesophageal dysmotility, sclerodactyly, telangiectasia) to progressive systemic sclerosis. Of 33 people with anticentromere antibody, 21 had CREST and two had scleroderma. Of the other 10 with a positive anticentromere antibody, three had systemic lupus erythematosus (two with digital vasculitis), three very active seronegative polyarthritis, three Raynaud's phenomenon, and one a claudication syndrome involving the legs. A positive antinuclear antibody test does not always indicate the presence of a connective tissue disease, but the presence of anticentromere antibody without systemic sclerosis or CREST often indicates the presence of another sometimes serious underlying rheumatic or connective tissue disease.

The value of GnRH analogue therapy in IVF in women with unexplained infertility

Seventy-six women with unexplained infertility, undergoing in-vitro fertilization and embryo transfer (IVF-embryo transfer), were selected for three different ovulation induction protocols. In group I, induction of ovulation was performed with pure follicle-stimulating hormone/human menopausal gonadotrophin/human chorionic gonadotrophin (pFSH/HMG/HCG). Group II patients were given a combined therapy consisting of a gonadotrophin-releasing hormone (GnRH) analogue, decapeptyl (DTRP6) followed by pFSH/HMG/HCG. In group III, patients underwent two IVF-embryo transfer cycles, serving as their own controls. The initial cycle was induced with pFSH/HMG/HCG while the second was stimulated using decapeptyl/pFSH/HMG/HCG. Significantly higher rates of fertilization, cleavage and pregnancy (P less than 0.001, P less than 0.07, P less than 0.001, respectively) were achieved in group II patients to whom combined GnRH agonists and gonadotrophins were given. Furthermore, among group III patients, no pregnancies occurred during the initial IVF-embryo transfer cycles whereas a 23% pregnancy rate (P less than 0.001) was obtained after GnRH agonist therapy. Our results indicate that the combination of GnRH agonists and gonadotrophins is of value in cases of unexplained infertility. Further, larger studies must be performed before the true efficacy of this mode of therapy can be determined in women with unexplained infertility.

Pregnancy outcome following early exposure to maternal luteinizing-hormone-releasing hormone agonist (buserelin)

A human pregnancy exposed to a luteinizing-hormone-releasing hormone agonist (buserelin) in its early stages is reported. The possible mechanisms leading to conception under this mode of treatment and its consequences are discussed.

Heterotopic pregnancy after IVF-ET: report of a case and a review of the literature

A case of heterotopic, intrauterine and tubal ectopic pregnancy is reported, following in-vitro fertilization and transfer of four 4-cell embryos. The literature on the subject is reviewed and the possible aetiological factors, as well as the clinical essentials for early pre-operative diagnosis are discussed.

The impact of high progesterone levels in the follicular phase of in vitro fertilization (IVF) cycles: a comparative study

Estrogen (E2) and plasma progesterone (P4) levels are valuable parameters for follicular development in in vitro fertilization (IVF) cycles. Furthermore, the progesterone concentration prior to, during, and following human chorionic gonadotropin (hCG) administration is an important marker for the detection of early luteinization and premature ovulation. The pattern of hormonal profile in relation to the number of oocytes retrieved, fertilized, and cleaved and the fate of the pregnancies achieved were compared in three groups of patients treated by the same protocol. Group I included 22 women who conceived with high progesterone levels on day hCG + 1 (P4, greater than 2.5 ng/ml). Group II included 43 women who conceived with low P4 values (P4, less than 2.5 ng/ml), while group III included 46 patients in whom no pregnancies occurred. A significant decrease in fertilization, cleavage, and pregnancy rates was observed in patients with high progesterone levels on day hCG + 1, compared to those with normal levels. Nevertheless, it is suggested that cycles with high P4 levels in the preovulatory phase should not be canceled, as a fair chance for pregnancy still exists.

IVF-ET in women with refractory polycystic ovarian disease

Polycystic ovarian disease may be a cause of hormonal infertility. This condition is often refractory to therapy. Three groups of randomly chosen women with refractory polycystic ovarian disease (PCOD) were treated by induction of ovulation with pFSH/hCG, pFSH/hMG/hCG or after down-regulation of the ovaries with a GnRH analogue (Decapeptyl). Out of 18 patients six conceived in the first in vitro fertilization-embryo transfer (IVF-ET) cycle, and two further women conceived in a later cycle. It is suggested that patients with refractory PCOD should be referred for IVF-ET therapy, possibly after treatment with a GnRH analogue.

Is elective cerclage justified in the management of triplet and quadruplet pregnancy?

The main complication in multiple gestation with more than two fetuses is prematurity, with its concomitant increase in perinatal mortality and morbidity. Clearcut indications as to management of these pregnancies are lacking, and the efficiency of elective cerclage is controversial. Twelve triplets and three quadruplets out of 27 multiple pregnancies were electively sutured and compared to 10 triplets and two quadruplets without this procedure. Otherwise, both groups were managed uniformly regarding bed-rest, beta-mimetic drugs and dexamethasone for the enhancement of fetal lung maturity. Mean duration of pregnancy in patients with cerclage was 35 weeks, significantly longer than those who did not undergo this procedure (30.7 weeks) (p < 0.01). Furthermore, in the former group, the mean neonatal weight was significantly higher (p < 0.01), mean Apgar scores were better, significantly lower rates of respiratory distress syndrome occurred (p < 0.05), perinatal mortality rate was significantly reduced (p < 0.01) and the mean hospitalization period was shorter (p < 0.025). It seems that elective cervical suture is a definite contribution to the successful management of multiple pregnancies with more than two fetuses.

Ovarian cyst formation: a complication of gonadotropin-releasing hormone agonist therapy

Since gonadotropin-releasing hormone (GnRH) analogs were introduced into clinical therapeutic use, several side effects directly related to the hypoestrogenic state have been reported. The authors have encountered a rather infrequent complication, namely ovarian cystic formations, when using these compounds for selected in vitro fertilization and embryo transfer (IVF-ET) cases. In 7 of 24 patients with Decapeptyl (D-Trp6-luteinizing hormone-releasing hormone [LH-RH], Ferring, Kiel, FRG) treatment, and in 5 of 22 patients treated with Buserelin (Superfact, Hoechst A.G., Frankfurt, FRG), solitary ovarian cysts developed during the down-regulation phase. Their growth did not change during ovulation induction with menotropins. Although the mechanism of ovarian cyst formation during GnRH agonist treatment is not clear, their presence does not appear to interfere with the fertility of these women.

The vanishing fetus. A report of 17 cases of triplets and quadruplets

The incidence of multiple conceptions is higher than the incidence of multiple deliveries. The "vanishing fetus" is a relatively new concept being a direct result of the advent of ultrasonography. Early first trimester loss of one or more conceptuses accounts for this phenomenon. The patient may be symptomatic (bleeding, pain, abdominal cramps) but in most instances, the finding is fortuitous. We report 17 cases of a vanishing fetus in a multiple gestation of greater than twins. In 13 patients one fetus vanished in the course of pregnancy while in four cases two fetuses disappeared from each gestation. The phenomenon was observed up to the 16th week of pregnancy. It is our feeling that the finding of a vanishing fetus should be recorded early, as the prognosis for pregnancy bleeding is different than in the singleton pregnancy. Thus information regarding this phenomenon should be given to couples who consider artificial reduction of fetuses in the multiple gestation.