Dale W. Stovall

Endometriosis-associated pelvic pain: evidence for an association between the stage of disease and a history of chronic pelvic pain

OBJECTIVEnTo track the severity and location of pelvic pain associated with endometriosis throughout the reproductive-age years and to evaluate the association between these pain parameters and the stage of disease.nnnDESIGNnHistorical prospective study.nnnSETTINGnTertiary care center.nnnPATIENT(S)nForty-eight women with endoscopically staged endometriosis and chronic pelvic pain who had undergone medical and/or conservative surgical therapy.nnnINTERVENTION(S)nEach participant was administered a questionnaire that included a determination of the severity and location of her pain.nnnMAIN OUTCOME MEASURE(S)nThe stage of disease, the area of the pelvis that contained the bulk of disease, the severity of pain, and the location of the most severe pain were recorded.nnnRESULT(S)nThe mean duration from the initial diagnosis until follow-up was 15.7 +/- 3.1 years, Twenty-one (43.8%) subjects denied any symptoms of pain on follow-up evaluation. Of the 27 patients with persistent pain, 21 (78%) identified the location of their most severe pain as being the same as at initial diagnosis. The stage of disease at initial diagnosis was significantly associated with a higher degree of pain at follow-up.nnnCONCLUSION(S)nThese data suggest that endometriosis-associated chronic pelvic pain commonly persists throughout the reproductive years and that endometriosis stage is directly related to the persistence of pelvic pain.

Sperm recovery and survival: two tests that predict in vitro fertilization outcome

OBJECTIVESnTo determine if human sperm recovery during swim-up and sperm survival after 24 hours, as obtained from a screening semen specimen, are predictive of subsequent IVF and clinical pregnancy rates (PRs) and to determine if these techniques can identify men with normal semen analysis parameters and poor IVF success.nnnDESIGNnHistorical prospective study.nnnSETTINGnAll semen evaluations and IVF cycles were performed at the University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, Pennsylvania.nnnPATIENTS, PARTICIPANTSnCouples undergoing IVF at Magee-Womens Hospital from August 1988 through June 1993.nnnINTERVENTIONSnA screening semen analysis and swim-up procedure were performed on all couples undergoing IVF. The number of spermatozoa recovered after swim-up and the percentage of motile spermatozoa present after a 24-hour incubation were recorded.nnnMAIN OUTCOME MEASURESnFertilization and PRs were compared according to the parameters obtained from routine semen analysis, the number of spermatozoa obtained with swim-up, and the percentage of motile spermatozoa at 24 hours.nnnRESULTSnUsing chi2 or Fishers exact test, fertilization rates were significantly different according to the number of spermatozoa recovered after swim-up (< or = 2.0 and > 2.0 x 10(6) spermatozoa recovered, 48.3% versus 71.4%) as were PRs (16.9% versus 29.8%). Similarly, the percentage of motile spermatozoa present at 24 hours (< or = 20% and > 20%) discriminated between fertilization rates (45.9% versus 65.8%) and PRs (16.4% versus 36.5%). Among a subset of men with normal semen analyses and total motile sperm counts > or = 40 x 10(6), the results from swim-up and survival discriminated between men with high and low fertilization and PRs. Receiver operating characteristic analysis revealed that swim-up results better discriminated between pregnant and nonpregnant IVF patients than sperm motility, but that the percentage of motile spermatozoa present at 24 hours was no better in this regard than sperm motility.nnnCONCLUSIONSnThe number of spermatozoa recovered after swim-up and the percentage of spermatozoa that maintain their motility after 24 hours were both helpful in assessing IVF and PRs and may be helpful in altering physicians to a subset of men having normal semen analysis parameters yet poor IVF success.

Assessment of Insulin Resistance and Impaired Glucose Tolerance in Lean Women with Polycystic Ovary Syndrome

OBJECTIVEnTo analyze insulin resistance (IR) and determine the need for a 2-hour oral glucose tolerance test (OGTT) for the identification of IR and impaired glucose tolerance (IGT) in lean nondiabetic women with polycystic ovary syndrome (PCOS).nnnMETHODSnThis was a cross-sectional analysis of treatment-naive women with PCOS who enrolled in a university-based clinical trial. Nondiabetic women with PCOS based on the Eunice Kennedy Shriven National Institute of Child Health and Human Development (NICHD) definition, aged 18-43 years and weighing ≤113u2009kg, were evaluated. Glucose and insulin levels were assessed at times 0, 30, 60, 90, and 120 minutes after a 75-g glucose load. Lean was defined as body mass index (BMI) <25u2009kg/m(2). Multiple linear regression was performed.nnnRESULTSnA cohort of 78 women was studied. The prevalence of IR was 0% among lean women vs. 21% among nonlean subjects based on fasting insulin I(0) and 40%-68% based on two different homeostatic model assessment (HOMA) cutoff points (pu2009<u20090.005). All women with IR had a BMIu2009≥u200928. Controlling for age and race, BMI explained over 57% of the variation in insulin fasting (I(o)), glucose fasting/Io (G(o)/I(o)), the qualitative insulin sensitivity check index (QUICKI), and HOMA and was a highly significant predictor of these outcomes (pu2009<u20090.0001). Only 1 of 31 (3%) of the lean PCOS women had IGT based on a 2-hour OGTT, and no lean subjects had IGT based on their fasting blood glucose.nnnCONCLUSIONSnDiabetes mellitus, IGT, and IR are far less common in young lean women with PCOS compared with obese women with PCOS. These data imply that it is unnecessary to routinely perform either IR testing or 2-hour OGTT in lean women with PCOS; however, greater subject accumulation is needed to determine if OGTT is necessary in lean women with PCOS. BMI is highly predictive of both insulin and glucose levels in women with PCOS.

Endometriosis impairs the efficacy of gamete intrafallopian transfer: results of a case-control study*

OBJECTIVEnTo determine whether pelvic endometriosis impairs the efficacy of GIFT.nnnDESIGNnMatched follow-up study.nnnSETTINGnUniversity-based assisted reproduction program.nnnPARTICIPANTSnPatients undergoing GIFT between 1987 and 1991. Cases had a primary diagnosis of endometriosis. Controls had no endometriosis and were matched with cases according to age, number of mature eggs transferred, and sperm grade.nnnINTERVENTIONnGamete intrafallopian transfer was performed in all patients in an identical manner independent of their underlying diagnosis.nnnMAIN OUTCOME MEASURESnPregnancy and delivery rates.nnnRESULTSnOf 114 laparoscopic egg retrievals performed in the endometriosis group, there were 37 pregnancies (32.5%) and 27 deliveries (23.7%). Of the 214 retrievals in the control group, there were 101 pregnancies (47.2%) and 76 deliveries (35.5%). Mantel-Haenszel estimates of relative risk indicated that endometriosis significantly impaired pregnancy and delivery rates. There was no statistically significant difference in pregnancy rates according to severity of disease among endometriosis cases. There was no statistically significant difference in pregnancy rates according to severity of disease among endometriosis cases.nnnCONCLUSIONSnOur finding that GIFT pregnancy rates were lower in women with a primary diagnosis of endometriosis than in matched controls suggests that endometriosis is associated with reduced efficacy of GIFT.

Current management of unexplained infertility.

During the last decade, numerous studies have evaluated the effectiveness of various treatments for unexplained infertility. Few studies employ a design that allows for appropriate comparison with an untreated control group. This article reviews the efficacy of clomiphene citrate, human menopausal gonadotropin, intrauterine insemination, superovulation with intrauterine insemination, and gamete intrafallopian transfer in the treatment of unexplained infertility. Treatment for patients with unexplained infertility with superovulation or gamete intrafallopian transfer is promising, but the incremental contributions of intrauterine insemination, superovulation, or gamete intrafallopian transfer beyond untreated controls await appropriately designed trials. When counseling patients regarding treatment options, both the expected increase in cycle fecundity and treatment expense should be considered.

Smoking and infertility: a committee opinion

Approximately 21% of women of reproductive age and 22% of men of reproductive age in the United States smoke cigarettes. Substantial harmful effects of cigarette smoke on fecundity and reproduction have become apparent but are not generally appreciated. This committee opinion reviews the potential deleterious effects of smoking on conception, ovarian follicular dynamics, sperm parameters, gamete mutations, early pregnancy, and assisted reproductive technology (ART) outcomes. It also reviews the current status of smoking cessation strategies. This document replaces the 2012 ASRM Practice Committee document of the same name (Fertil Steril 2012;98:1400-6).

Endometriosis and associated pathology.

The natural history of endometriosis, including the belief that it is a progressive disease, is reviewed with the help of a large, cross-sectional, prospective study and a smaller longitudinal study. Two studies are reviewed that address the role of growth factors in the development of endometriosis. These studies demonstrated that the peritoneal fluid of patients with endometriosis contained significant growth factor activity against human endometrial stromal cells. In a mouse model, macrophage-derived factors stimulated endometrial cell proliferation. The possible correlation between endometriosis and decreased bone mineral density, which was reported by an earlier study, is reviewed. Recent data, however, have shown no correlation between bone mineral density and endometriosis. Finally, several reports on the usefulness of endometrial antibodies and serum CA 125 levels in the diagnosis and treatment of patients with endometriosis are reviewed. These data suggest that both endometrial antibodies and CA 125 measurements may be useful in the diagnosis and treatment of patients with endometriosis.

Persistence with oral contraceptive pills versus metformin in women with polycystic ovary syndrome.

OBJECTIVEnWe studied patient persistence with oral contraceptive pills (OCPs) compared to metformin for treatment of polycystic ovary syndrome (PCOS) in an urban university clinic population.nnnMETHODSnWe conducted a retrospective cohort study of women with PCOS who were treated in our specialty clinic between 2004 and 2006. All women with the diagnosis of PCOS, defined as oligomenorrhea or amenorrhea in conjunction with clinical or biochemical evidence of hyperandrogenism, with exclusion of other causes, were included in the study. We abstracted data on demographic characteristics, medical history, anthropometrical measures, desire for pregnancy, prescribed treatment, and patient report of persistence with treatment at 3, 6, and 12 months. The primary outcome measure was persistence with prescribed treatment.nnnRESULTSnOne hundred nineteen subjects were included in the study. Demographic and anthropometrical characteristics were similar between the groups. At 3 months, 57.1% were persistent with OCPs, and 57.8% were persistent with metformin (p=0.93). At 6 months, the percentages dropped to 38.1% with OCPs and 43.9% with metformin (p=0.46). At 12 months, only 21.7% continued with OCPs compared to 31.2% with metformin (p=0.19). Subjects were significantly more likely to be persistent with either OCPs or metformin at 3 months compared to either 6 or 12 months (p<0.01).nnnCONCLUSIONSnWomen with PCOS showed similar persistence rates with OCPs compared to metformin. Persistence with either treatment precipitously decreases over time and is modest at 12 months.

Evaluation of the azoospermic male: a committee opinion

The purpose of this document is to review the current methods of diagnosis and evaluation for men with azoospermia.

American Society for Reproductive Medicine position statement on uterus transplantation: a committee opinion

Following the birth of the first child from a transplanted uterus in Gothenburg, Sweden, in 2014, other centers worldwide have produced scientific reports of successful uterus transplantation, as well as more recent media reports of successful births. The American Society for Reproductive Medicine recognizes uterus transplantation as the first successful medical treatment of absolute uterus factor infertility, while cautioning health professionals, patient advocacy groups, and the public about its highly experimental nature.