David Bider

Outcome of hysteroscopic resection of submucous myomas for infertility

OBJECTIVEnTo examine the reproductive outcome after operative hysteroscopic resection of submucous myomas in women for whom no other infertility factor was identified.nnnDESIGNnFifteen infertile women with submucous myomas underwent an intensive workup to exclude other causes of infertility. Operative hysteroscopy for resection of the submucous myomas was performed using a rigid 26 French resectoscope (Karl Storz GmbH & Co., Tuttlingen, Germany).nnnSETTINGnAcademic tertiary referral center.nnnRESULTSnThe mean +/- SD duration of the procedure was 25.5 +/- 5.6 minutes. No operative or postoperative complications occurred and all patients were discharged within 6 hours. The follow-up period was 12.0 +/- 4.2 months (mean +/- SD). Seven women conceived (pregnancy rate of 47%) and six of them subsequently delivered at term.nnnCONCLUSIONnThe results of this study indicate that operative hysteroscopy achieved a pregnancy rate comparable to myomectomy via laparotomy. These results suggest that operative hysteroscopy is the procedure of choice for the resection of submucous myomas in infertile women.

Cytokine levels in follicular fluid of polycystic ovaries in patients treated with dexamethasone

Objective To assess the levels of cytokines in the follicular fluid of stimulated ovaries. Design The study included two groups of four patients with polycystic ovarian disease. These were diagnosed by clinical and ultrasonic features and characteristic hormonal profiles, treated with gonadotropin-releasing hormone-analogue and human menopausal gonadotropin. One group received dexamethasone (DEX). Main Outcome Dexamethasone is capable of directly affecting granulosa and immune cells. It was also expected to affect cytokine production of granulosa and immune cells of the ovary. Results This study demonstrates that FF from patients treated with DEX has reduced tumor necrosis factor (TNF) activity and elevated colony-stimulating factor levels. Regardless of the treatment with DEX, the follicles with high levels of TNF contained minimal concentrations of estradiol. Interleukin-6 did not differ between the FF samples. Conclusions These results suggest a role for cytokines in the process of folliculogenesis and ovarian maturation. Modification of cytokines by DEX might explain the beneficial effect of fertility.

Intraumbilical vein injection of prostaglandin F2α in retained placenta

Abstract A randomized protocol was used to study the effect of intraumbilical prostaglandin F 2 α (Hembate, Upjohn) and oxytocin injection in women with retained placenta. Prostaglandin F 2 α, 20 mg, diluted to 20 ml in normal saline solution (10 women, group 1), 30 IU of oxytocin, diluted to 20 ml in normal saline solution (11 women, group 2), or 20 ml of normal saline solution alone (7 women, group 3), were injected into the umbilical vein 1 h after delivery. Nine women (group 4, controls) underwent manual removal of the retained placenta. In group 1, placental expulsion occurred in all patients and the duration of the placental expulsion after prostaglandin F 2 α injection was 6.8 ± 1.36 (mean ± SE) min: in group 2, six placental expulsions occurred after 13.3 ± 1.97 min (mean ± SE); and in group 3, no effect was recorded after intraumbilical saline injection. We suggest that intraumbilical vein injection of prostaglandin F 2 α might be a beneficial, non-surgical method for treating retained placenta. Oxytocin might reduce the incidence of manual lysis of the placenta and achieve partial success.

Hysteroscopy in a program of in vitro fertilization

Two hundred twenty-four women underwent hysteroscopic evaluation without anesthesia after at least two failed attempts of in vitro fertilization and embryo transfer. One hundred fifty-three (68%) women were diagnosed as having mechanical infertility, and abnormal hysteroscopic findings were observed in 32 (21%). Forty-one women were diagnosed as having unexplained infer-tility (18%) and six (15%) had abnormal findings with hysteroscopy. Of the 30 couples who entered the in vitro fertilization regimen program because of male infertility, 4 (13%) had abnormal findings. The overall rate of abnormal findings was 19%; cervical canal and intrauterine abnormalities were found in 10 and 32 patients, respectively. Ten patients were treated during hysteroscopic evaluation procedure, and four patients subsequently underwent operative hysteroscopy under general anesthesia. We suggest that diagnostic hysteroscopy should be a routine procedure before in vitro fertilization and embryo transfer therapy.

Limitations in the Use of Combined Gonadotropin Releasing Hormone Analog and Human Menopausal Gonadotropin for In Vitro Fertilization

Ovarian stimulation is an important step in in vitro fertilization (IVF) therapy which has had a profound impact upon the success or failure of the whole procedure. It is now recognised that no single ovarian stimulation agent or dosage is optimal for all patients and that stimulation should be tailored and adjusted to best suit the patient’s own hormonal status. However, as with every stimulation protocol, 20% to 40% of the patients are cancelled before ovum pick-up mainly due to premature Luteinizing Hormone (LH) surge.

Sequential transfer of day 3 embryos and blastocysts after previous IVF failures despite adequate ovarian response.

The purpose of this study was to compare IVF outcome following sequential embryo transfer (ET) with that following the transfer of early cleavage embryos among patients with previous multiple IVF failures but adequate ovarian response. A retrospective matched case-control analysis was made of the medical files of 66 women who underwent sequential transfer of day 3 embryos and blastocysts in the Chaim Sheba Medical Centre between January 1999 and May 2004. The control group included 117 matched women who underwent embryo transfer on day 3 only. Sequential transfer of embryos in women resulted in a pregnancy rate of 30.3% (20/66) compared with 17.1% (20/117) following day 3 ET (P < 0.05). Multiple pregnancies (most of them twins) were significantly more common in women undergoing sequential transfer (10/20 versus 2/20; P < 0.02). Sequential transfer of embryos may be indicated for women with repeated IVF cycles, but the number of embryos transferred must be limited in order to prevent multifetal gestations. More data are needed to support this approach.

Subsequent successful pregnancy and delivery after intracytoplasmic sperm injection in a patient with XY gonadal dysgenesisms.

Report of a rare case of subsequent twin delivery after intracytoplasmic sperm injection (ICSI) into donated oocytes in a 30-year-old woman with a diagnosis of XY dysgenesis, who underwent a gonadectomy at the age of 13 years. Her husband suffers from severe oligo-astheno-terato-spermia.

Intra-uterine insemination with prepared sperm vs. unprepared first split ejaculates. A randomized study.

Summary. In this randomized prospective study, we determined the conception rate following intra‐uterine insemination with washed and prepared sperm, or with the first portion of a split ejaculate, in couples with longstanding male (n = 27, 70 treatment cycles) or cervical infertility (n = 14, 29 treatment cycles). Folliculogenesis and ovulation were induced by human menopausal gonadotropin and human chorionic gonadotropin. Significantly more couples conceived in the male infertility group following intra‐uterine insemination with washed sperm, than after intrauterine insemination with split ejaculate (9 vs. 2; P<0.05), while no difference in pregnancy rate (2 vs. 2) was found by the two intra‐uterine insemination methods in the cervical infertility group.

Addin of Exogenous Estrogens To Improve Cervical Mucus Following Clomiphene Citrate Medication: Patient Selection

Medication with Clomiphene Citrate and its effects on the quality of cervical mucus and the addition of exogenous estrogens in order to suppress abnormal mucus secretion are controversial issues. We have prospectively studied a group of 19 anovulatory women who were treated with clomiphene citrate in order to characterize those patients most likely to respond to the addition of exogenous estrogens. On day 14 of the cycle, 17 β estradiol and cervical ‐re were measured and 1 mg estradiol benzoate was injected intramuscularly. Cervical scores were below 7 in 12 out of the 19 patients before estradiol benzoate administration. In these patients, 17 β estradiol rose from 751±541 to 1321±648 pg/ml (p<0.03).and cervical scores rose from 3.75±2.1 to 7.1±3.7 (p<0.0l), after estradiol benzoate administration. Patients with cervical scores of 8‐12 did not improve significantly. In the 12 patients with cervical scores below 7, those (n=6) with 17 β estradiol below 600pg/ml experienced a significant improvement in cervical score, in contrast to those (n=6) with 17 8 estradiol above 600pg/ml who had no improvement. The reduction in cervical mucus accomplished with clomiphene citrate can be further improved by adding exogenous estrogens, mainly in patients who have low 17 β estradiol levels concomitant with low cervical score.

Unsuccessful methotrexate treatment of a tubal pregnancy with a live embryo

Two cases with unsuccessful local and systemic methotrexate (MTX) therapy of tubal pregnancy with fetal heart rate activity are reported. The three modes of therapy, the first with local potassium chloride solution injection, the second with local MTX injection, and the third with systemic MTX injection, failed in the resolution of viable ectopic pregnancy. Therapy of MTX in cases of tubal pregnancy with demonstrable fetal heart rate beats, should be reconsidered.