Deborah A. Metzger

A comparative analysis of the cycle fecundity rates associated with combined human menopausal gonadotropin (hMG) and intrauterine insemination (IUI) versus either hMG or IUI alone

Human menopausal gonadotropin (hMG) superovulation combined with washed intrauterine insemination (IUI) has been advocated for the treatment of various forms of infertility when more traditional therapy has failed. To assess the relative efficacy of combined treatment with hMG and IUI compared with either hMG or IUI alone, pregnancy outcomes of the three treatment groups were compared in couples having infertility because of male factor, cervical factor, endometriosis, or unexplained. A total of 751 cycles were analyzed from 322 couples. The mean cycle fecundity rate associated with hMG/IUI therapy was significantly higher than either hMG or IUI therapy alone for all patients (hMG/IUI = 19.6%, hMG = 6.3%, IUI = 3.4%). The improvement in cycle fecundity rates with hMG/IUI therapy was also observed when the couples were separated by infertility diagnostic groups: male factor (hMG/IUI = 15.3%, hMG = 4.4%, IUI = 3.0%), cervical factor (hMG/IUI = 26.3%, hMG = 7.9%, IUI = 5.1%), endometriosis (hMG/IUI = 12.85%, hMG = 6.6%), and unexplained infertility (hMG/IUI = 32.6%, hMG = 5.5%, IUI = 0%). Moreover, in patients who had failed to conceive with hMG or IUI alone, the cycle fecundity rate when they were switched to hMG/IUI therapy equaled that of patients who received combined therapy from the onset. We conclude that cycle fecundity rates and cumulative pregnancy rates are significantly greater using a combination of hMG and IUI compared with either modality alone in the treatment of male factor, cervical factor, endometriosis, or unexplained infertility. Indeed, in couples with nontubal related infertility, cycle fecundity rates with hMG/IUI approach the rates seen with in vitro fertilization and gamete intrafallopian tube transfer.

Superovulation with human menopausal gonadotropins is associated with endometrial gland-stroma dyssynchrony *

OBJECTIVE To investigate the prevalence of endometrial inadequacy in endometrial biopsies from women undergoing superovulation with hMG and to correlate these findings with the hormonal milieu. DESIGN Controlled, retrospective analysis. SETTING University-based, tertiary referral, outpatient infertility clinic. SUBJECTS Endometrial biopsies were performed during the late luteal phase in 89 women undergoing hMG superovulation combined with IUI. Results were compared with the initial biopsies obtained as part of their routine infertility evaluation. MAIN OUTCOME MEASURES Biopsies were dated by two different observers using standard dating criteria. Serum samples obtained during the midluteal phase were assayed in duplicate for E2 and P levels using commercially available RIAs. RESULTS Fifty-seven percent of the endometrial biopsies showed differences in the dating of the glandular epithelium that differed by > 2 days when compared with the stroma. In contrast, only 13% of endometrial biopsies obtained during a nonstimulated cycle showed gland-stroma dyssynchrony. When cycles associated with gland-stroma dyssynchrony were compared with cycles associated with coordinated development of the glands and stroma, no significant differences were observed in E2 level on the day of hCG administration, midluteal serum P, midluteal E2 level, or P:E2 ratios. CONCLUSIONS This study demonstrates that when endometrial biopsies are obtained during the late luteal phase in patients undergoing ovarian hyperstimulation there is a significant dyssynchrony in the maturation of the glandular epithelium and the stroma. This may reflect the degree of responsiveness of an individual womans endometrium rather than a result of the hormonal milieu.

Conservative management of interstitial pregnancy

Earlier detection of ectopic pregnancies allows the patient and physician the option of conservative management. Conservative surgical management of ampullary ectopic pregnancies has been well described. Traditional management of interstitial or cornual gestation has been by salpingectomy with or without cornual resection or by hysterectomy. In this paper we present a case report of alternative, less radical surgical management and review the literature on conservative surgical and medical management of interstitial pregnancies.

Slow excretion of exogenous human chorionic gonadotropin simulating repeated pregnancies and pregnancy losses

We report a patient undergoing hMG-induced superovulation who demonstrated delayed excretion of hCG, originally believed to be because of successive biochemical pregnancies. However, sequential hCG titers after administration of exogenous hCG demonstrated a longer than normal half-life for the excretion of hCG in this patient. To what extent delayed excretion of hCG contributes to the diagnosis of biochemical pregnancy in assisted reproductive technology programs has yet to be determined.

Histologic features associated with hormonal responsiveness of ectopic endometrium

OBJECTIVE To correlate histologic parameters of endometriosis with hormonal responsiveness. DESIGN Seven hundred sixty-eight unselected endometriotic implants and the corresponding intrauterine endometrium from 196 patients were classified by standard endometrial dating criteria. In addition, other histologic characteristics of endometriotic implants such as the amount of stroma, amount of fibrosis, the presence of surface epithelium, presence of focal hemorrhage, and gland characteristics were also noted. SETTING Academic tertiary referral center. MAIN OUTCOME MEASURES Comparison of histologic dating between endometriotic implants and the corresponding endometrium as a function of histologic parameters. RESULTS Implants that were synchronous with the corresponding eutopic endometrium had more stroma than those that were out of phase. The amount of fibrosis was inversely related to hormonal responsiveness. The presence of surface epithelium in implants was also associated with an impaired response (28.0% versus 48.0% in phase). Endometriomas were found to be in phase with the corresponding endometrium less often than other types of implants (21.7% versus 43.3%). Although endometriomas had similar amounts of stroma when compared with other implants, they had significantly more fibrosis (850.2 microns versus 195.0 microns). CONCLUSIONS These results suggest that the unpredictable response of endometriotic implants to cyclic endogenous hormones and hormonal therapy may be related to the architectural relationships between the cellular elements found in normal endometrium.

Applications of hormone receptors in obstetrics and gynecology

Abstract Actions of all hormones are predominantly mediated by specific receptors. Progress in understanding the basic mechanisms of hormone-receptor interactions has led to several clinical applications of this receptor technology. Current applications include diagnosis and management of neoplasms of hormone-responsive tissues in the woman, diagnosis of previously inexplicable endocrine disorders, and development of new hormonal therapeutic agents. Our future diagnostic and therapeutic repertoire should continue to expand as these new molecular biology techniques mature.