Ingrid A. Rodi

Biologic and morphologic development of donated human ova recovered by nonsurgical uterine lavage

Using uterine lavage performed 5 days after the luteinizing hormone peak, we collected 25 uterine ova from five fertile donors who had had a single, periovular artificial insemination. After examination, all recovered ova were transferred to recipient uteri and resulted in three intrauterine and one tubal pregnancy. Morphologic development ranged from degenerating single-cell ova to mature blastocysts. Ages of the ova at recovery ranged from 93.5 to 130.0 hours postovulation. Mean age of the five blastocysts, 109.1 hours, was not significantly different from the mean age of the 20 less mature ova, 108.1 hours. Neither the mean interval from insemination to recovery for blastocysts nor the mean interval from insemination to ovulation for blastocysts was significantly different from the mean intervals of the other ova. The five blastocysts resulted in intrauterine pregnancies in three recipients. There were no intrauterine pregnancies from the other 20 transfers (p less than 0.004). A transferred 12-cell ovum with degenerating blastomeres was associated with tubal pregnancy in the recipient. The large variability in the state of intrauterine ova observed in the relatively fixed postovulatory interval of this study appears to be due to differences in viability and maturation, not differences in ovum age. Maturational state of the ova at the time of transfer appears to be a significant determinant of the likelihood of ensuring pregnancy.

Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial *

Unruptured tubal pregnancies diagnosed at laparoscopy were treated with either methotrexate/citrovorum factor (MTX/CF) (n = 21) or observation (n = 5). Entry criteria required that the ectopic pregnancy be visualized, less than or equal to 3 cm in diameter, with intact serosa and no active bleeding. Treatment selection was based upon preoperative levels of beta-human chorionic gonadotropin (beta-hCG), with MTX/CF given to subjects exhibiting a plateaued or rising pattern and observation alone given to those with falling levels. Twenty-five of 26 ectopic pregnancies resolved without need of laparotomy. Two subjects received blood transfusions and one required a second operation for intra-abdominal bleeding. In both cases, fetal cardiac activity was noted pretreatment on ultrasound. The authors conclude the following: (1) MTX/CF may be safely used to treat selected unruptured ectopic pregnancy; (2) many ectopic pregnancies resolve spontaneously; and (3) ectopic pregnancies that form fetal elements, as evidenced on ultrasound, should not be managed medically.

Timely diagnosis of early ectopic pregnancy using a single blood progesterone measurement.

We obtained a single serum P measurement in 70 subjects at risk for an EP. Retrospectively, a P less than 15 ng/ml was 100% predictive of either an EP or otherwise nonviable IUP, while P greater than 15 ng/ml would have ruled out an EP in all cases. Because of this high degree of diagnostic accuracy, we speculated on the clinical utility of an outpatient D and C for those patients in our series having a P less than 15 ng/ml. Laparoscopy would be reserved for those cases without identifiable chorionic villi on frozen section of curettings. Following this course of management could have potentially diagnosed all EPs at the first ER visit without disruption of a single normal IUP in our series. This sequence could have expedited the diagnosis of EP by up to 14 days compared with a standard hCG/US protocol. This report describes a promising new test for the early detection of EP. The findings, however, require confirmation in a prospective trial before widespread clinical implementation.

The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience *

Seven women with unruptured tubal pregnancies diagnosed on laparoscopy were treated with methotrexate and citrovorum rescue. Criteria for inclusion in the study were that the level of human chorionic gonadotropin (hCG) be plateaued or rising, that the ectopic pregnancy not exceed 3 X 3 cm, that the tubal serosa be intact, and that there be no active bleeding. The women were followed with serial measurements of hCG, complete blood counts, and liver function tests. All women responded to a single course of therapy. The median time to resolution (from the first day of treatment to when the hCG was undetectable) was 31 days (range, 5 to 50 days). Follow-up hysterosalpingograms were available for five women. Four women demonstrated tubal patency, and one showed a unilateral occlusion on the side of the ectopic. One woman was found to have an intrauterine pregnancy prior to the scheduled time of hysterosalpingogram.

Survey of attitudes regarding the use of siblings for gamete donation

We conclude that the acceptability of using a sister for gamete donation is high among couples desiring ovum donation. On the contrary, couples undergoing AID generally rejected the concept of using the husbands brother as a known donor. Thus, although similar in concept, disparity exists regarding the use of siblings for gamete donation. Though the use of sibling gamete donation may provide a short-term solution to the dwindling supply of acceptable gamete donors, the long-term acceptability of such practice remains unknown.

Patient selection for laparoscopic myomectomy

STUDY OBJECTIVE To determine if preoperative criteria could select patients who were likely to be managed successfully by laparoscopic myomectomy. DESIGN Prospective. SETTING Two community hospitals. PATIENTS Premenopausal women who had symptomatic uterine myomata and met the following criteria underwent laparoscopic myomectomy: uterine size less than or equal to 14 weeks after 12 weeks of gonadotropin-releasing hormone (GnRH) agonist therapy; no individual myoma larger than 7 cm; no leiomyoma near the uterine artery, or near the tubal cornua if fertility was desired; and at least 50% of the leiomyoma subserosal, to be accessible and to allow adequate repair of the myometrium through the laparoscope. INTERVENTIONS Laparoscopic assessment of the pelvis and laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS Forty-one patients entered the study: 23 met the selection criteria and were accepted for laparoscopic myomectomy, but 4 were excluded during laparoscopic assessment of the pelvis. Clinical examination or initial sonogram correctly predicted successful laparoscopic myomectomy in 13 of 19 women. After 3 months of GnRH agonist therapy, clinical examination or sonogram identified four additional candidates. In six patients in whom the optimum approach was still uncertain, laparoscopic assessment found two additional appropriate candidates for laparoscopic myomectomy. Nineteen patients underwent the procedure without the need to convert to laparotomy. None experienced any complications. CONCLUSIONS Careful patient selection can decrease the likelihood of inappropriate performance of laparoscopic myomectomy and avoid the need to convert to laparotomy.

Polysiloxane vaginal rings and cylinders for physiologic endometrial priming in functionally agonadal women

17 beta-estradiol (E2)-and/or crystalline progesterone (P)-impregnated polysiloxane vaginal rings and cylinders were tested as a system for endometrial priming in functionally agonadal women awaiting donor embryo transfer. Endometrial tissue was obtained by a transcervical biopsy procedure on simulated cycle day 26. The adequacy of the replacement regimen was judged by endometrial histologic dating, scanning electron micrographs, receptor content, and circulating E2 and P serum concentrations. Endometrial dating was consistent with cycle day 26. Electron micrographs showed normal surface characteristics. E2 and P receptor concentrations were within the normal range. Serum E2 levels were midfollicular, 105 +/- 12.8 pg/ml (mean +/- SEM), and midcycle, 254 +/- 28.6 pg/ml. P levels during the simulated follicular phase were undetectable (less than 0.2 ng/ml) but rose to a mean peak level of 17.3 +/- 1.8 ng/ml. The steroid-impregnated polysiloxane vaginal ring and cylinder system provided continuous and sustained hormone release, morphologically and endocrinologically normal endometrium, serum levels of E2 and P within the normal range for the entire menstrual cycle, and a convenient and physiologic therapeutic alternative to oral, vaginal, or intramuscular steroid replacement.

Unilateral vulvar edema after intraperitoneal Hyskon administration

Two patients are presented who developed vulvar edema after intraperitoneal instillation of Hyskon. Regardless of the route of extravasation, Hyskons high molecular weight and osmotic effects may lead to further soft tissue swelling. Correct diagnosis warrants the exclusion of wound infection, hematoma, or seroma. Special attention to ensuring peritoneal closure may lessen the risk for the development of this complication.

Preimplantation genetic diagnosis (PGD) as both a diagnostic and therapeutic tool in assisted reproductive technology (ART)

Materials/Methods: All patients entered into the study met all inclusion criteria and were then randomized into PGD or control in one of the 3 groups. All stimulation protocols utilized Follistim/Antagon and Pregnyl. Oocyte recovery was performed by ultrasound guided transvaginal approach. On day #3 post oocyte recovery all 6–8 cell embryos in the PGD group underwent blastomere biopsy and fixation. Slides were then federal expressed to St. Barnabas Hospital in Livingston, New Jersey. FISH was performed utilizing the following probes: x, y, 13, 15, 16, 17, 18, 21, 22. On day #5 post oocyte recovery results were obtained and embryo transfer of no more than 3-chromosomally normal embryos was performed. Medications including corticosteroids, antibiotics, low dose aspirin (80–81mg) and progestational supplementation were utilized. Serum B-HCG levels were obtained 12 days post embryo transfer. Results: See table