Isaac Z. Glatstein

Observer variability in the diagnosis and management of the hysterosalpingogram

OBJECTIVE To determine the reproducibility of hysterosalpingogram (HSG) interpretation and clinical management recommendations among trained observers. DESIGN Fifty HSG films were distributed to five fertility practitioners with a mean of 20 years clinical experience. Each observer evaluated components of uterine and tubal status and provided clinical recommendations for hysteroscopy and laparoscopy. SETTING University hospital-affiliated reproductive endocrine practice. INTERVENTION(S) None MAIN OUTCOME MEASURE(s): The level of agreement among observers for each uterine and tubal category as determined by the kappa(kappa) statistic. Determinants of clinical recommendation for further diagnostic studies were assessed. RESULT(S) The level of agreement between observers as determined by kappa ranged from 0.645 in the hydrosalpinx category, indicating fair reliability, to 0.111 for pelvic adhesions, indicating poor reliability. The composite kappa for uterine status was 0.345 whereas the composite kappa for tubal status was 0.430. Agreement among observers concerning management showed marginal reproducibility with a kappa of 0.261. Overall, more than one abnormality of either the cavity or the fallopian tubes led to a diagnostic recommendation for further workup in > or = 90% of cases. CONCLUSION(S) In a group of five experienced clinicians, there was considerable variability in the interpretation as well as the clinical management of the HSG. Physicians caring for infertile couples should be aware of this discrepancy and should, if possible, review carefully both the original films as well as the report of the attending radiologist in formulating their diagnostic evaluation and management plan.

The predictive value of discriminatory human chorionic gonadotropin levels in the diagnosis of implantation outcome in in vitro fertilization cycles

OBJECTIVE To determine if early serum hCG levels are predictive of implantation outcome in patients undergoing IVF-ET. DESIGN Retrospective study of IVF cycles using receiver operator characteristic curve (ROC) analysis. SETTING Tertiary-care, university hospital-affiliated IVF program. PATIENTS Three hundred fifty-one conception cycles were studied. INTERVENTIONS None. MAIN OUTCOME MEASURE Implantation failure, defined as chemical pregnancies, ectopic gestations, and first trimester abortions, or implantation success, defined as delivered singleton and multiple pregnancies, and second trimester abortions. RESULTS For each post-ET day 14 to 20, mean hCG levels of the implantation success group were significantly greater than implantation failure outcomes (P < 0.0001). Using ROC curve analysis, hCG cutoff values for each post-ET day were calculated for optimal discrimination of implantation failure from implantation success cycles. A patient with an hCG measurement greater than the calculated cutoff value had a > or = 90% chance of having an implantation success after IVF-ET. CONCLUSION Discriminatory hCG cutoff values may be useful in predicting implantation outcome in IVF-ET cycles and may guide clinicians in identifying those pregnancies at risk for adverse outcomes and instituting more intensive surveillance in this population. This information also may be useful in providing counseling to IVF patients regarding pregnancy prognosis and result in cost savings.

Successful pregnancies with the use of laminaria tents before embryo transfer for refractory cervical stenosis

OBJECTIVE To determine whether laminaria tents are a safe and effective method of cervical dilatation in patients with a history of cervical stenosis and difficult ET. DESIGN Case reports describing two patients. SETTING Tertiary care, assisted reproduction practice. PATIENT(S) Two patients with cervical stenosis and a history of multiple failed cycles of IVF. INTERVENTION(S) Laminaria tents were placed intracervically before ET. MAIN OUTCOME MEASURE(S) Presence of a gestational sac and fetal heartbeat on ultrasound. RESULT(S) Successful clinical pregnancies occurred in both patients after laminaria placement and ET. CONCLUSION(S) Laminaria tent cervical dilatation appears to be a safe and effective option to assist ET in patients with a history of cervical stenosis.

Premature luteinization and in vitro fertilization outcome in gonadotropin/gonadotropin-releasing hormone antagonist cycles in women with polycystic ovary syndrome

OBJECTIVE To determine the incidence of premature luteinization in patients with polycystic ovary syndrome (PCOS) undergoing controlled ovarian hyperstimulation (COH) with exogenous gonadotropin/GnRH antagonist (GnRH-a); to compare clinical outcomes in patients with and without premature luteinization. DESIGN Retrospective case series. SETTING IVF clinic. PATIENT(S) Thirty-five treatment cycles in 30 patients with PCOS. INTERVENTION(S) Controlled ovarian hyperstimulation with gonadotropin/GnRH-a protocol. MAIN OUTCOME MEASURE(S) Premature luteinization defined as a P concentration of >/=1.3 ng/mL on the day of hCG administration; number of oocytes and two pronuclei (2PN) embryos; implantation and clinical pregnancy rates (PR). RESULT(S) The incidence of premature luteinization was 28%. Compared with those without premature luteinization, patients with premature luteinization had a higher number of oocytes retrieved (24.1 +/- 13.3 vs. 12.0 +/- 5.9) and greater number of mature oocytes (19.7 +/- 11.7 vs. 9.5 +/- 4.5), respectively. The number of good quality embryos and embryos transferred was not significantly different between groups. Although implantation rates (56% vs. 40%) and clinical PRs (36% vs. 30%) were higher in patients without premature luteinization, the differences were not statistically significant. CONCLUSION(S) The patients with PCOS with premature luteinization had a higher number of oocytes retrieved and mature oocytes, and similar clinical PRs as patients with PCOS without premature luteinization.