J. Shalev

Elective Cervical Suture of Twin Pregnancies Diagnosed Ultrasonically in the First Trimester following Induced Ovulation

The efficiency of elective cervical suture in preventing premature delivery thus reducing neonatal mortality was studied in a group of 50 twin pregnancies. All pregnancies occurred after induction of ovulation and twins were diagnosed early by ultrasound. 25 randomly selected patients underwent elective cervical suture. 22 sutured and 23 non-sutured patients were followed until delivery, while 5 patients aborted in the second trimester. The benefit of suturing on the duration of pregnancy and its outcome were assessed. Of the sutured patients, 10 (45.4%) delivered prematurely and the neonatal death rate was 18.2%. In the non-sutured patients, 11 (47.8%) delivered prematurely and the neonatal death rate was 15.2%. This study demonstrates that elective cervical suture was not effective in prolonging gestation or improving fetal outcome in twin pregnancies following induced ovulation.

Pregnancy outcome after unwinding of twisted ischaemic-haemorrhagic adnexa

Six women who became pregnant after human menopausal gonadotrophin/human chorionic gonadotrophin (hMG/hCG) treatment regimens were operated on between 6 and 21 weeks gestation with an intra‐operative diagnosis of twisted ischaemic‐haemorrhagic adnexa. During operation unwinding of the adnexa was performed in all patients. Monitoring of the pregnancy before and after operation by ultrasonography was normal. The postoperative period and the rest of the pregnancy were uneventful. Three women were delivered normally at term. One patient was delivered by caesarean section because of twin pregnancy with malpresentation, and two pregnancies are still ongoing beyond the first trimester. This preliminary study suggests that detorsion of ischaemic‐haemorrhagic adnexa during pregnancy is an option that is not associated with subsequent complications. This approach might be adopted relatively safely when preservation of future fertility is a goal.

The effect of clomiphene citrate and tamoxifen on the cervical mucus.

The anti‐estrogenic effect of clomiphene citrate (CC) and tamoxifen (TMX) on cervical mucus was evaluated in a prospective crossover study. Ten women underwent randomized alternate cyclical treatment with either 100 mg CC, 40 mg TMX daily, or with placebo. The effect of CC, TMX and placebo on serum estradiol (E2), cervical mucus secretion and on the development of ovarian follicles was evaluated. Compared with placebo, treatment with CC and TMX significantly increased the number of mature ovarian follicles on the day of assumed ovulation (p <0.05), elevated E, secretion (p <0.05) and decreased cervical score (p <0.05). It can be concluded that anti‐estrogenic agents reduced the secretion of cervical mucus. However, in most cases, the excessive E, production due to multiple follicular growth overcomes the anti‐estrogenic effect.

Suppression with Gonadotropin-Releasing Hormone Analogues Prior to Stimulation with Gonadotropins: Comparison of Three Protocols

This study compared three groups of patients treated with three different protocols of suppression of the pituitary-ovarian axis prior to and during gonadotropin stimulation for in vitro fertilization with a nonsuppressed control group. Patients treated with daily injections of DTRp6 (Decapeptyl 0.5 mg) or with a single injection of Decapeptyl depot (3.2 mg CR) had a longer folicular phase than patients treated with Buserelin (1.2-1.5 mg daily) and the patients in the control group. The number of human menopausal gonadotropin ampules required to reach adequate stimulation was also significantly higher in the former two groups of patients. The number of oocytes recovered (6-7 per patient), fertilized (45-58%) and cleaved (92-100%) did not differ among the groups. Peak estradiol levels and the pregnancy rate were highest in the group treated with Buserelin. The overall picture would indicate that suppression with Buserelin was the least profound.

An Unexpectedly High Rate of Ectopic Pregnancy Following the Induction of Orulation with Human Pituitary and Chorionic Gonadotrophin

Sir, McBain et a1 reported an incidence of ectopic pregnancies of 3 1 % after hPG-hCG induced ovulation. This rate is higher than in the general population, and occurred in the absence of predisposing factors. Two of their six cases were combined with intrauterine pregnancy. They found an association between ectopic pregnancy and elevated urinary total oestrogens (>200 pg/24 hours) around the time of the ovulation. On reviewing our data we could not confirm such a high incidence. In the infertility clinic of the Sheba Medical Center, Tel-Hashomer we have treated over 800 women with hMG-hCG (Pergonal) in over 3000 cycles. Three women had 4 ectopic pregnancies, a rate of I .14% (4:350 pregnancies), This rate is slightly higher than in our general population, but the incidence of ectopic pregnancy in our hospital has increased over the last 4 years from an overall rate of 0.82% (1:121 pregnancies) to 1.17% (1:85 pregnancies). This increased rate might be due to an increased rate of pelvic inflammatory disease and also to improved methods of diagnosis of the early or clinically uncertain ectopic pregnancy such as ultrasound, laparoscopy and particularly serum hCCi beta subunits. On reviewing the laparoscopies of those three women, we found that two of the three had a mechanical factor. Only in one case did the tubal pregnancy occur without any known tubal pathology. Urinary total oestrogens on the day of hCG administration in all four cases of ectopic pregnancy was between 80-160 ygj24 hours, which is the optimal range (100-200 pg/24 hours). If high oestrogen levels are associated with ectopic pregnancy, the incidence should be higher in cycles with hyperstimulation. We have a 19.8 % hyperstimulation rate in those cycles resulting in pregnancy. This syndrome is mainly associated with high oestrogen levels. In view of the 10% ectopic pregnancy rate reported by McBain in cycles with urinary oestrogens above 200 pg/24 hours it is expected that there would be at least 8 ectopic pregnancies in our hyperstimulated patients, but there were none. Although it has been postulated that high oestrogen levels during ovulation might accelerate tubal transport, and. low levels cause delay of tubal transport or locking, these are more likely to result in degeneration of the ovum (Burdick and Pincus, 1935) rather than ectopic pregnancy. We feel therefore that McBain’s results, although interesting, are not supported by our data.

Lack of association between ovarian follicular size and number and the occurrence of multiple pregnancies in menotropin cycles

A high rate of ovarian multifollicular development and resulting multiple pregnancy remains the main problem of ovulation induction with human menopausal gonadotropins. The aim of this study was to examine a possible correlation between the number and size of ovarian follicles at the time of human chorionic gonadotropin (hCG) administration and to find parameters that can predict the occurrence of multiple pregnancies. Sixty-eight intrauterine pregnancies, 53 singletons and 15 multiple pregnancies in 51 patients, were included in this study. We found no significant difference in the mean estradiol levels, the total number of pre-ovulatory follicles, or the mean number of large, intermediate or small follicles at the time of hCG administration between women who had singleton pregnancies and those with multiple pregnancies. Our study demonstrates that estradiol levels and ovarian ultrasonography do not provide criteria for the prediction of the occurrence of multiple pregnancies in menotropin cycles.

Fetal heart rate changes following external cephalic version under tocolysis near term

Fifty eight gravidas near‐term underwent external cephalic version using tocolytic treatment and continuous fetal monitoring by cardiotocograph and real‐time ultrasound. No unfavorable maternal or fetal effects were recorded. Fetal heart rates showed a significant decline at 10 and 30 min after the procedure with complete recovery at 1 h after external version, but no pathologic tracing was recorded. No uniform heart rate patterns due to external cephalic version could be found.

Breast Stimulation in Late Pregnancy

The effect of breast stimulation on the prostaglandin secretion was tested in 13 patients at 38-40 weeks of gestation. Uterine contractions following breast stimulation were documented in all cases. There was an increase in prostaglandin metabolite levels 10 min after breast stimulation.

Pituitary and ovarian suppression rate after high dosage of gonadotropin‐releasing hormone agonist

Ten infertile menstruating women were treated with daily injections of gonadotropin-releasing hormone agonist (GnRH-a). The GnRH-a (Buserelin; Hoe 766, Hoechst-AG, Frankfurt/Main, West Germany) was administered subcutaneously (SC) from day 9 of the cycle for 6 days, and intranasally (1.2 mg) for 15 days. Before treatment, all ten women had a normal response to Buserelin challenge test and the GnRH test, and seven of the ten responded to estradiol (E2) benzoate test (2 mg intramuscularly). The SC administration of Buserelin (1.5 mg) for 6 days resulted in suppression of pituitary activity. Continuous treatment with Buserelin (1.2 mg for 3 weeks) was effective as demonstrated by decreasing serum E2 levels to below 20 pg/ml, and in the absence of ovarian follicles in ultrasonographic scanning. Three days after cessation of Buserelin treatment, the pituitary again responded to the GnRH test. Thus, the authors concluded that the administration of Buserelin in very high doses can induce medical hypophysectomy within 6 days, but over 3 weeks of suppression therapy are required to abolish ovarian findings. Desensitization of the pituitary was reversible within 3 days of cessation of the treatment.