Jeffrey B. Russell

Resectoscopic management of müllerian fusion defects

Of the 103 patients taken to the operating room for hysteroscopic resection of a septum, 72 underwent successful resection of the septum. The initial hysterogram can identify those patients who may benefit from the procedure but cannot discriminate between bicornuate and septate uteri. Knowledge of the size and contour of the uterus is essential to the final decision to proceed transcervically, opposed to transabdominally. In the transcervical repair group, at the time this article was written, there were 58 term deliveries and 5 ongoing pregnancies greater than 30 weeks (1 had a spontaneous abortion after surgery and subsequently conceived a term pregnancy), for a successful pregnancy rate of 86%. This correlated well with the pregnancy rates observed after metroplasty. Therefore, hysteroscopic resection constitutes a valuable alternative to the classical transabdominal approach.

Outcome of in vitro fertilization in women with low response to ovarian stimulation

The occurrence of low-response (LR) cycles (defined as peak estradiol levels less than 300 pg/ml) in an in vitro fertilization program using a 3 ampule/day human menopausal gonadotropin regimen were retrospectively reviewed. LR occurred in 51 of 564 patients (9%). The LR serum estradiol levels were categorized into four different patterns that were further analyzed for outcome in these initial cycles, as well as for their predictive value of response in subsequent in vitro fertilization cycles. Changing the stimulation protocol to a combination of clomiphene citrate and human menopausal gonadotropin did not improve the ovarian response in this group of LR patients, and their chance to complete a subsequent normal-response treatment cycle was 32%. Suggestions are made to predict outcome and govern management of women with previous LR cycles.

A paired analysis of in vitro fertilization and cleavage rates of first- versus last-recovered preovulatory human oocytes exposed to varying intervals of 100% CO2 pneumoperitoneum and general anesthesia.

This study compares the in vitro fertilization and cleavage rates of paired first- and last-recovered preovulatory human oocytes that were exposed to a 100% CO2 pneumoperitoneum and general anesthesia. In 305 consecutive cycles of laparoscopy, 1741 oocytes (5.7/cycle) were recovered. The exact time of aspiration (T) was recorded for each oocyte. The time interval (T1 to T2) between recovery of first and last oocytes ranged from 0 to 38 minutes and represented differences in the exposure time of first and last oocytes to the CO2 pneumoperitoneum and to general anesthesia. For all cycles (n = 305) without regard for T1 to T2, last-recovered oocytes fertilized less often than first-recovered eggs (P = 0.06; McNemars test). When T1 to T2 was short (less than or equal to 5 minutes), first- and last-recovered oocytes fertilized at comparable rates (70.8% and 74.0%). When only cycles with T1 to T2 greater than 5 minutes were considered (n = 209), the difference in fertilization rates between first and last oocytes (68.5% versus 56.4%) was highly significant (P less than 0.01; McNemars test). Pairing negated differences due to patient, cycle, or semen variables and first- and last-recovered oocytes had comparable maturity scores (4.0 +/- 0.5 versus 4.3 +/- 0.8). There were no significant differences in cleavage rates for first- and last-recovered oocytes that fertilized, regardless of the exposure interval (T1 to T2). We conclude that exposure to a 100% CO2 pneumoperitoneum and/or general anesthesia may adversely affect oocyte quality.

The use of pure follicle-stimulating hormone for ovulation induction in normal ovulatory women in an in vitro fertilization program

Many ovulation induction protocols for follicular development have been reported. The present study examines pure follicle-stimulating hormone (pFSH) and human menopausal gonadotropin for ovulation induction in an in vitro fertilization and embryo transfer program. The study compares the number of ampules, the level of estradiol on the day of human chorionic gonadotropin administration and at laparoscopy, the number of oocytes retrieved, fertilization, cleavage, and pregnancy rates. The peak levels of estradiol on the day of human chorionic gonadotropin administration and the day of laparoscopy were similar, although fewer ampules of pFSH were required to reach similar criteria for oocyte maturation prior to retrieval. The fertilization rates were similar, but the cleavage and pregnancy rates favored the use of pFSH. The use of pFSH may be more physiologic in orchestrating follicular steroidogenesis in normal ovulatory women in an in vitro fertilization and embryo transplant program that subsequently could produce healthier oocytes and an improvement in the pregnancy rate.

The effect of polyploidy on embryo cleavage after in vitro fertilization in humans

The effect of polyploidy on the early development of human embryos is unknown. This study compares the early development of 90 polyploid and 275 diploid human embryos conceived in vitro. Between May 1983 and January 1986, 3081 oocytes were recovered during 631 cycles of laparoscopy for in vitro fertilization (4.9 oocytes/cycle); 1924 oocytes (62.4%) fertilized. There were 90 oocytes with more than two pronuclei (4.7% of fertilized oocytes), identified in 72 cycles (11.4% of cycles). In these cycles, the proportion of diploid oocytes (n = 275) that cleaved (cleavage rate) (92.7%) was significantly greater than the proportion of polyploid oocytes (n = 90) that cleaved (65.5%) (P less than 0.001). The cleavage rate for all diploid oocytes (n = 1834) was 90.4%. There was no significant difference in the stage of development (number of blastomeres; mean +/- standard deviation [SD]) on the day of embryo transfer between diploid (4.3 +/- 2.1) and polyploid (4.1 +/- 2.1) embryos that cleaved, but a plot of the frequency distribution of cleavage stages revealed that significantly more polyploid than diploid embryos had an uneven number of blastomeres at that time (33% versus 8%, respectively; P less than 0.001). Polyploidy confers an immediate developmental disadvantage; one third of polyploid embryos fail to cleave, and those that do divide demonstrate more asynchronous divisions.

Neosalpingostomy: comparison of 24- and 72-month follow-up time shows increased pregnancy rate

Seventy-two patients, 54 for 5 years and 18 for 6 years, were evaluated between 1 and 2 years and 5 and 6 years after bilateral neosalpingostomy. A 27.7% intrauterine pregnancy rate was reported in those patients treated between 1976 and 1978, with a 14% ectopic pregnancy rate. The subsequent 5- to 6-year follow-up study revealed an increase in the pregnancy rate to 41.6% and in the ectopic pregnancy rate to 17.1%. The increase in the pregnancy rate may reflect the ability of the fallopian tube for ciliogenesis and intrinsic repair. Thus if patients have not conceived within 2 years of neosalpingostomy for distal tubal obstruction, significant reproductive potential still exists.

Serum prolactin response to embryo transfer during human in vitro fertilization and embryo transfer

Serum prolactin (PRL) concentrations around the time of embryo transfer (ET) have not been studied, despite the fact that transient hyperprolactinemia regularly occurs in response to laparoscopy for oocyte recovery and ET itself may be stressful enough to induce a PRL rise. Hyperprolactinemia might compromise luteal support for implantation and contribute to the limited success of ET. We measured serum PRL concentrations in 10 normoprolactinemic women immediately before, during, and after ET and compared the PRL response around ET to that induced by laparoscopy as a measure of the competency of the stress-prolactin axis. Nine of ten patients demonstrated a significant PRL response to surgery. The mean (±SEM) intraoperative PRL concentration (124.0±19.6 ng/ml) was significantly higher than the preoperative level (12.3±2.4 ng/ml) (P<0.01). Three hours after surgery PRL levels had decreased (44.8±11.5 ng/ml) but remained above baseline. All subjects were normoprolactinemic 48 hr after laparoscopy. Serum PRL concentration did not change significantly in response to ET, with levels of 10.4±1.7, 12.4±1.1, and 10.6±1.8 ng/ml immediately before, during, and 3 hr after ET, respectively. While laparoscopy for in vitro fertilizationembryo transfer commonly induces hyperprolactinemia, the PRL rise is transient, with no carryover to the time of ET. Embryo transfer itself does not induce a significant PRL rise.

The effect of naloxone and metoclopramide on the hypothalamic pituitary axis in oligomenorrheic and eumenorrheic swimmers

Eight highly competitive swimmers were followed over a 9-month period during a vigorous training schedule. When compared, four oligomenorrheic (group I, greater than 60 days without menses) and four eumenorrheic (group II) swimmers were not significantly different for age, years of training, body fat, intensity of training, and baseline estradiol (E2) levels. Both groups were challenged during the peak of their training schedule with 10 mg of naloxone and 10 mg of metoclopramide. The naloxone infusion revealed a significant increase in baseline luteinizing hormone (LH) levels in the oligomenorrheic swimmers when compared with the eumenorrheic swimmers. During the metoclopramide infusion prolactin (PRL) increased in all subjects, with a slightly higher increase in PRL in the eumenorrheic swimmers. The study suggests the menstrual dysfunction observed in these strenuously training swimmers to be related to the abnormalities of endorphin physiology as revealed by the elevation in LH after a naloxone infusion.

Weight of babies conceived in vitro

SummaryRecent studies suggested that infants delivered after in vitro fertilization and embryo transfer IVFET had low birth weights. To assess further the relationship between birth weight and EGA in these offspring, a review was made of all infants delivered at our institution from May 1, 1983 to July 15, 1986. Forty-five infants in 39 deliveries were identified. Seventeen of 37 (46%) were delivered vaginally, 20 by cesarean section. Forty-two infants were delivered at term (after 36 weeks). The six sets of twins delivered at 254±7 days (mean, 36 weeks). Eighteen of 39 deliveries (46%) delivered at or beyond 40 weeks EGA. The mean weight at delivery for the term infants was 3225±90 g. Thirtyeight infants were size appropriate for dates as assessed by the Lubchenco scale, while the weight in the remaining seven infants exceeded the 90th percentile for their gestational age. We conclude that infants conceived through IVF-ET are not predisposed per se to a low birth weight or delivery at an early gestational age. However, prior studies suggesting lower birth weights for IVF infants may have resulted in part from early delivery due to patient pressure and anxiety.