Josef Shalev

Ovarian hyperstimulation syndrome: prediction by number and size of preovulatory ovarian follicles *

Monitoring of human menopausal gonadotropin (hMG) treatment for induction of ovulation according to either preovulatory estrogen levels or the presence of a dominant ovarian follicle was found insufficient to prevent ovarian hyperstimulation syndrome (OHS). In 65 infertile patients treated with hMG and human chorionic gonadotropin (hCG), a possible correlation between the number and size of all ovarian follicles on the day of assumed ovulation and the occurrence of OHS was evaluated in order to assess the value of ultrasonography in predicting OHS. It was found that patients with OHS had significantly more follicles at the time of hCG than patients without OHS. Mild OHS was characterized by the presence of eight to nine follicles, 68.7% of which were of intermediate size (9 to 15 mm). In moderate to severe OHS 95% of the preovulatory follicles were less than 16 mm, most of them (54.7%) less than 9 mm in diameter. It can be concluded that a specific preovulatory follicular configuration characterizes mild and severe hyperstimulation. This is important information before hCG administration and emphasizes the value of ovarian ultrasonography in predicting OHS.

The improving outcome of triplet pregnancies.

During the period 1975 to 1988, 78 triplet pregnancies that reached a gestational age greater than or equal to 20 weeks were treated in our department--a prevalence of 1/849 deliveries. A total of 69 (88%) of the pregnancies occurred after treatment with ovulation-induction agents. The most common complication of pregnancy was premature contractions. Elective cervical cerclage neither prolonged gestation nor decreased fetal loss. The mean gestational age at delivery was 33.2 weeks + 3.8 weeks and 86% of the patients were delivered of premature infants. The perinatal and neonatal mortality rates were 93/1000 and 51/1000, respectively. Our results show a higher proportion of low Apgar scores and respiratory disorders in the third vaginally delivered infants. Follow-up of very low birth weight infants revealed four infants (10.5%) with severe neurologic handicaps. Results of this study suggest that cesarean section is the preferred mode of delivery in triplet pregnancies. Maternal, fetal, and neonatal risks of triplet gestations are relatively low and compare favorably with recent reports on twin pregnancies.

A prospective comparison of the outcome of triplet pregnancies managed expectantly or by multifetal reduction to twins

OBJECTIVEnOur aim was to compare the outcome of triplet pregnancies managed expectantly or by multifetal reduction to twins.nnnSTUDY DESIGNnFrom January 1984 through January 1992, 140 triplet gestations were diagnosed before the ninth gestational week. Multifetal pregnancy reduction was performed at the patients request in 34 women. The remaining 106 triplet pregnancies were managed expectantly. All patients were prospectively followed up and delivered in a single perinatal department.nnnRESULTSnLoss of the entire pregnancy before 25 gestational weeks occurred in 20.7% of the triplet pregnancies managed expectantly as compared with 8.7% in the group with reduction to twins. A successful pregnancy as defined by the discharge home of at least one infant occurred in 88.2% of the group with reduction to twins and 74.5% of the triplets managed expectantly. Fetal reduction to twins was associated with a significantly lower incidence of the following: prematurity (p < 0.001), low-birth-weight infants (p < 0.001), and very-low-birth-weight infants (p < 0.001). Pregnancy complications and neonatal morbidity and mortality were less in the group with reduction to twins.nnnCONCLUSIONSnMultifetal pregnancy reduction of triplet pregnancies to twins resulted in improved pregnancy outcome without an excess loss of the entire pregnancy as compared with the outcome of triplet gestations managed expectantly.

Selective reduction in multiple gestations: pregnancy outcome after transvaginal and transabdominal needle-guided procedures

Selective fetal reduction was performed in the first trimester of pregnancy in 20 women with multifetal gestations after ovulation induction with human menopausal gonadotropin (hMG). In 10 women (group A) reduction was performed transabdominally, and in 10 women (group B) the transvaginal approach was used. The transvaginal technique achieved penetration of several gestational sacs without withdrawing the needle from the uterus. Fetal termination using either procedure occurred with intrafetal injection of potassium chloride. Six (60%, group A) and eight (80%, group B) patients delivered healthy newborns. One patient (group B) is at 30 weeks gestation. Four (40%, group A) and one (10%, group B) aborted 1 day to 8 weeks after the procedure (1 septic abortion, each group). Our results suggest that transvaginal fetal reduction offers a better outcome, with minimal complications, to patients referred for selective continuation of pregnancy.

Rescue of menotrophin cycles prone to develop ovarian hyperstimulation

Summary. In an attempt to prevent the loss of‘overstimulated cycles’ associated with human menopausal gonadotrophin (hMG)‐induced ovulation, oestradiol levels and ovarian follicular state were monitored in 12 women with‘overstimulated cycles’ after withholding hMG for several days. Human chorionic gonadotrophin (hCG) was administered when oestradiol levels were 1700 pg/ml and the leading follicles between 17 and 22 mm in diameter. During the withholding period follicular growth continued in all patients, while oestradiol levels declined in all but three. These three patients conceived. Ovulation was observed in six additional women. Ovarian hyperstimulation did not occur in any of the 12 patients. We conclude that a rescue of‘overstimulated cycles’ is sometimes possible. Conception seems to depend on a continuing rise of E2 levels and early detection of‘overstimulation’.

Subtorsion of the ovary: sonographic features and clinical management.

To define the sonographic imaging criteria of ovarian subtorsion.

Double (consecutive) transfer of early embryos and blastocysts: aims and results

OBJECTIVEnThe aim of this study was to evaluate the consecutive transfer approach of early embryos and blastocyst(s).nnnDESIGNnCase-control study.nnnSETTINGnPublic assisted reproduction technology unit.nnnPATIENT(S)nThe study population consisted of three groups. In Group 1, a double transfer was performed on 136 consecutive women, that is, a standard transfer of embryos on day 2 or 3, and a second transfer of a blastocyst(s). In Group 2, an early transfer of only two embryos and a second transfer of one blastocyst were performed on 29 women from group 1 who had more than three high-quality embryos available for early transfer. In Group 3, a single early transfer was performed on 139 consecutive women who received three high-quality embryos (controls).nnnINTERVENTION(S)nEarly embryo transfer, extended culture of the spare embryos, and a second transfer of a blastocyst(s).nnnMAIN OUTCOME MEASURE(S)nImplantation and pregnancy rates. RESULTSs): No differences were detected among the three groups in either pregnancy or implantation rates (pregnancy: 36.8%, 41.4%, and 37.4%, respectively; implantation: 14.6%, 19.9%, and 19.8%, respectively).nnnCONCLUSION(S)nThe double (consecutive) transfer of early embryos and blastocyst(s) does not offer any advantage over the traditional early transfer. This may be from the adverse effect of the second transfer on the implantation process.

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 (E 2 ) benzoate test (2 mg intramuscularly). The SC administration ofBuserelin (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 E 2 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.

Comparison of five clomiphene citrate dosage regimens: follicular recruitment and distribution in the human ovary

One hundred fifty-six women with cycle disorders presenting as absence or infrequency of ovulation and with luteal phase deficiency (group II, according to the World Health Organization classification) received clomiphene citrate (CC) for ovulation induction. The administered dosage ranged from 50 to 250 mg/d. The follicular development in terms of numbers of small (less than 8 mm), intermediate (9 to 15 mm), and large (greater than 15 mm) follicles and their distribution in either one or both ovaries on the day of assumed ovulation was related to the dosage of CC. A statistically significant increase was found in the total number of follicles in relation to the dosage of CC (P less than 0.003). In view of the development of the mature follicles, the gradual increase in CC daily dosage was thought to be associated with additional mature follicles before ovulation. However, this increased follicular recruitment was not regarded as statistically significant. Treatment with low doses of CC resulted in follicular development in only one ovary, whereas increased follicular recruitment after high CC dosage was found in association with follicular development in both ovaries.

Improved results in multifetal pregnancy reduction: a report of 72 cases

OBJECTIVEnTo evaluate pregnancy outcome after either transabdominal or transvaginal multifetal pregnancy reduction.nnnDESIGNnA study of 72 consecutive multifetal pregnancy reductions.nnnSETTINGnDepartment of Obstetrics and Gynecology, The Chaim Sheba Medical Center Tel Hashomer, Israel.nnnPATIENTSnSeventy-two patients with multifetal pregnancies: 2 twins, 27 triplets, 26 quadruplets, 10 quintuplets, 3 sextuplets, 1 septuplet, 2 nontuplets, and one pregnancy with 12 fetuses.nnnINTERVENTIONnMultifetal pregnancy reduction was performed at 9 to 13 weeks gestation by either transabdominal or transvaginal potassium chloride injection.nnnMAIN OUTCOME MEASURESnEarly and late complications related to the procedure, outcome of pregnancy, and comparison of two periods.nnnRESULTSnProcedures performed between 1984 and 1989 (36 patients) were associated with a 33.3% pregnancy loss, whereas those performed between 1990 and 1992 (36 patients) were associated with no pregnancy loss. Of the 17 patients with quintuplets or more, 10 (59%) delivered live and healthy newborns. No difference was found when comparing the transabdominal and the transvaginal approaches.nnnCONCLUSIONSnBoth transvaginal and transabdominal approaches are comparable. There is a remarkable decrease in pregnancy loss with experience.