Karen R. Hammond

Prostate-specific antigen in vaginal fluid as a biologic marker of condom failure

Forty women participated in three clinic visits during which they were exposed to their partners semen (10 microL, 100 microL, and 1 mL). At each visit they took vaginal fluid samples before exposure to their partners semen, immediately after, and at 1, 24, and 48 h after exposure. PSA was measured with an enzyme-linked immunoassay. The mean PSA level for preexposure swabs ranged between 0.43 and 0.88 ng/mL. The mean PSA levels were 193 immediately after exposure to 10 microL, 472 after 100 microL, and 19,098 after 1 mL. The PSA levels declined within 1 h, and returned to background at 48 h. The findings confirm that our procedure is a sensitive and specific method for detecting recent semen exposure, and indicate that PSA levels depend on exposure intensity and time since exposure. Application of this method in condom efficacy studies provides objective evidence of condom failure that enhances the interpretation of self-report.

Hormonal treatment of functional ovarian cysts: a randomized, prospective study *

Estrogen (E)/progestin therapy for functional ovarian cysts is widely used in clinical practice, but the efficacy of this treatment has not been determined in controlled trials. In this study, we examined the effect of E/progestin administration in a group of infertility patients enrolled in a program of ovulation induction who had cysts identified by transvaginal sonography. Patients were randomized to receive either norethindrone 1 mg/mestranol 0.05 mg/d (group A, n = 24) or no treatment (group B, n = 24) for up to 6 weeks. Patients were re-evaluated by sonography at 3, 6, and 9 weeks after entry into the protocol. The ages, mean cyst diameters, and proportions of patients having received gonadotropins in the previous menstrual cycle were not significantly different among the two groups. All patients who had a sonographic abnormality persisting for 9 weeks were surgically explored and found to have pathological cysts. The rate of disappearance of functional ovarian cysts was not affected by E/progestin treatment.

Multifetal reduction of high-order multiple pregnancy : comparison of obstetrical outcome with nonreduced twin gestations

OBJECTIVE To compare the obstetric outcomes of twin pregnancies obtained as a result of multifetal pregnancy reduction to those in which pregnancy reduction had not been used. DESIGN Retrospective analysis. SETTING University-based tertiary care infertility clinic. PATIENTS Seventy-four twin pregnancies continuing beyond 10 weeks. Of these, 32 gestations had undergone reduction to twins at 10 weeks. MAIN OUTCOME MEASURES Gestational age at delivery, birth weights, pregnancy complications. RESULTS All pregnancies advanced beyond 20 weeks gestation. The mean gestational age at delivery of the reduction group was 33.8 versus 35.7 weeks in the nonreduced group; only 25% of reduced pregnancies reached 37 weeks compared with 57.9% of nonreduced twins. The mean fetal birth weights of the two groups differed significantly (reduced: 2,038 g, nonreduced: 2512 g). The gestational age at delivery in patients reduced from triplets was significantly greater than in pregnancies reduced from quadruplets or higher. Multiple regression analysis revealed that for a given gestational age at delivery, a history of pregnancy reduction was associated with decreased birth weight. CONCLUSION These data suggest that multifetal pregnancy reduction does not reverse completely the decreased gestational age and impaired fetal growth associated with high-order multiple pregnancy. Furthermore, fetal growth of reduced pregnancies seems to be impaired independent of the gestational age at which delivery occurs.

Effect of obesity on recombinant follicle-stimulating hormone absorption: subcutaneous versus intramuscular administration.

OBJECTIVE To determine whether recombinant follicle-stimulating hormone (rFSH) should be administered intramuscularly (i.m.) or subcutaneously (s.c.) to obese women. DESIGN Randomized, single-center, two-way crossover study. SETTING Academic clinical research center. SUBJECT(S) Nineteen healthy women of reproductive age with body mass indices of 19.9 kg/m(2)-42.8 kg/m(2). INTERVENTION(S) Leuprolide acetate 3.75 mg i.m. to achieve pituitary down-regulation as determined by serum E(2) levels. Subjects were then given a single dose of 300 IU rFSH either i.m. or s.c.. Multiple blood sampling was performed over the next two weeks, and after retreatment with leuprolide, a second 300 IU rFSH dose was given via the other administration route. MAIN OUTCOME MEASURE(S) Serum samples were analyzed in duplicate for follicle-stimulating hormone (FSH) using a standard radioimmunoassay in a single run. Maximum concentrations (C(max)), times to C(max) (T(max)), and extent of absorption (area under curve [AUC]) with i.m. vs. s.c. administration were compared using paired analysis. RESULT(S) Maximal concentrations were achieved within 24 hours with both s.c. and i.m. routes. No significant differences were found in C(max), T(max), or AUC with s.c. vs. i.m. administration. A decline of AUC occurred among subjects of higher body mass index (BMI) with rFSH given either s.c. or i.m.. Subcutaneous administration achieved AUCs comparable to i.m. administration in both normal-weight and obese subjects. CONCLUSION(S) Our data indicate that the s.c. administration of rFSH is appropriate for women regardless of body mass.

Performance anxiety during infertility treatment: effect on semen quality

The requirement to obtain a semen sample at a specific time for an infertility treatment procedure has potential to produce considerable performance anxiety. This study was designed to evaluate the semen quality of men participating in infertility treatments associated with heightened performance anxiety. The most recent pretreatment semen analysis and the infertility treatment semen analysis, as well as the first and last procedure semen analyses, were compared using paired t-tests for 77 patients undergoing assisted reproductive technology procedures and 121 patients undergoing intrauterine insemination. No significant differences were noted in either of these groups of patients. However, in men with total motile sperm counts of less than 40 million, semen parameters improved significantly in the procedure semen analyses. Thus, participation in infertility treatments associated with performance anxiety does not appear to be detrimental to semen quality, and in certain groups of patients semen quality may improve.

Fertility outcomes after electroejaculation in men with spinal cord injury

Ten thousand new cases of spinal injury occur annually in the United States. More than 80% of these patients are men, and 80% of these newly injured men are 18 to 45 years of age (1). Less than 15% of these men retain ejaculatory function after their injury (2). Anejaculatory men require electroejaculation when vibratory stimulation fails. Significant complications are rare, and electroejaculation is well tolerated by most men (3). Sperm retrieval is successful in more than 90% of cases, but pregnancy rates with IUI are disappointing—7% to 14% per cycle (4 ‐ 8). Use of IVF, with or without ICSI, would probably improve pregnancy rates. We report our experience with electroejaculation in men with spinal cord injury. We obtained institutional review board approval for our study. All patients undergoing electroejaculation were evaluated by history and physical examination by one of two investigators. All patients who underwent electroejaculation had failed to ejaculate with vibratory stimulation. Electroejaculation was performed without anesthesia in an office setting except in sensate patients, in whom general anesthesia was used. Our early technique consisted of 30-second bursts of stimulation at 12 to 18 V and current of 400 to 600 mAmp. We later used a method that consists of dialing up the voltage progressively starting at low levels, dialing up briefly and back down. Voltage usually did not exceed 14 to 18 V, and the current did not exceed 600 mAmp. Blood pressure was monitored throughout the procedure. Rectal examination was done to check for bleeding and heating of the rectal wall (3). Between 1983 and 2001, 27 patients underwent 112 electroejaculation procedures. One hundred ten procedures (98%) produced some ejaculate. Complications, all of which were self-limited, occurred during 36 electroejaculation attempts (32%). The initial prep median total motile sperm count and motility per procedure were 6 10 6 and 7%, respectively. Thirty-nine (35%) electroejaculation attempts yielded an initial prep total motile sperm count of at least 5 10 6 , and 28 cycles (25%) yielded no motile sperm. Nine couples desired to have children. Twenty-five cycles of IUI were performed, some with superovulation; these attempts resulted in one pregnancy (rate, 4% per cycle) but no live birth. Initial and final prep total motile sperm counts were 12.8 10 6 and 3 10 6 , respectively, and motility was 19% and 21%, respectively, for the IUI cycles. Three cycles of IVF were performed, resulting in one twin pregnancy and the birth of one set of twins. Two cycles of IVF-ICSI were performed, resulting in one twin pregnancy and the birth of one set of twins. Total pregnancy and live delivery rates for IVF cycles were both 40% per cycle (Table 1). Ejaculatory dysfunction is a rare cause of male infertility and accounts for approximately 2% of cases (3). Sperm can be successfully retrieved from most anejaculatory men with spinal cord injury by using vibratory stimulation or electroejaculation. If sperm cannot be retrieved by these techniques, vasal aspiration or testicular sperm extraction may be required (9 ‐12). The poor quality of semen obtained by electroejaculation from men with spinal cord injury has been attributed to prolonged abstinence, antisperm antibodies, heat from the procedure, and reactive oxygen species (13, 14). No corrective therapy is currently available, and advanced fertility techniques are required to circumvent this problem.

Identification of early pregnancy landmarks by transvaginal sonography: analysis by logistic regression

OBJECTIVE To assess the feasibility of logistic regression analysis for determining the gestational ages at which detection of early pregnancy landmarks first can be observed. DESIGN Retrospective analysis. SETTING University-based tertiary care clinic. PATIENT(S) Eighty-two women with viable singleton pregnancies in whom ovulation had been achieved by an injection of hCG. INTERVENTION(S) Two hundred fifteen transvaginal sonographic scans. MAIN OUTCOME MEASURE(S) Logistic regression was used to estimate the probability of detection of sonographic findings as a function of gestational age. RESULT(S) We found that the likelihood of visualization of a gestational sac or fetal heart motion could be represented accurately by logistic equations. Gestational age at which there was 95% probability of visualization was 35.5 days for the gestational sac and 44.5 days for fetal cardiac activity. The probability of detecting fetal cardiac activity was 95% when the mean gestational sac diameter was 1.6 cm and was 99% at 1.9 cm. CONCLUSION(S) The sonographic appearances of developmental landmarks in early pregnancy occurs within well-defined gestational time periods, and the probabilities for visualization can be closely approximated using a logistic model. Our results suggest that the number of sonographic examinations required to document infertility treatment success can be minimized by surveillance at standardized gestational ages.

Assisted reproduction in patients with early-stage ovarian malignancies

OBJECTIVE To determine the outcome of women with early-stage ovarian malignancies who subsequently underwent assisted reproductive technologies (ART). DESIGN Retrospective study. SETTING Academic assisted reproductive technology program. PATIENT(S) Four infertile women who were previously diagnosed with early-stage ovarian malignancies. INTERVENTION(S) Controlled ovulation hyperstimulation, IVF, and/or gamete intrafallopian transfer treatments using clomiphene citrate and/or gonadotropins. MAIN OUTCOME MEASURE(S) Development of tumor recurrence and disease-free interval. RESULT(S) All four women remain free of disease for up to 15 years after treatment. Three of the four women achieved pregnancy. CONCLUSION(S) In patients with early-stage ovarian malignancies, conservative therapy followed by ovarian stimulation for assisted reproduction is an acceptable strategy.

A one-year experience with a capitated health care plan for infertility

OBJECTIVE To report on a one-year experience participating in a capitated healthcare plan for infertility. DESIGN Prospective study. SETTING University population. PATIENT(S) Reproductive-age women 15 to 50 years. INTERVENTION(S) The first-generation Lewin infertility algorithm and CATHI software were used to negotiate infertility services under a capitated arrangement for

The effect of routine breast examination on serum prolactin levels

0.50 per member per month. The following reports our experience for the fiscal year 1997. MAIN OUTCOME MEASURE(S) Infertility services rendered, pregnancy rate, cost of services, collection rates. RESULT(S) Five thousand forty-six women representing 39,689 member months generated 39 new and 198 return visits. Thirty-two percent of the patients required three visits or less; six patients generated 22% of the visits. Fifty-one percent listed infertility as one of their chief complaints; 31% had mixed diagnoses. Eight (7.6%) patients required surgery, 11 (10.5%) patients underwent either IVF or GIFT cycles. Total charges submitted were