M. Reuben Peyser

The Development of an Efficient Ambulatory In Vitro Fertilization (IVF) and Embryo TrAnsfer (ET) Program Using Ultrasonically Guided Oocyte Retrieval

Until recently most of the current in vitro fertilization and embryo transfer (IVF‐ET) programs used laparoscopy for oocyte retrieval and included hospitalization in the treatment. The establishment of a successful ambulatory IVF program that uses ultrasonically guided oocyte aspiration, is described. Between August 1985 and February 1987, 384 percutaneous transvesical ultrasonically and transvaginally guided follicle aspirations were performed on 414 patients, following ovarian stimulation with hMG and hCG. Ninety two clinical pregnancies were confirmed by ultrasound. The clinical pregnancy rate was 26.8% when based on the number of embryo transfers. There were 16 multiple pregnancies (17.4%), 18 miscarriages (19.5%), and two tubal pregnancies (2.1%). The most important factors contributing toward the success of this program were rigid adherence to clinical and laboratory protocols, and the maintenance of a strict quality control. The ambulatory management was very well accepted by the patients, who during the entire period of ovarian stimulation had minimal disruption of their routine activities.

Prospective study of incidence and predisposing factors for clavicular fracture in the newborn

Objective. To determine the incidence of clavicular fractures, associated fetal and maternal risk factors and its connection with quality care control.

Pregnancy associated with pemphigus.

Case report A 24 year old healthy, Ashkenazi Jewish woman complained of intermittent vulval and left axillary lesions for two years. The lesions included vegetation, erosion and pustules covered with crusts. Vulva1 biopsy demonstrated hyperkeratosis, parakeratosis, suprabasal cleft formation, acantholysis, papillomatosis, and eosinophilic infiltration of the dermis and epidermis. Immunofluorescence showed precipitation of immunoglobulin-G (IgG) and C, in the intercellular spaces of the epidermis. Electron microscopy demonstrated destruction of desmosomes. Based on these findings, pemphigus vegetans was diagnosed. Serum indirect immunofluorescence was negative. Histocompatibility antigens (HLA) typing demonstrated A-1 1, A-28, B-14, B-35, CW4, DR1, DRW1, and BW6 alleles. Steroid treatment with 80 mg fluorcortolone (Ultralan, Schering AG/Berlin) was started, and later azathioprine (100 mg/day) was added, in addition to local treatment with wet dressings and antibiotics. Gradual healing was accompanied by the development of hyperkeratosis and fissure formation in the vulval skin. Two years later, during one of her remissions, she conceived. The pregnancy was uneventful with a vaginal delivery at term of a healthy newborn. In subsequent years she suffered from intermittent flare-ups of the disease that were restricted to the vulva. She was treated with steroids during the flare-ups, but later tried homeopathy. During her second pregnancy there was a severe exacerbation of the disease, and at 26 weeks of pregnancy she was admitted to hospital. On admission, bullae and crustae covered an extensive part of her skin and mucous membranes. The labia majora were covered with erosions, with no vegetations or pustules. Skin biopsy showed typical pemphigus vulgaris changes with acantolysis, suprabasal cleft formation, and direct immunofluorescence demonstrated IgG autoantibodies within the intercellular spaces of the epidermis. There was no eosinophyllic infiltration in the dermis or epidermis. Indirect immunofluorescence demonstrated a titre of 1 : 80 serum IgG autoantibodies against the intercellular space of the epidermis. Based on these findings, pemphigus vulgaris was

Management of severe postpartum hemorrhage by intrauterine irrigation with prostaglandin E2

Continuous intrauterine irrigation with minute amounts of prostaglandin E2 was used in 22 patients with severe postpartum hemorrhage unmanageable by conventional therapy. Twenty-one women were treated because of uterine atonic hemorrhage and one because of late postpartum hemorrhage from subinvolution. A quick tetanic contraction of the uterine muscle with dramatic and sustained hemostasis was achieved in all patients. The therapeutic response was continuous and uninterrupted regardless of the predisposing factors for the hemorrhage or the hemodynamic condition of the patients. No side effects were observed.

The performance of primary and secondary unexplained infertility in an in vitro fertilization-embryo transfer program

The term unexplained infertility is applied to a couple in whom after an elaborate workup no apparent reason for infertility is found. Between August 1985 and May 1987, 435 patients underwent 720 treatment cycles in an in vitro fertilization-embryo transfer (IVF -ET) unit. Eighty-three of the patients had unexplained infertility as their indication for IVF-ET. Fifty-two (group A) had primary unexplained infertility and 31 (group B) had secondary unexplained infertility. Group A underwent 87 and group B underwent 50 treatment cycles. Forty-six ET were performed in group A and 34 in group B. Clinical pregnancies were achieved in 20 patients of group A (11.5% per treatment cycle) and 13 of group B (26.0%), for a combined rate of 16.8% per cycle. Patients with tubal infertility treated in the program had a pregnancy rate of 18.8% per treatment cycle. The performance of the secondary unexplained infertility group is significantly better than that of the primary unexplained infertility group. However, the overall results with patients with unexplained infertility are similar to those patients treated for tubal infertility.

ANTENATAL DIAGNOSIS OF BILATERAL CONGENITAL CHYLOTHORAX WITH PERICARDIAL EFFUSION

Abstract. Many fetal anomalies can be detected by ultrasound examination. The antenatal diagnosis of pathological disorders in the fetus can complicate management plans.

Acid accumulation during end‐stage bradycardia in term fetuses: how long is too long?

Objective To estimate the existence and degree of fetal accumulation of acid during end‐stage bradycardia as reflected by the base deficit. This may set a criterion for proper intervention during labour.

A second thought on second look laparotomy

Between 1982 and 1987, 43 patients with epithelial ovarian carcinoma, identified as International Federation of Gynaecology and Obstetrics Stages I‐IV, underwent second‐look laparotomy as a part of their treatment protocol. Twenty‐nine patients (67%) had no evidence of residual disease, five (11.6%) had residual disease 1 cm, and nine patients (20%) had residual disease 1 cm at re‐exploration. Persistent disease at the second operation was positively correlated with the initial clinical stage, and negatively correlated with the extent of the original cytoreductive surgery. Fifteen of 29 patients with negative findings (52%) developed recurrent disease within two years. All recurrences were limited to the abdominal cavity only. Three and five years survival, for the patients with negative findings, was 62% and 48% respectively. No documented benefit to the patients could be demonstrated by adopting second‐look laparotomy as a routine procedure in the management of patients with epithelial ovarian carcinoma. In view of our data, as well as that of others, such operations cannot be considered a valuable routine procedure. At this point, second‐look laparotomy may have a role in evaluating the efficacy of a post‐surgical new chemotherapy treatment regimen.

Estrone-3-glucuronide chemiluminescence immunoassay: an alternative method for monitoring induction of ovulation with human menopausal gonadotropin in an in vitro fertilization program

A simple, rapid, and sensitive solid-phase immunoassay procedure for the determination of estrone-3-glucuronide (E1-3-G), which uses chemiluminescence as the end point in unextracted morning urine, is described. Thirty-one patients undergoing induction of ovulation in an in vitro fertilization (IVF) unit participated in the study. From day 3 of the menstrual cycle until the day of hCG administration, morning blood samples and morning urine specimens were collected for the determination of serum 17 beta-estradiol (E2) and urine E1-3-G, respectively. A good correlation was noted between E2 measured by radioimmunoassay (RIA) and the E1-3-G measured by chemiluminescence immunoassay (CIA), from day 5 up to the day of hCG administration (0.6 less than r less than 0.85, P less than 0.001). It is evident from this study that the CIA measurement of E1-3-G in morning urine is an accurate and rapid (2.5 hours) method and is convenient for monitoring induction of ovulation with human menopausal gonadotropins.

Fistulization: An Effective Treatment for Bartholin's Abscesses and Cysts

We describe our experience with the technique of fistulization for the treatment of Bartholins abscesses and cysts. The principal objective of this treatment is the restoration of the normal glands function. The study group included 46 patients who underwent the procedure during a 12‐year period. Eight patients had to undergo a refistulization, a recurrency rate of 17.4%. The fistulization procedure provides satisfactory results in a high percentage of cases. It is a simple procedure requiring very little surgical time and has fewer recurrences than marsupialization and other forms of drainage.