Mark V. Sauer

Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial *

Unruptured tubal pregnancies diagnosed at laparoscopy were treated with either methotrexate/citrovorum factor (MTX/CF) (n = 21) or observation (n = 5). Entry criteria required that the ectopic pregnancy be visualized, less than or equal to 3 cm in diameter, with intact serosa and no active bleeding. Treatment selection was based upon preoperative levels of beta-human chorionic gonadotropin (beta-hCG), with MTX/CF given to subjects exhibiting a plateaued or rising pattern and observation alone given to those with falling levels. Twenty-five of 26 ectopic pregnancies resolved without need of laparotomy. Two subjects received blood transfusions and one required a second operation for intra-abdominal bleeding. In both cases, fetal cardiac activity was noted pretreatment on ultrasound. The authors conclude the following: (1) MTX/CF may be safely used to treat selected unruptured ectopic pregnancy; (2) many ectopic pregnancies resolve spontaneously; and (3) ectopic pregnancies that form fetal elements, as evidenced on ultrasound, should not be managed medically.

Timely diagnosis of early ectopic pregnancy using a single blood progesterone measurement.

We obtained a single serum P measurement in 70 subjects at risk for an EP. Retrospectively, a P less than 15 ng/ml was 100% predictive of either an EP or otherwise nonviable IUP, while P greater than 15 ng/ml would have ruled out an EP in all cases. Because of this high degree of diagnostic accuracy, we speculated on the clinical utility of an outpatient D and C for those patients in our series having a P less than 15 ng/ml. Laparoscopy would be reserved for those cases without identifiable chorionic villi on frozen section of curettings. Following this course of management could have potentially diagnosed all EPs at the first ER visit without disruption of a single normal IUP in our series. This sequence could have expedited the diagnosis of EP by up to 14 days compared with a standard hCG/US protocol. This report describes a promising new test for the early detection of EP. The findings, however, require confirmation in a prospective trial before widespread clinical implementation.

The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience *

Seven women with unruptured tubal pregnancies diagnosed on laparoscopy were treated with methotrexate and citrovorum rescue. Criteria for inclusion in the study were that the level of human chorionic gonadotropin (hCG) be plateaued or rising, that the ectopic pregnancy not exceed 3 X 3 cm, that the tubal serosa be intact, and that there be no active bleeding. The women were followed with serial measurements of hCG, complete blood counts, and liver function tests. All women responded to a single course of therapy. The median time to resolution (from the first day of treatment to when the hCG was undetectable) was 31 days (range, 5 to 50 days). Follow-up hysterosalpingograms were available for five women. Four women demonstrated tubal patency, and one showed a unilateral occlusion on the side of the ectopic. One woman was found to have an intrauterine pregnancy prior to the scheduled time of hysterosalpingogram.

Survey of attitudes regarding the use of siblings for gamete donation

We conclude that the acceptability of using a sister for gamete donation is high among couples desiring ovum donation. On the contrary, couples undergoing AID generally rejected the concept of using the husbands brother as a known donor. Thus, although similar in concept, disparity exists regarding the use of siblings for gamete donation. Though the use of sibling gamete donation may provide a short-term solution to the dwindling supply of acceptable gamete donors, the long-term acceptability of such practice remains unknown.

Effect of abstinence on sperm motility in normal men

We investigated the effect of varying the length of ejaculatory abstinence on sperm motility by a method of automated videomicrography. Ten fertile donors to an artificial insemination clinic provided semen samples at randomly assigned intervals of 12, 24, 72, and 120 hours. All specimens were produced on site, immediately incubated at 37 degrees C, and processed in triplicate. In comparing ejaculates obtained after 12 hours abstinence with those after 120 hours, semen volume and sperm concentration demonstrated a significant increase with increasing abstinence time (p = 0.03). However, no correlation between abstinence time and percentage of motility, lateral head amplitude, cross-beat frequency, mean velocity, and mean linearity was found. We conclude that motility does not change with ejaculatory frequency and that in normal men prescribed abstinence before analysis of semen for motility characterization may not be necessary.

Effects of Extracellular Ionized Calcium, Diltiazem and Camp on Motility of Human Spermatozoa

In order to elucidate the effects of ionized calcium and calcium channel blockers on human sperm motility, an in vitro study was conducted looking at the effects of exogenous calcium, ethylene diamine tetraacetic acid (EDTA), diltiazem and dibutyrl cyclic adenosine monophosphate (db-cAMP) on per cent motility and mean velocity of human sperm. Washed spermatozoa from 21 fertile donors were incubated with ionized calcium (zero, five, 10 and 50 mM), EDTA (one and 10 mM), diltiazem (one, 10, 100 microM and one mM) and cAMP (five mM). Per cent motility and mean velocity determinations were made at 10 and 120 min. by computerized analysis of videomicrographs. Over a wide range of extracellular ionized calcium concentrations (50 microM to 50 mM), per cent motility and mean velocity of human sperm were not stimulated or inhibited. At ionized calcium concentration less than 1 microM, achieved by addition of EDTA (10 mM), per cent motility decreased by 68% and 79% and mean velocity decreased by 44% and 48% compared to controls at 10 and 120 min. respectively (p less than 0.001). The decrease in mean velocity was reversible by addition of calcium to the EDTA (10 mM) sample to return ionized calcium to control concentration (0.5 mM). This reversibility suggests EDTA did not have a direct toxic effect on spermatozoa and that its action was mediated by changes in ionized calcium concentration. Diltiazem (one mM) decreased sperm mean velocity by 26% and 28% compared to controls at 10 and 120 min. respectively (p less than 0.01), but had no effect at lower concentrations (one, 10 or 100 microM). Db-cAMP (five mM) increased per cent motility by 25% and 20% and mean velocity by 36% and 34% compared to controls at 10 and 120 min. respectively (p less than 0.05). These results indicate that a minimum level of extracellular ionized calcium is essential to normal sperm motility and suggest that sperm are more dependent on the intracellular translocation of calcium ions for the regulation of motility than on the extracellular ionized calcium concentration. While db-cAMP does significantly increase per cent motility and mean velocity of human sperm, its clinical usefulness for the treatment of male infertility remains to be demonstrated.

Polysiloxane vaginal rings and cylinders for physiologic endometrial priming in functionally agonadal women

17 beta-estradiol (E2)-and/or crystalline progesterone (P)-impregnated polysiloxane vaginal rings and cylinders were tested as a system for endometrial priming in functionally agonadal women awaiting donor embryo transfer. Endometrial tissue was obtained by a transcervical biopsy procedure on simulated cycle day 26. The adequacy of the replacement regimen was judged by endometrial histologic dating, scanning electron micrographs, receptor content, and circulating E2 and P serum concentrations. Endometrial dating was consistent with cycle day 26. Electron micrographs showed normal surface characteristics. E2 and P receptor concentrations were within the normal range. Serum E2 levels were midfollicular, 105 +/- 12.8 pg/ml (mean +/- SEM), and midcycle, 254 +/- 28.6 pg/ml. P levels during the simulated follicular phase were undetectable (less than 0.2 ng/ml) but rose to a mean peak level of 17.3 +/- 1.8 ng/ml. The steroid-impregnated polysiloxane vaginal ring and cylinder system provided continuous and sustained hormone release, morphologically and endocrinologically normal endometrium, serum levels of E2 and P within the normal range for the entire menstrual cycle, and a convenient and physiologic therapeutic alternative to oral, vaginal, or intramuscular steroid replacement.

Identification of prostate-specific antigen in the vaginal secretions of a male pseudohermaphrodite

Prostatic glycoprotein was detected in the vaginal fluid of a male pseudohermaphrodite with use of an enzyme-linked immunosorbent assay. Following orchiectomy, prostatic glycoprotein concentrations fell from levels greater than 60 to less than 10.0 ng/ml. The decline in prostatic glycoprotein levels postoperatively implies that prostatic glycoprotein expression is controlled by androgens.