Mary Wood Molo

Transvaginal ultrasonography and the assessment of luteal phase endometrium

OBJECTIVE The goal of this study was to determine if ultrasonography of the endometrium could be used to identify in a noninvasive manner patients with luteal phase defects. STUDY DESIGN Patients underwent midluteal transvaginal ultrasonography with photographing of the endometrial image, an endometrial biopsy, and two serum hormonal profiles. The ultrasonographic images were graded and compared with the histologic results and the serum hormonal profiles. RESULTS There was a trend toward a higher grade image being associated with normal histologic studies. There was no significant difference between the mean hormonal profiles in patients with normal and those with abnormal biopsy specimens. There was no significant difference between the hormonal values drawn before and those drawn after the biopsies. CONCLUSIONS Although the endometrial appearance on ultrasonography appears to reflect secretory transformation, it cannot replace endometrial biopsy for full evaluation of luteal endometrial development. Short-term variability in serum concentrations of midluteal hormones was not demonstrated.

Optimizing tubal epithelial cell growth promotes mouse embryo hatching in coculture

AbstractPurpose: This study investigates the relationship between human tubal epithelial cell growth characteristics and mouse embryonic development to determine which cellular requirements should be preferentially provided in a coculture system. Methods: Cell growth and viability were assessed for 5 days in α-minimal essential medium or human tubal fluid supplemented with 10% human serum or 10% synthetic serum. Two-cell mouse embryo development to blastocyst and hatching blastocyst stages was also assessed with or without coculture. Results: Both epithelial cell growth and embryo development were dependent on serum supplementation with better cell viability and growth rates in human serum and better blastocyst development in synthetic serum. The highest proportion of hatching blastocysts was found in α-minimal essential medium and human serum with coculture. Conclusions: Culture conditions which improve tubal epithelial cell growth also improve the hatching rate of mouse embryos in coculture. This indicates that by meeting the metabolic and nutritional demands for epithelial cell growth, the beneficial effects of coculture on embryo development may be optimized.

Bacterial contamination after transvaginal aspiration (TVA) of oocytes

Transvaginal sonography with needle aspiration is a rapid and efficient approach to oocyte retrieval for in vitro fertilization (IVF). Ultrasound guidance allows for easy delineation of pelvic vessels and viscera, therefore minimizing complications; nevertheless, transvaginal puncture introduces an inherent risk for pelvic infection which may adversely affect pregnancy outcome and future reproductive capacity. In this prospective study, we examined bacterial contamination of the follicular fluid after transvaginal aspiration (TVA) and of the peritoneal fluid at the time of tubal embryo transfer (TET), and their effect on pregnancy outcome.

Selective salpingography for the diagnosis and treatment of early tubal pregnancy

OBJECTIVE To determine whether selective salpingography can accurately diagnose and treat patients with early ectopic pregnancies (EPs). DESIGN Prospective clinical case study. SETTING Selective salpingography was performed in an outpatient setting under i.v. sedation. PATIENTS Selective salpingography was performed in 10 women who had clinical presentation suggestive of EP, two consecutive abnormal hCG measurements < 2,000 mIU/mL, and inconclusive vaginal probe sonogram. INTERVENTION Selective salpingography was performed under fluoroscopy. A cervical cannula was placed, and the tubal ostium was cannulated with a curved selective salpingography catheter (Bard Gynecology and Radiology, Covington, GA). Methotrexate (MTX) (25 or 50 mg) was injected into the affected tube through the selective salpingography catheter. MAIN OUTCOME MEASURE The accuracy of selective salpingography in the diagnosis of early EP was determined by the rate of fluoroscopic imaging of an ampullary radiolucency upon injection of contrast material through the selective salpingography catheter. Resolution of the EP after injection of MTX into the tube was detected by serial declining hCG measurements. RESULTS Selective injection of contrast material into the fallopian tubes detected seven ampullary pregnancies in 10 patients. Two patients demonstrated neither tubal pregnancy nor intrauterine pregnancy. One patient with apparent bilateral proximal cornual occlusions on selective salpingography underwent laparoscopy, followed by salpingostomy of an ampullary pregnancy. All 7 patients who received MTX through the selective salpingography catheter completely resolved the EP. Four patients demonstrated patent fallopian tubes on hysterosalpingograms performed 3 to 6 months later. CONCLUSION Selective salpingography may diagnose early tubal pregnancies of some patients with equivocal clinical, laboratory, and sonographic findings. These patients can be successfully treated at the same time with a single dose of MTX delivered into the affected tube. Selective salpingography reduced the need for laparoscopy and operative intervention. Selective salpingography is a simple and relatively inexpensive diagnostic and therapeutic alternative in patients with suspected early tubal pregnancy.

Hormonal profiles of early gestations with abnormal karyotype.

OBJECTIVE To describe the hormonal profiles of chromosomally abnormal pregnancies during the first trimester. DESIGN A prospective study from 1984 through 1990 in which infertility patients who conceived were monitored weekly with serum E2, P, and beta-hCG levels. SETTING The infertility practice at Rush-Presbyterian-St. Lukes Medical Center in Chicago, Illinois. PATIENTS Study included 15 women who had dilatation and curettage for first trimester fetal losses with confirmed abnormal karyotype, 6 women with chromosomally normal male abortuses, and 60 consecutive women whose pregnancies yielded normal term infants. RESULTS After natural conception, E2 demonstrated a moderate rise in both normal and chromosomally abnormal pregnancies to approximately 300 pg/mL by day 29 (6 weeks of gestation). In normal gestations, E2 continued a steady increase to exceed the level of 1,000 pg/mL by day 64 (11 weeks of gestation). In chromosomally abnormal pregnancies, the mean E2 plateaued and remained at approximately 200 pg/mL until fetal demise was noted. In stimulated conceptions, the rise of E2 was sharp and early (1,200 pg/mL by day 29); in normal pregnancies, E2 steadily increased to an average of 1,400 pg/mL by the end of the first trimester, whereas in karyotypically abnormal gestations, E2 declined to approximately 200 pg/mL by day 64. In pregnancies yielding a male abortus, a sharp decline and plateau at 800 pg/mL by day 56 (10 weeks of gestation) was observed. In both natural and stimulated normal pregnancies, hCG levels first demonstrated a linear rise, followed by a curvilinear increase from day 29 until day 56, with a peak of approximately 110,000 mIU/mL. The beta-hCG in chromosomally abnormal pregnancies, as well as in pregnancies yielding a male abortus, was characterized by a slow and gradual rise to a maximum of 40,000 mIU/mL, which remained relatively linear until day 64 when fetal demise was detected in all cases. Progesterone level data were excluded from analysis because of frequent P supplementation. CONCLUSIONS There were significant differences in the hormonal profiles of chromosomally normal and abnormal pregnancies. Serial measurements of serum E2 and beta-hCG from the 6th week of gestation may be useful in predicting an abnormal karyotype sooner than other current diagnostic tests.

Serum and follicular fluid (FF) estradiol (E2) levels in ovarian hyperstimulation syndrome (OHSS) during in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT) conception cycles after pituitary suppression

Initaial hope that ovarian hyperstimulation syndrome (OHSS) would be less likely to occur after pituitary suppression with gonadotropin releasing-hormone agonists (GnRH-a) has not been substantiated. GnRH-alhuman menopausal gonadotropin (hMG) protocols often lead to OHSS with markedly elevated circulating estradiol (E2) levels in susceptible patients. This study was undertaken to determine whether or not intrafollicular E2 secretion is increased in these cases. Fifty-two in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT) conception cycles treated with GnRH-alhMG were included in the study. GnRH-a, leuprolide, 0.5 mg, was administered subcutaneously from day 20 of the preceding cycle and the ovaries were stimulated with hMG, 75-225 IU bid intramuscularly, followed by human chrionic gonadotropin (hCG), 5000 IU. Twenty cycles (Group I) were associated with moderate or severe OHSS and 32 cycles (Group II) did not result in OHSS. E2 was measured in the serum on the day of hCG (day 0), on the day of oocyte retrieval (day 2), and at midluteal phase (days 6–8), as well as in the follicular fluid (FF) using a solid-phase direct RIA. Mean serum E2 was significantly higher at all three sampling times in Group I (OHSS) than in Group II. Both the number of follicles and the number of oocytes were also significantly higher in Group I. Mean (±SD) FF E2 concentrations in both groups were similar (367±109 and 364±188) in follicles >15 mm in diameter but were increased in follicles ≤15 mm in diameter in OHSS (479±111) versus non-OHSS (230±32) patients. It appeared that OHSS was a function of an increased number of stimulated follicles as well as a result of altered steroidogenic function at the follicular level.