Ramaa Rao

The Luteinized Unruptured Follicle Syndrome and Endometriosis

The identity of luteal structures was evaluated laparoscopically in 199 women. All had evidence of ovulation as judged by dated endometrial biopsies and/or elevated levels of plasma progesterone or urinary pregnanediol. Luteal structures were identified in 159 cases. The stigma was present in 32%, absent in 38%, and questionable in 30% of the latter. No significant differences in the distribution of these findings were observed between patients with endometriosis and patients with male or tubal causes of infertility. However, in patients with clinically diagnosed ovulatory dysfunction, stigmata were observed significantly less frequently. The frequency of stigmata was not related to the varying severity of endometriosis. The earliest time in the menstrual cycle when the stigma was identified was on the day of the basal body temperature (BBT) dip prior to its rise and when the endometrium was late-proliferative. The latest was 11 days after the BBT dip and on day 26 according to endometrial histology. Uncertainty as to the presence of the stigma was frequent. The stigma was present in 33% of women with endometriosis. In some, a corpus luteum with the stigma and endometriosis were present on the same ovary. The hypothesis postulated by some investigators that the luteinized unruptured follicle (LUF) syndrome may be the cause of infertility in women with endometriosis does not appear to be accurate. However, endocrine factors probably play a role in the origin of LUF.

Use of Albumin Gradients for X and Y Sperm Separation and Clinical Experience with Male Sex Preselection

Semen samples obtained from 18 normal males and 37 husbands requesting male child preselection were separated on concentration gradients of human serum albumin. Separated semen obtained from the husbands was then used for artificial homologous insemination (AIH). A significant increase in the sperm motility, progressive drive, and percentage of Y-bearing sperm along with a decrease in the total sperm count and percentage of abnormal forms were observed in separated specimens. Fathers of three or more female children had a slightly smaller but statistically significant percentage of Y-bearing sperm in their semen samples than did normal males. Ten conceptions were achieved with separated semen. Seven pregnancies terminated in normal deliveries of five male and two female infants, one ended in a spontaneous abortion of a male fetus, and two patients are still expecting. The ratio of male to female conceptions in this small study parallels the ratio of Y to X sperm in the final specimen used for AIH.

Artificial Insemination Homologous with Oligospermic Semen Separated on Albumin Columns

Semen samples obtained from 27 infertile men were separated on human serum albumin (HSA) columns prior to artificial homologous insemination (AIH). The columns contained either a single 7.5% HSA layer or two 17.5% and 7.5% HSA layers. Separated specimens were free of seminal debris, had significantly improved motility and progressive drive, and had a decreased percentage of abnormal forms. The total sperm count was also significantly decreased after separation, especially with the two-layer technique. No conceptions occurred in 21 couples when two-layer separation was used, but four pregnancies in 12 couples resulted from AIH with semen separated on the single-layer column. The mean total count of motile sperm obtained for AIH was 5 million with the two-layer and 31 million with the one-layer technique.

A randomized prospective comparison between intrauterine insemination and fallopian sperm perfusion for the treatment of infertility

OBJECTIVE To determine if the pregnancy rates (PRs) in infertile women could be improved with fallopian sperm perfusion in comparison with IUI. DESIGN Randomized prospective analysis. SETTING Academically affiliated infertility center. PATIENTS Consecutive patients undergoing controlled ovarian hyperstimulation (COH). INTERVENTIONS After hCG administration, patients were randomized to either IUI or fallopian sperm perfusion. MAIN OUTCOME MEASURES Pregnancy rates with the two treatment modalities. RESULTS Of 240 COH cycles, those randomized to IUI included 44 clomiphene citrate (CC) (group I) and 76 gonadotropin (group III) cycles. Patients receiving fallopian sperm perfusion included 44 cycles of CC (group II) and 76 cycles of gonadotropin (group IV) treatment. The overall PRs per cycle (10.8% versus 10.8%) were similar for IUI and fallopian sperm perfusion, respectively. The PRs were also similar when compared for ovulation induction with CC (6.8% versus 9.1%) and gonadotropins (13.2% versus 11.8%). CONCLUSION We conclude that fallopian sperm perfusion offers no advantage over IUI. Because the process of fallopian sperm perfusion is more time consuming and more costly (because of increased media usage), fallopian sperm perfusion does not seem indicated as a routine infertility therapy and should not replace IUI.

Elevated tubal perfusion pressures during selective salpingography are highly suggestive of tubal endometriosis.

OBJECTIVE To investigate the possible etiologies of elevated tubal perfusion pressures. DESIGN Analysis of 48 consecutive female patients with infertility who underwent laparoscopy and a gynecoradiological investigation as part of their infertility work-up. SETTING Academically affiliated infertility center. INTERVENTIONS A gynecoradiological investigation was performed using a previously reported standardized contrast injection system. Laparoscopy was performed routinely. RESULTS Patients who demonstrated by laparoscopy to have endometriosis showed a significantly increased incidence of tubal blockage during initial hysterosalpingography (HSG) (12/26, 46.1%) compared with controls (2/14, 14.3%). Patients with endometriosis also demonstrated significantly more frequently elevated tubal perfusion pressures (22/26; 84.6%) than women without disease (2/14, 14.3%) and significantly higher mean tubal perfusion pressures than women with normal pelvises (576 +/- 264 versus 450 +/- 268 mm Hg). CONCLUSION Tubal blockage during initial HSG and elevated tubal perfusion pressures during selective salpingography are highly suggestive of tubal endometriosis. These data are the first evidence that tubal involvement with endometriosis may be more frequent than previously suspected. They also suggest that the performance of a gynecoradiological investigation, inclusive of selective salpingography, can greatly contribute to a presumptive diagnosis of endometriosis.

Conception following insemination with a freeze-preserved retrograde ejaculate.

Retrograde ejaculation, an infrequent cause of male infertility, may be the sequela of prostate or bladder neck surgery or the result of interruption in the sympathetic innervation to the bladder neck. The diagnosis is established by history and examination of the urine. In infertile couples artificial insemination homologous (AIH) using retrograde ejaculate recovered from the bladder has been successfully accomplished, but conception has occurred only in isolated cases. A literature review of the subject is presented. The technique of semen recovery from the bladder is time-consuming and uncomfortable to the patient, while the quality of the semen recovered is variable and the risk of iatrogenic urinary tract infection is increased. To avoid the above problems, and to have sperm available for AIH at the time of induced ovulation in an anovulatory wife, we were able to freeze-preserve ejaculate recovered from the bladder for future use. A case of conception following AIH with freeze-preserved retrograde ejaculate is presented.

PREMATURE LABOR TREATMENT WITH RITODRINE IN MULTIPLE PREGNANCY WITH THREE OR MORE FETUSES

Abstract. Modern treatment for anovulatory infertility increases the incidence of multiple pregnancies with three or more fetuses and predisposes to prematurity with high perinatal mortality and morbidity. Premature labor was successfully treated in four multifetal pregnancies with ritodrine hydrochloride, a beta‐mimetic drug relaxing the uterus. Another patient misdiagnosed as false labor was not treated and lost three out of four premature babies. Beta‐mimetic treatment is indicated in multiple pregnancies even in false labor, or when painless progress in cervical dilatation is observed, to avoid asymptomatic progression into true labor. In contrast to singleton pregnancies, advanced labor with more than four centimeters cervical dilatation should not preclude good chances for successful treatment. Persistence in treatment and repeated use of the most effective intravenous route combined with oral ritodrine administration is needed because of marked tendency to recurrences of premature labor. Progressive increase in the dose of oral ritodrine may be indicated by decrease in therapeutic response. Maternal tachycardia should be considered as an index of patient responsiveness to the beta‐mimetic treatment. The therapy is most successful when the patient is hospitalized from the first episode of treatment until at least the 37th week of pregnancy. This is probably less expensive than prolonged hospitalization of several prematures in an intensive care nursery.

Integrity of central dopaminergic system in women with postpartum hyperprolactinemia

In order to elucidate the role of elevated prolactin (PRL) on the central dopaminergic systems, the suppressive effects on PRL were studied after the administration of L-dopa and L-dopa plus carbidopa on consecutive days to the following three groups: 10 normoprolactinemic subjects, six nonnursing normal puerperal women, and seven hyperprolactinemic women without any evidence of pituitary tumor. In the normoprolactinemic subjects (basal PRL 13 +/- 2 ng/nl mean +/- SE), the suppressive effects of L-dopa alone and L-dopa plus carbidopa were similar (48% +/- 4% and 58% +/- 6%, respectively). In puerperal hyperprolactinemic subjects, the basal PRL (116.8 +/- 16.4 ng/ml) was suppressed 77% +/- 2% after administration of L-dopa and 51% +/- 7% after L-dopa plus carbidopa, significantly different from that of L-dopa alone (p less than 0.005), but similar to that observed in normal subjects. In the patients with idiopathic hyperprolactinemia, the baseline PRL (131 +/- 38 ng/ml) decreased 56.3% after the administration of L-dopa. In the presence of peripheral dopa decarboxylase inhibition, the administration of L-dopa decreased plasma PRL values 30%, a drop significantly different from that of L-dopa alone (p less than 0.02). Women with idiopathic hyperprolactinemia exhibit reduced central dopaminergic inhibition of PRL secretion similar to that in patients with pituitary tumor; whereas the response to central dopaminergic inhibition in postpartum women with comparable baseline PRL levels is similar to that in normoprolactinemic subjects. This indicates that hyperprolactinemia per se is not associated with a state of reduced central dopaminergic inhibition. The increased pituitary sensitivity to L-dopa observed in puerperal women may be due to alterations in PRL receptors or vascularity.

University of Chicago in Vitro Fertilization Program at Michael Reese Hospital and Medical Center.

The in Vitro Fertilization-Embryo Transfer (IVFET) Program at Michael Reese Hospital and Medical Center was organized by April I, 1983, and our first procedure was performed on May 25, 1983. The criterion for acceptance into the program is infertility due to tubal pathology in normal ovulating, married females Jess than 40 years of age. The male should have a normal semen analysis, although certain cases of poor sperm count or motility are considered if sperm morphology is acceptabIe. This preliminary report describes the methodology and results of the first 14 weeks of experience with !VFET at Michael Reese Hospital and Medical Center.

The effect of albumin gradients and human serum on the longevity and fertilizing capacity of human spermatozoa in the hamster ova penetration assay**Supported by the Medical Research Institute Council and Michael Reese Hospital and Medical Center.

The motility and the capability to penetrate zona-free hamster eggs of Y-enriched or washed sperm were evaluated after protracted in vitro incubation with and without the addition of preheated human serum. The addition of 50% preheated serum decreased the motility loss over time for both the washed and Y-enriched sperm. Such motility loss was decreased by 25% and 27% at 20 hours, by 31% and 39% at 30 hours, and by 30% and 40% at 40 hours of incubation for the washed and Y-enriched sperm, respectively. The washed and Y-enriched sperm suspensions with and without addition of preheated human serum achieved 100% penetration rate after 2 hours of preincubation. However, when scored by the sperm per egg ratio, washed sperm achieved 1.2 +/- 0.2 (mean +/- standard error [SE]) sperm per egg, while the Y-enriched sperm achieved 3.0 +/- 0.4 sperm per egg. After 24 hours of incubation, penetration by washed sperm decreased to a mean of 62.8%. The Y-enriched sperm penetrated a mean of 18% of the ova. Addition of preheated serum increased the egg penetrating capacity of washed sperm at 24 hours but failed to improve the Y-enriched spermatozoa. This study suggests that for optimum conception rates, precise ovulation timing is crucial when Y-enriched fractions are used for insemination.