Robert Israel

Single luteal phase serum progesterone assay as an indicator of ovulation

A study was undertaken to determine whether solitary progesterone as says performed on serum samples obtained in the midluteal phase would provide the clinician with a convenient indicator that ovulation had occurred in that cycle. After a normal luteal-phase range was establish ed, single luteal-phase serum progesterone sampling was performed in 51 infertile women with regular menses and 35 oligomenorrheic women undergoing clomiphene citrate therapy. In the follicular phase of the cycle, progesterone levels were consistently less than 2 ng/ml. Between 11 and 4 days prior to the onset of menses in presumptively ovulatory cycles, serum progesterone levels were always 3 ng/ml or greater. Progesterone values in this range were always accompanied by a secretory endometrium and can be considered presumptive evidence of ovulation. This rapid, easily performed technique enables 1 technician to assay 30 or more samples for progesterone in a single working day and the results are available within 24 hours. This assay technique is easier to perform and more reproducible than a urinary pregnanediol assay, and it is expected that clinical laboratories will soon perform serum progesterone assays as a routine procedure.

Hysteroscopic management of recurrent abortion caused by septate uterus

Between April 1982 and April 1986, 91 patients underwent hysteroscopy for treatment of septate uteri. In 88 patients simultaneous laparoscopy was performed and one patient had a simultaneous laparotomy. Ninety procedures were performed on an outpatient basis with the patients under general anesthesia. The septum was incised with flexible scissors. Sequential estrogen-gestagen therapy was used immediately after operation to reepithelialize the freshly dissected surfaces. Patients were permitted to conceive in the first month after operation. The indications for hysteroscopy were multiple but included recurrent abortion in 79 patients. Among those patients in this category the pretreatment reproductive wastage was 95%. Most losses were in the first trimester. Among those patients who conceived after therapy, the gestational outcome markedly improved. Eighty-seven percent of the pregnancies have resulted in a living infant or have progressed beyond 20 weeks of gestation. Because the gestational outcome equals or exceeds that achieved by transabdominal metroplasty and because of its lower morbidity and the option for vaginal delivery, hysteroscopic incision of the symptomatic septate uterus should replace transabdominal metroplasty.

Monitoring techniques to predict and detect ovulation

This study was designed to evaluate the accuracy of various methods in predicting and detecting ovulation in 14 spontaneous and 17 clomiphene citrate (CC)-induced cycles. From cycle day 11 all subjects (n = 27) were followed with daily transvaginal ultrasound; rapid measurement of serum luteinizing hormone (LH) and estradiol (E2); determination of urinary LH with First Response (Tambrands Inc., Palmer, MA) and Ovustick (Monoclonal Antibodies, Inc., Mountain View, CA) kits; and recording of basal body temperature (BBT). The results demonstrated that transvaginal ultrasound detected ovulation in all cycles. Mean daily serum LH levels were similar in both groups, and peak values of 40 mIU/ml or greater preceded the day of ovulation in all cycles. Serum E2 peak was significantly greater in CC cycles (961 +/- 96 versus 463 +/- 39 pg/ml) (P less than 0.01) and preceded the LH peak in 97% of the cycles. First Response and Ovustick predicted ovulation in 53.3% and 87.5% of the cycles, respectively (P less than 0.01). BBT nadir predicted the day of ovulation in only 10% of cycles. In conclusion, this study revealed that transvaginal ultrasound is an excellent method for detection of ovulation and that Ovustick is a very useful method for prediction of the day of ovulation.

Endometrial thickness is a valid monitoring parameter in cycles of ovulation induction with menotropins alone

OBJECTIVE To evaluate the ability of an ultrasound (US)-measured periovulatory endometrial thickness to predict conception in hMG-stimulated cycles. DESIGN Retrospective. SETTING A university-based tertiary practice. PATIENTS One hundred twelve patients undergoing 292 cycles of ovulation induction with hMG alone. MAIN OUTCOME MEASURES A periovulatory transvaginal US measurement of endometrial thickness was obtained during cycles of ovulation induction with hMG alone. Clinical pregnancy was defined by fetal cardiac activity. Sensitivity and false-positive rates for multiple discriminatory values of endometrial thickness were calculated and a relative operating characteristic (ROC) curve was constructed to evaluate the performance of this test as a predictor of pregnancy. RESULTS Thirty-eight of 292 cycles resulted in pregnancy. Conception and nonconception cycles showed similar demographics, diagnoses, peak E2, maximum number of follicles, midluteal P, and mean endometrial thickness. Ovulatory dysfunction was a more frequent diagnosis in the conception group. Relative operating characteristic analysis for endometrial thickness as a predictor of pregnancy yielded an area under the curve of 0.623 +/- 0.049 (mean +/- SD). CONCLUSION Endometrial thickness is a valid screening test for conception outcome in cycles stimulated with hMG. A periovulatory endometrial thickness > or = 10 mm defined 91% of conception cycles. No pregnancy occurred when the endometrium measured < 7 mm.

An individualized graduated therapeutic regimen for clomiphene citrate

Abstract In a 3 year period, 105 patients with infertility and oligomenorrhea or amenorrhea were treated with clomiphene citrate and had adequate follow-up. Of these 105 women, 96 (91.4 per cent) ovulated with clomiphene and 40 (38.1 per cent) conceived. Twenty-eight women failed to ovulate at the maximum dosage (100 mg. per day × 5 days) recommended in the product brochure, but 19 of these patients ovulated at higher doses and 9 conceived. Eight (20 per cent) patients required longer than the recommended 3 months to conceive. In all, 14 (35 per cent) of the 40 women who conceived required more than the recommended dosage and/or needed more than 3 months of treatment. The over-all spontaneous abortion rate was 20.5 per cent. There was one multiple gestation. Ovarian cysts developed in 7 patients (6.7 per cent). Most of those who failed to conceive had additional infertility factors. When these multiple infertility factor patients are eliminated, the pregnancy rate in clomiphene-treated patients was 85.7 per cent.

Gestational outcome following hysteroscopic lysis of adhesions

Thirty-eight infertile women conceived 43 times following treatment for intrauterine adhesions (IUA). Adhesions were classified as being minimal in 7 women, moderate in 20 others, and extensive in 11. All women underwent hysteroscopy with division of all adhesions utilizing miniature scissors and high-dose estrogen treatment for 2 months. In addition 35 of the 38 women had either an intrauterine contraceptive device or a Foley catheter placed to prevent readherence of the walls, and 31 women had the uterine cavity investigated again prior to attempting a pregnancy. Prior to treatment for IUA only 16.7% of all pregnancies in those women with no other cause for pregnancy loss resulted in the delivery of a living infant. However, following treatment 87.2% of these pregnancies resulted in the delivery of a viable infant (P less than 0.001). No instances of placenta accreta occurred, and manual removal of the placenta was not required. Division of adhesions under hysteroscopic control together with the adjunctive measures utilized is superior to all other methods of therapy for IUA and should replace them.

Comparative quantitation of menstrual blood loss with the Lippes Loop Dalkon Shield and copper T intrauterine devices.

The magnitude of menstrual blood loss and the incidence of menorrhagia associated with 2 plastic intrauterine devices (IUDs), THE Lippes loop and standard-size Dalkon shield, were compared with a copper T device (TCu 300). In order to evaluate long-term as well as short-term effects, blood loss was measured at postinsertion levels of 6, 12, and 18 months in 72 women wearing the Lippes loop, in 73 wearing the Dalkon shield, and in 82 with TCu 300. Increases in the mean blood loss over controls (35.3 ml) for the Lippes loop at 6, 12, and 18 months were 112%, 60%, and 95%, respectively. Corresponding increases for the Dalkon shield were 71%, 112%, and 86%; those for the TCu 300 were 54%, 56%, and 41%. There was significantly less bleeding with the TCu 300 than with either of the other 2 devices (p.05). The Lippes loop and the Dalkon shield were associated with fluctuating blood loss values whereas blood loss with the TCu 300 was relatively stable at all study periods.

Hysteroscopic incision of the septate uterus

Fifteen women underwent hysteroscopic incision of symptomatic septate uteri between April, 1982, and July, 1983. All procedures were performed on an outpatient basis with general anesthesia, by means of dextran hysteroscopy with direct-vision scissors incision of the septa under external laparoscopic guidance. No significant intraoperative nor postoperative complications occurred. Preoperative indications included repetitive pregnancy loss (eight), repetitive pregnancy loss and infertility (four), infertility and total uterine septum (one), preinsemination by donor (one), and intractable dysmenorrhea (one). A total of 72 hysteroscopic septal incision/resection procedures unassociated with any significant morbidity have been reported in the literature. Compared to transabdominal metroplasty, hysteroscopy is an outpatient procedure that avoids abdominal and uterine incisions and requires no long-term postoperative delay in attempting pregnancy. In addition, subsequent pregnancy does not require cesarean section. With these advantages, hysteroscopic incision of the symptomatic septate uterus can replace transabdominal metroplasty and allow liberalization of operative indications.

Evaluation of a large cohort of men presenting for a screening semen analysis

OBJECTIVE To determine: [1] what percentage of men in an infertile relationship will have a semen abnormality, [2] the average value for each semen parameter in this group of men, [3] the distribution of abnormal semen parameters in this group, and [4] if our data support the hypothesis that sperm concentration is declining. DESIGN Retrospective cohort study. SETTING County hospital university-based infertility clinic. PATIENT(S) Male partners of women presenting for an infertility evaluation. INTERVENTION(S) Semen specimens were collected after 2-5 days of abstinence. MAIN OUTCOME MEASURE(S) Sperm concentration, motility, and morphology. RESULT(S) Fifty-two percent of samples had at least one sperm abnormality based on World Health Organization criteria. Fifty-one percent had an abnormality in sperm motility, 18% in sperm concentration, and 14% in sperm morphology. Four percent of the patients were azoospermic. CONCLUSION(S) No decline in sperm density was revealed in semen collected by men presenting for an initial screening semen analysis.

A study of the copper T intrauterine contraceptive device (TCu 200) in nulliparous women

A study of the effectiveness and complications associated with the Model 200 copper T intrauterine device in 471 nulliparous women ranging in age from 14-33 years is reported, including 6044 woman-months of device use. 128 of the patients had had 1 or more previous abortions. This T-shaped device is made of polyethylene impregnated with barium sulfate, wound with .2 mm diameter copper wire providing a copper surface area of 200 square mm, and is inserted easily without anesthesia and with minimal pain. Continuation and failure rates were calculated for the first 12 months of use by life-table analysis. The overall continuation rate of device use was 74.2 per 100 women, the expulsion rate was 5.4, removal rate for bleeding or pain was 10.7, and pregnancy failure occurred at a rate of 1.7 per 100 women per year. These discontinuation event rates are lower than those reported for other IUDs in nulliparous women and comparable to IUD rates in multiparas. In the past, other IUD designs have been very unsatisfactory in nulliparas because of high expulsion and removal rates, but this study indicates that the TCu 200 IUD model is well accepted by nulliparas with good safety and effectiveness, and provides a promising and highly desired contraceptive alternative to oral contraception for young women.