Ron Rabinowitz

Measurement of fetal urine production in normal pregnancy by real-time ultrasonography

Serial measurements of fetal bladder volume were obtained by real-time ultrasonography at 2- to 5-minute intervals, and the hourly fetal urine production rate was calculated. The mean hourly fetal urine production rate increased from 5 ml/hr at 20 weeks gestation to 51 ml/hr at 40 weeks. These values are double those reported in previous studies that measured fetal bladder volumes at 15- to 30-minute intervals because the cycle length is shorter than previously thought.

Risk factors and prognostic variables in the ovarian hyperstimulation syndrome

This study was undertaken to clarify discriminative roles of multiple epidemiologic, hormonal, and biophysical variables for causation of ovarian hyperstimulation syndrome. Three hundred ninety-six patients with anovulatory infertility had ovulation induction with human menopausal gonadotropin throughout 1822 treatment cycles; 54 cycles (3%) were complicated by ovarian hyperstimulation syndrome. Early follicular serum estradiol and prolactin levels were higher in this group than in controls: 75.5 versus 46.2 pg/ml and 18.5 versus 11.7 ng/ml, respectively (p less than 0.01). On the day of human chorionic gonadotropin administration (day 0) the mean serum estradiol level was 1047 +/- 381 in the group with ovarian hyperstimulation syndrome and 719 +/- 339 pg/ml in controls (p less than 0.0001). In all follicular sizes and in all grades of ovarian hyperstimulation syndrome there was a tendency for more recruited follicles, with significantly more small follicles (12 to 14 mm) present on day 0 in all grades of ovarian hyperstimulation syndrome than in controls. Stepwise logistic regression performed on 22 variables identified a high-risk group for this syndrome; the major features are illustrated by young, lean patients who, after relatively few ampules of human menopausal gonadotropin, develop high estradiol levels and multiple small follicles.

Correlation between the zona-free hamster egg sperm penetration assay and human in vitro fertilization*

The association between in vitro fertilization (IVF) and the zona-free hamster egg sperm penetration assay (SPA) was studied in 134 couples. The indications for IVF were tubal disease in 82 couples, unexplained infertility in 23, male infertility in 10, and combined mechanical and male factors in 19. In general, a positive SPA was a good predictor of subsequent IVF (91 of 107 couples). Specificity (number of couples with fertilization in vitro divided by the number of couples with a positive SPA times 100) was 94% for tubal infertility, 76% for unexplained infertility, and 46% for male infertility. A negative SPA predicted an overall fertilization failure of 78% (21 of 27 couples). Sensitivity of the test (number of couples with IVF failure divided by the number of couples with a negative SPA times 100) was 100% for tubal and unexplained infertility but only 63% for male infertility. The high predictive value of the SPA for subsequent IVF outcome in tubal infertility and unexplained infertility warrants its routine use for prescreening in IVF programs. Because of the lack of association between SPA and IVF in oligoasthenospermia, the bioassay should not be relied upon for predicting IVF outcome in male subfertility. The overall high association between the animal model and human IVF reinforces the use of the SPA for both basic research and clinical decision-making.

The value of ultrasonographic endometrial measurement in the prediction of pregnancy following in vitro fertilization

This work was undertaken for evaluation of the value of endometrial thickness as an early predictor for the success of in vitro fertilization (IVF). Endometrial changes were evaluated ultrasonographically in 47 women undergoing IVF. A high-dose gonadotropin protocol was used for induction of multiple follicular development. Thirty-seven women did not conceive following the procedure (group I), and 10 conceived (group II). Ultrasonographic endometrial measurements were performed repeatedly throughout the cycle. Serum 17 beta-estradiol and progesterone levels were evaluated concomitantly. Three consecutive growth patterns of the endometrium were observed. The first was a rapid one with a daily growth rate of about 0.5 mm from approximately 9 mm on day -3 to 12 mm on day +2 (day 0 being the day of human chorionic gonadotropin administration). The second phase, following follicular aspiration, showed a decrease in growth rate to about 0.1 mm per day until day +11, when a thickness of about 13 mm was measured. In group I growth was arrested from day +11 until menstruation, whereas in group II an accelerated growth rate of about 0.4 mm per day could be demonstrated from day +14 onward. Endometrial growth did not correlate with serum estradiol or progesterone levels. No conception occurred with an endometrial thickness below 13 mm on day +11. It is concluded that endometrial thickness follows a distinct pattern of growth in human menopausal gonadotropin-induced cycles and does not correlate with serum sex hormones.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative study of ultrasonically guided percutaneous aspiration with local anesthesia and laparoscopic aspiration of follicles in an in vitro fertilization program

Twenty patients from our in vitro fertilization program were randomly divided into two groups. Ten women underwent follicular aspiration during laparoscopy while they were under general anesthesia and 10 women had an ultrasonically guided follicular aspiration with local anesthesia. All patients had mechanical infertility, and ovulation was induced with human menopausal gonadotropins. In both groups the same aspiration system with a needle of 1.4 mm inner diameter and a continuous suction at 120 mm Hg were used. In the laparoscopy group the oocyte recovery rate was 82.5% and the fertilization rate 62.5%, with one twin pregnancy; in the ultrasound group the oocyte recovery rate was 75%, and the fertilization rate 61.9%, with a singleton pregnancy. Implications of these results are discussed.

Ultrasonically guided oocyte collection under local anesthesia: the first choice method for in vitro fertilization—a comparative study with laparoscopy

Ultrasonically guided oocyte collection gradually replaces laparoscopy in many in vitro fertilization (IVF) centers. In the present study we compare the efficacy of both methods in our IVF program. One hundred twenty patients were prospectively randomized into two groups. Sixty women underwent oocyte collection during laparoscopy under general anesthesia, and 60 women under ultrasound guidance with local anesthesia. Superovulation was induced with human menopausal gonadotropin/human chorionic gonadotropin. For the oocyte collection a cannula with a trocar was used for single percutaneous puncture, through which both ovaries could be reached by the aspiration needle. The number of aspirated oocytes and transferred embryos was higher in the laparoscopy group as compared with the ultrasound group (5.3 versus 4.0 per woman and 3.0 versus 2.3 per woman, respectively); but the clinical pregnancy rate per cycle was similar in both groups (12.5% versus 14.5%). Ultrasound aspiration seems to be as effective as laparoscopy in terms of oocyte retrieval and conception rates. Because the procedure is simple and inexpensive, we believe that it may replace laparoscopy as a method for oocyte collection in most patients who undergo IVF.

Use of enzyme replacement therapy for Gaucher disease during pregnancy

OBJECTIVEnTo date there has been little published experience with enzyme replacement therapy in pregnant women with symptomatic type I Gaucher disease.nnnSTUDY DESIGNnWe describe six patients, including three with repeated early pregnancy loss, five of whom successfully carried pregnancies to term; the last pregnancy was terminated because of pulmonary hypertension.nnnRESULTSnAll pregnancies were uneventful and five resulted in healthy newborns.nnnCONCLUSIONnWe concluded that in patients with Gaucher disease of childbearing age,for whom obstetric complications are an important symptom of the disease, pregnancy is not contraindicated (unless there is evidence or suspicion of pulmonary hypertension) and treatment should not be interrupted because the clinical improvement engendered by enzyme replacement therapy is conducive to fewer complications during pregnancy and delivery and post partum.

Ultrasonically guided oocyte recovery for in vitro fertilization: an improved method

Ultrasonically guided follicular aspiration is now routinely used for in vitro fertilization (IVF) in many centers. We present an improved method for oocyte recovery. One hundred nine consecutive patients with mechanical infertility submitted for IVF were included in the study. Superovulation was induced with human menopausal gonadotropin (hMG)/human chorionic gonadotropin (hCG). Oocyte recovery was ultrasonically guided, the bladder filled with phosphate-buffered saline (PBS), and a cannula with trocar used for single percutaneous puncture. The aspiration needle was of 1.6 mm in internal diameter. When compared to published data using smaller-bore needles, it seems that this improved needle increased the number of oocytes recovered to a mean of 6.5 and the number of embryos replaced to a mean of 3.9 per patient, with a pregnancy rate of 20% per transfer.

Cholesterol and steroid levels in human follicular fluids of human menopausal gonadotropin-induced cycles for in vitro fertilization.

Fifty-eight follicular fluids (FF) were obtained from 18 women undergoing in vitro fertilization (IVF). Follicular development was induced by human menopausal gonadotropin (hMG) and follicular aspiration was performed 36 hr after an ovulatory dose of human chorionic gonadotropin (hCG). Two stages of oocyte-corona-cumulus complexes (OCCCs) morphological maturation was identified in this population: intermediate and mature. FF from which intermediate and mature OCCCs were obtained did not differ in 17β-estradiol (E2, progesterone (P), and cholesterol levels. Fifty OCCCs were fertilized and eight were not fertilized. No difference was found in E2, P, and cholesterol levels in those two populations of OCCCs. Forty hours after insemination 50% of the oocytes were at the two-cell stage and 50% were at the three-cell stage. Steroids and cholesterol levels did not differ in FF from which those two groups of embryos originated. A direct correlation was found among the levels of cholesterol, E2, and P in the FF. An inverted ratio of high-density lipoprotein (HDL) to low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL) was found in FF compared to serum in 10 women. It is concluded that FF cholesterol levels have no value in predicting follicular maturation.