Samuel J. Chantilis

Use of Crinone vaginal progesterone gel for luteal support in in vitro fertilization cycles.

OBJECTIVE To investigate the efficacy and safety of intravaginal Crinone 8% (Columbia Research Laboratories, Miami. FL) versus IM progesterone for luteal phase support after IVF-ET. DESIGN Prospective open trial with comparison to historical controls. SETTING University hospital. PATIENT(S) Two hundred six women undergoing IVF-ET. INTERVENTION(S) One hundred patients received Crinone vaginal progesterone gel (90 mg once daily) and 106 patients received IM progesterone (50 mg once daily) beginning on the evening of oocyte retrieval. MAIN OUTCOME MEASURE(S) Pregnancy and miscarriage rates, and midluteal serum progesterone levels. RESULT(S) Positive beta-hCG pregnancy rates, clinical pregnancy rates per transfer, and ongoing pregnancy rates were similar for the Crinone and IM progesterone groups. Women who received Crinone had higher rates of biochemical pregnancy loss but lower rates of clinical pregnancy loss (i.e., spontaneous abortion) than women who received IM progesterone. Midluteal serum progesterone concentrations were significantly higher in the IM progesterone group (94.3+/-8.8 ng/mL versus 57.7+/-7.4 ng/mL). Several women who received Crinone had vaginal bleeding 11-13 days after oocyte retrieval. CONCLUSION(S) For all age categories, positive beta-hCG and ongoing pregnancy rates were similar when Crinone or IM progesterone was given for luteal phase support in IVF-ET cycles, despite lower serum progesterone concentrations and higher rates of biochemical pregnancy loss with Crinone. Although the results of this study support the use of Crinone as an acceptable alternative for luteal support after IVF-ET, differences in bleeding patterns and rates of biochemical pregnancy loss demonstrate the need for a prospective randomized study.

Recognition of depression in obstetric/gynecology practices

Depression is a common and serious health problem that occurs twice as often in women as in men. The lifetime prevalence of major depression in women is estimated to be as high as 21%. Although less severe and less common, mild depression and dysthymia (chronic mild depression) can cause functional disability and require treatment. Regardless of severity or duration, depression can be difficult to recognize because it frequently is masked by complaints that accompany other common obstetric and gynecologic illnesses and events. This article reviews the various depressive disorders in women with a focus on presentations that occur in obstetric and gynecologic practice.

Noninferiority, randomized, controlled trial comparing embryo development using media developed for sequential or undisturbed culture in a time-lapse setup.

OBJECTIVE To study whether a culture medium that allows undisturbed culture supports human embryo development to the blastocyst stage equivalently to a well-established sequential media. DESIGN Randomized, double-blinded sibling trial. SETTING Independent in vitro fertilization (IVF) clinics. PATIENT(S) One hundred twenty-eight patients, with 1,356 zygotes randomized into two study arms. INTERVENTION(S) Embryos randomly allocated into two study arms to compare embryo development on a time-lapse system using a single-step medium or sequential media. MAIN OUTCOME MEASURE(S) Percentage of good-quality blastocysts on day 5. RESULT(S) Percentage of day 5 good-quality blastocysts was 21.1% (standard deviation [SD] ± 21.6%) and 22.2% (SD ± 22.1%) in the single-step time-lapse medium (G-TL) and the sequential media (G-1/G-2) groups, respectively. The mean difference (-1.2; 95% CI, -6.0; 3.6) between the two media systems for the primary end point was less than the noninferiority margin of -8%. There was a statistically significantly lower number of good-quality embryos on day 3 in the G-TL group [50.7% (SD ± 30.6%) vs. 60.8% (SD ± 30.7%)]. Four out of the 11 measured morphokinetic parameters were statistically significantly different for the two media used. The mean levels of ammonium concentration in the media at the end of the culture period was statistically significantly lower in the G-TL group as compared with the G-2 group. CONCLUSION(S) We have shown that a single-step culture medium supports blastocyst development equivalently to established sequential media. The ammonium concentrations were lower in the single-step media, and the measured morphokinetic parameters were modified somewhat. CLINICAL TRIAL REGISTRATION NUMBER NCT01939626.

Laparoscopic removal of gonads containing an occult seminoma in a woman with complete androgen resistance

A 20-year-old woman with complete androgen resistance (AR; 46,XY), underwent prophylactic laparoscopic gonadectomy because of the known increased risk of gonadal malignancy. The procedure was performed with electrocoagulation using a four-puncture technique. Pelvic and abdominal inspection revealed no gonadal or metastatic tumor. The testes and attached structures were retracted medially, and the peritoneum and gonadal vessels were incised after electrocoagulation, thereby removing the gonads from the sidewalls. The gonads were individually placed into a specimen retrieval bag and removed through the suprapubic cannula site. Pathologic examination revealed an occult 8-mm seminoma in the let gonad, as well as bilateral Sertoli cell hamartomas, fallopian tube remnants, and smooth muscle tissue (mullerian remnants) adjacent to the gonads. Postoperatively, tumor markers were normal, and abdominal and pelvic computerized tomographic scans and chest radiographs were negative for possible metastatic disease. This case confirms that laparoscopic removal of testes in women with AR is effective, safe, and quick. Because of normal-appearing gonad may contain an occult tumor, we recommend using a retrieval bag, which may prevent dissemination of potentially malignant cells that may occur with unprotected morcellation.

The effect of gonadotropin-releasing hormone agonist on thyroid-stimulating hormone and prolactin secretion in adult premenopausal women

OBJECTIVE To investigate the effects of chronic administration of GnRH agonists (GnRH-a) on pituitary TSH and PRL secretion in adult women. DESIGN Prospective case-controlled study. SETTING Academic division of Reproductive Endocrinology, Department of Obstetrics and Gynecology. PATIENTS Ten ovulatory women and 10 women treated with monthly depot injections of leuprolide acetate (3.75 mg) were studied. INTERVENTIONS All subjects underwent pituitary stimulation with human thyrotropin-releasing hormone (TRH), 500 micrograms IV. MAIN OUTCOME MEASURES Basal and post-TRH-stimulated serum levels of TSH and PRL at 15, 30, 45, 60, 90, 120, and 180 minutes were compared among the two groups. Also, basal of T4, triiodothyronine, and triiodothyronine resin uptake studies were obtained and compared among the GnRH-a-treated and control groups. RESULTS No statistically significant difference between baseline or TRH-stimulated serum TSH and PRL could be detected between control and GnRH-a-treated groups of women. Furthermore, these groups were similar with respect to routine thyroid function assays. CONCLUSION Gonadotropin-releasing hormone agonist does not significantly affect baseline or TRH-stimulated TSH and PRL levels nor basal serum T4 and triiodothyronine levels or triiodothyronine resin uptake in adult women.

Steroid cell tumor associated with primary amenorrhea and virilization.

A 22-year-old woman sought medical advice because of primary amenorrhea and virilization that was manifested by facial hirsutism, temporal balding, and clitorimegaly. Plasma steroid levels were determined at the time of initial assessment; androstenedione and testosterone were increased in comparison with normal values. Vaginal ultrasonography revealed the presence of a mass localized to the right ovary. The patient underwent oophorectomy, and pathologic examination of the surgical specimen led to the identification of a steroid cell tumor associated with a polycystic ovary. Tumor steroid-metabolizing enzymes were evaluated in vitro: 17alpha-hydroxylase, 3beta-hydroxysteroid dehydrogenase/ delta5-->4-isomerase, 17beta-hydroxysteroid oxidoreductase, and 5a-reductase, which are required for androgen synthesis, were present in the tumor tissue. Postoperatively, plasma androstenedione and testosterone levels returned to normal. This study demonstrated that the tumor was the source of the increased levels of androgen precursor and androgen in this woman; excess tumor-derived androgen may have been the trigger in the development of the polycystic ovary.