T. Mukherjee

Hydrosalpinx fluid has embryotoxic effects on murine embryogenesis: a case for prophylactic salpingectomy

OBJECTIVE To ascertain if hydrosalpinges are associated with reduced pregnancy rates and increased pregnancy loss after IVF-ET. Increased volume and leakage of hydrosalpinx fluid may exert negative effects on follicular development and embryo quality and/or render the uterine environment hostile to embryogenesis. We undertook this study to examine the effect of hydrosalpinx fluid on murine embryogenesis in vitro. DESIGN Descriptive study. SETTING Tertiary care facility. PATIENT(S) Premenopausal females undergoing salpingectomy or salpingostomy for hydrosalpinges. INTERVENTION(S) Collection of discarded hydrosalpinx fluid and development of a dose response curve for the effect of hydrosalpinx fluid on murine embryogenesis. MAIN OUTCOME MEASURE(S) Development of single cell mouse embryos in vitro. RESULT(S) All samples of tubal fluid obtained from hydrosalpinges demonstrated a significant embryo toxic effect at either the 100% or 10% concentration. Hydrosalpinx fluid demonstrated pH values (8.45 to 8.65) significantly higher than the physiologic range. Correction of pH to that of media did not affect cavitation rate. CONCLUSION(S) There is a well-defined and significant toxic effect of hydrosalpinx fluid. Procedures such as salpingectomy or proximal tubal occlusion to circumvent the passage of hydrosalpinx fluid into the uterine cavity may have beneficial effects on the developmental environment for embryos in vivo.

An elevated day three follicle-stimulating hormone:luteinizing hormone ratio (FSH:LH) in the presence of a normal day 3 FSH predicts a poor response to controlled ovarian hyperstimulation

OBJECTIVE To determine if an elevated FSH:LH ratio predicts response in infertile patients undergoing controlled ovarian hyperstimulation (COH) for IVF-ET. DESIGN Retrospective study. SETTING The Division of Reproductive Endocrinology at the Mount Sinai Medical Center, New York, New York. PARTICIPANTS Seventy-four patients undergoing IVF-ET using similar protocols for COH with day 3 FSH, LH, and E2 testing available for analysis. All patients were < 41 years of age and had day 3 serum FSH < 15 mIU/mL (conversion to SI unit, 1.00). MAIN OUTCOME MEASURES Follicle-stimulating hormone:LH ratio, day 8 serum E2, peak serum E2, cancellation rate, pregnancy rate, and number and size of follicles. RESULTS An FSH:LH ratio > or = 3.6 (group I) predicted a poor response to COH (sensitivity 85.7% and specificity 95%). There were no significant differences regarding day 3 serum FSH and ampules of gonadotropins used for COH. Group I (ratio > or = 3.6) patients responded to COH with lower day 8 E2 (97 +/- 18 versus 319 +/- 36 pg/mL; conversion factor to SI unit, 3.671), peak E2 (422 +/- 115 versus 2,368 +/- 183 pg/mL), and fewer follicles > 15 mm (1.3 +/- 0.5 versus 17.1 +/- 1.0). In group I the cycle cancellation rate (12/14) was significantly higher than the group II cycle cancellation rate (2/60) and pregnancy rate in group II (ratio < 3.6) was 25%. CONCLUSIONS The FSH:LH ratio may increase before a dramatic increase in serum FSH is observed and appears to be a useful marker of ovarian reserve.

Severe ovarian hyperstimulation despite prophylactic albumin at the time of oocyte retrieval for in vitro fertilization and embryo transfer.

OBJECTIVE To report two cases of severe ovarian hyperstimulation syndrome (OHSS) despite the administration of 50 g IV albumin at the time of oocyte retrieval. Two previous published series failed to observe OHSS in patients receiving prophylactic IV albumin. DESIGN Case reports of two women undergoing controlled ovarian hyperstimulation with E2 > 4,500 pg/mL (conversion factor to SI unit, 3.671) on the day of hCG administration who developed OHSS despite prophylactic albumin administration. SETTING The division of reproductive endocrinology at the Mount Sinai Medical Center. INTERVENTIONS Fifty grams IV albumin (200 mL of a 25% albumin solution) were administered over 30 minutes at the time of oocyte retrieval. MAIN OUTCOME MEASURES Prevention of interstitial fluid accumulation such as ascites, pleural effusions, and generalized edema. The other goals of albumin administration included avoiding hemoconcentration, renal insufficiency, and thrombotic complications. RESULTS The patients developed sequelae of severe OHSS requiring hospitalization, despite administration of IV albumin. CONCLUSION Albumin is a promising agent in the prevention of OHSS. However, until the basic pathophysiology of this disorder can be elucidated, the mechanism of its action will remain elusive. Attempts to quantify and report clinical outcomes and the ultimate completion of a prospective randomized study will assist in the prevention and management of this enigmatic disorder.

Parental karyotype may reveal the source of a pregnancy loss even in the presence of a reportedly euploid fetal karyotype

OBJECTIVE To present a case of a fetal loss in which a normal fetal karyotype was obtained by banding studies. Identification of an abnormal maternal karyotype prompted subsequent reanalysis using fluorescence in situ hybridization (FISH). DESIGN Case report. SETTING University-affiliated IVF center. PATIENT(S) A 32-year-old woman, G1 P0, underwent a fetal loss at 8 weeks, and a suction curettage was performed. The patient had a previous first-trimester loss. INTERVENTION(S) The fetal tissue was evaluated by banding studies and found to be normal. Parental karyotyping was performed, and the fetal tissue was reanalyzed by FISH. MAIN OUTCOME MEASURE(S) Analysis of fetal karyotype by targeted FISH. RESULT(S) Maternal karyotype demonstrated a translocation [46,XX, t(8;10)(q24.3:q25.2)]. The fetal tissue was reanalyzed by FISH, and a segment of chromosome 10 was found on chromosome 8. CONCLUSION(S) A normal fetal karyotype, as measured by banding, does not exclude a genetic etiology for pregnancy loss. In this case, maternal translocation prompted the genetics laboratory to search for a small segment of translocated extra chromosomal material. This demonstrated that despite the finding of a normal fetal karyotype, in some cases parental karyotyping may have value.

Ovarian hyperstimulation syndrome complicated by uterine prolapse

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