Zion Ben-Rafael

Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy

A series of 201 cycles of ovarian hyperstimulation syndrome (OHSS) in 154 women were reviewed. Pregnancy occurred in 75 of 201 cycles. Twelve pregnant women (16%) presented with torsion of hyperstimulated ovary, but only 3 out of 126 patients (2.3%) who did not conceive had torsion. Because diagnosis of adnexal torsion is usually uncertain and surgical intervention is likely to be delayed, these infertile women risk losing their ovaries. The clinical picture of torsion of adnexa in patients with OHSS is presented here. The combination of ovarian enlargement, abdominal pain, nausea, progressive leukocytosis, and anemias might indicate torsion of adnexa. Although during operation the adnexa appears dark, hemorrhagic and ischemic, we suggest that it can be saved by simply unwinding it. In 11 such cases intraoperative unwinding of the adnexa was performed, and in 8 patients it was the only operative procedure. No postoperative complications were noted and in all the cases the ovaries were proven functional by ultrasonography. We concluded that torsion of hyperstimulated adnexa in patients who conceived after gonadotropin therapy, is a special entity that requires more attention to achieve early diagnosis. Nevertheless even with delayed diagnosis, the ovary can still be saved.

Aging of endometrium and oocytes : observations on conception and abortion rates in an egg donation model

OBJECTIVE To assess the comparative contribution of endometrial and oocytic aging to the decline in fertility with age. DESIGN Retrospective analysis of conception and abortion rates in an egg donation program, with respect to donor and recipient ages. PATIENTS All oocyte recipients had ovarian failure. Donors were women undergoing in vitro fertilization who contributed up to a third of retrieved oocytes. INTERVENTIONS None. RESULTS Thirty pregnancies (28 intrauterine) were recorded in 169 reception cycles originating from 91 donation cycles. Women who conceived were younger than those who did not (median age 31 versus 37; P less than 0.046), with no difference in age of donors. There was a significant difference in spontaneous abortion rate by age of donor rather than by age of recipient. Donors to successful pregnancies were younger than donors to aborted pregnancies (median age 27.5 versus 33; P less than 0.0211), but the 11 women with aborted pregnancies did not differ in age from the 17 women with successful pregnancies. CONCLUSIONS In women, endometrial function as expressed by conception rate in the recipients declines with age, whereas it is oocyte age that primarily influences risk of abortion.

Ovarian hyporesponsiveness in combined gonadotropin-releasing hormone agonist and menotropin therapy is associated with low serum follicle-stimulating hormone levels *

The study was designed to evaluate if ovarian hyporesponsiveness, which is associated with combined gonadotropin-releasing hormone agonist (GnRH-a) and human menopausal gonadotropin (hMG) therapy is because of suboptimal serum follicle-stimulating hormone (FSH) levels. Two groups of 12 patients each were suppressed with GnRH-a and stimulation with a fixed dose of hMG. The control group (n=10) received equal doses of hMG only. The follicular phase and the number of hMG ampules was significantly higher in the study group. Basal FSH levels and FSH levels during hMG treatment were significantly lower in patients treated with GnRH-a. Peak estradiol levels and the outcome of in vitro fertilization treatment were similar in the three groups. We suggest that the delay in ovarian response in patients treated with a combination of GnRH-a and hMG is because of lack of endogenous contribution of FSH, resulting in low circulating levels of FSH. An increase of serum FSH levels by administration of higher doses of hMG can reverse this effect.

Pregnancy potential of human oocytes : the effect of cryopreservation

Abstract Background. In vitro fertilization, sometimes involving the cryopreservation of human embryos, has become a routine procedure for the treatment of infertility. Even though there are embryos available for transfer in about 85 percent of the treatment cycles, the rate of pregnancy rarely exceeds 25 percent per cycle. We designed this study to investigate two questions: Does this high rate of failure result from inadequate technique, or does it simply reflect the maximal potential of a cohort of aspirated eggs to produce a pregnancy? And to what extent does cryopreservation affect the capacity for implantation of embryos? Methods. The study was conducted among patients enrolled in an egg-donation program. Aspirated eggs from a given cohort were distributed to the donor herself and a few recipients. The recipients were prepared by a standard protocol of hormone replacement and were assigned at random to the transfer of either fresh or frozen and thawed embryos. The donors received only fresh embryos....

Combined gonadotropin releasing hormone agonist/human menopausal gonadotropin therapy (GnRH-a/hMG) in normal, high, and poor responders to hMG

Patients who failed to conceive after gonadotropin stimulation in in vitro fertilization treatment were classified into normal, high, or poor responders. They were routinely offered another cycle with a combination of a gonadotropin releasing hormone agonist and gonadotropin therapy (in order to evaluate whether this combined therapy could improve their response). The gonadotropin-induced cycle was compared with the combined therapy cycle. With the combination treatment, in the normal responders the phase of ovarian stimulation was significantly (P<0.001) prolonged, and the number of follicles and oocytes collected (5.7±0.7 vs 3.1±0.4) was increased, without any change in serum estradiol level compared to the control cycle. In high responders the number of oocytes was not modified by the combined treatment compared with the control cycle. However, serum estradiol level was significantly (P<0.005) decreased. The combined therapy did not modify any parameter of response in poor responders. We conclude that the response to combined agonist/gonadotropin therapy is dependent on the patients own basal response. No improvement in response was expected in poor responders.

Pregnancy outcome after unwinding of twisted ischaemic-haemorrhagic adnexa

Six women who became pregnant after human menopausal gonadotrophin/human chorionic gonadotrophin (hMG/hCG) treatment regimens were operated on between 6 and 21 weeks gestation with an intra‐operative diagnosis of twisted ischaemic‐haemorrhagic adnexa. During operation unwinding of the adnexa was performed in all patients. Monitoring of the pregnancy before and after operation by ultrasonography was normal. The postoperative period and the rest of the pregnancy were uneventful. Three women were delivered normally at term. One patient was delivered by caesarean section because of twin pregnancy with malpresentation, and two pregnancies are still ongoing beyond the first trimester. This preliminary study suggests that detorsion of ischaemic‐haemorrhagic adnexa during pregnancy is an option that is not associated with subsequent complications. This approach might be adopted relatively safely when preservation of future fertility is a goal.

Spontaneous pregnancy and its outcome after human menopausal gonadotropin/human chorionic gonadotropin-induced pregnancy.

The fertility in previously sterile women who conceived at least once following hMG/hCG-induced ovulation is investigated. The study comprises 141 women. The cumulative spontaneous pregnancy rate (CSPR) was calculated using life table analysis and was found to be 30.4% after 5 years. The CSPR for subsequent pregnancies reached 91.3% after 5 years. This figure is similar to that of normal parous women, although the study group (previously infertile women) requires a larger exposure period to attain the figure. The spontaneous abortion rate in the hMG/hCG-induced pregnancies was 29%; whereas in subsequent spontaneous pregnancies this rate was 8.8%. This difference in rate was found to be statistically significant, and the possible reasons are discussed.

Laparoscopic unwinding of twisted ischemic hemorrhagic adnexum after in vitro fertilization

We present a case where, for the first time, unwinding of ischemic hemorrhagic adnexum was performed successfully through the laparoscope without the need to operate. Aspiration of ovarian fluid before detorsion facilitates the procedure; follow-up showed spontaneous follicular growth. We conclude that laparoscopic detorsion of ischemic adnexum is feasible. Apparently, oocytes are not damaged by the torsion and the ovary resumes normal function. This procedure should be considered in women during the reproductive age and in every case where malignancy can be ruled out.

Meteorological factors in hypertensive disorders, vaginal bleeding and premature rupture of membranes during pregnancy

In order to determine whether there is a correlation between meteorological factors and the occurrence of hypertensive disorders, vaginal bleeding during pregnancy and premature rupture of the fetal membranes, we stratified all the patients hospitalized with such complications between the years 1984 and 1988 by the months of occurrence, weather, humidity and heat. During this period, there were 276 women hospitalized with exacerbation of hypertension and toxemia, 349 because of vaginal bleeding during pregnancy and 35 women following premature rupture of the fetal membrane between 30 and 33 weeks of gestation. The occurrence of pre-eclampsia and exacerbation of pregnancy-induced hypertension was significantly increased in the winter months (p less than 0.001).

Failure to fertilize in vitro in couples with male factor infertility: what next?

OBJECTIVE To assess the predictive value of a failure to fertilize in vitro in couples with sperm abnormalities on future fertility. DESIGN Retrospective file review. SETTING In vitro fertilization and embryo transfer (IVF-ET) program in the Sheba Medical Center during the years 1983 to 1990. PATIENTS Seventy-six couples with sperm abnormalities who had at least one IVF cycle during which fertilization did not occur. INTERVENTIONS None. MAIN OUTCOME MEASURES Occurrence of fertilization, percentage of fertilization, and pregnancies in additional IVF-ET cycles. RESULTS Of 44 couples who underwent an additional IVF attempt with husbands sperm, 36 (81.2%) fertilized, with a mean fertilization rate of 47.7% +/- 26.6%. Of 17 couples who failed twice, 11 attempted IVF again with husbands sperm and 7 fertilized, with a median rate of 33%. A higher sperm concentration was found on the cycles during which fertilization occurred. Men with single parameter abnormalities did not fertilize better than those with two or three defective parameters. CONCLUSIONS Failure to fertilize in vitro in couples with male factor infertility does not seem to predict future fertilization in IVF. At least two cycles of IVF should be tried before reverting to other options such as insemination by donor sperm or gamete micromanipulation.