The empiric use of gonadotropin therapy and intrauterine insemination.
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Female↗
Biomedical subjects
D L Olive
Publications and source records attributed to D L Olive.
Ovulation induction in the poor responder or hyperresponder.
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Female↗
Baseline cyst formation after luteal phase gonadotropin-releasing hormone agonist administration is linked to poor in vitro fertilization outcome.
OBJECTIVE: To investigate the prognostic significance of baseline ovarian cysts after luteal phase GnRH agonist (GnRH-a) administration for IVF-ET. DESIGN: All nondonor IVF-ET cycles in one program in which luteal phase GnRH-a was administered between July 1993 and January 1994 were assessed for the formation of baseline ovarian cysts defined as a mean diameter > or = 15 mm. Outcome data from the IVF cycles were compared between patients with and without baseline ovarian cysts. RESULTS: Of 78 IVF cycles, baseline cysts > or = 15 mm were noted in 26 cycles. Cycles in which cysts were formed were associated with significantly older patients with significantly higher baseline FSH values. Cycles in which cysts were present demonstrated fewer follicles, retrieved oocytes, and embryos. Cyst cycles also demonstrated a lower peak E2 level, implantation rate, and clinical pregnancy rate (PR) per initiated cycle (7.7% versus 32.7%). Cyst cycles also demonstrated a higher cancellation rate. Logistic regression modeling, accounting for age, confirmed significantly lower clinical PRs in cycles with a baseline cyst. CONCLUSIONS: Baseline cyst formation after luteal phase GnRH-a administration is both a marker for poor responders and a reliable predictor of poor stimulation and low PRs in a given IVF-ET cycle.
Chorionic Gonadotropin↗
Dilutional hyponatremia during hysteroscopic myomectomy with sorbitol-mannitol distention medium.
To determine the frequency of hyponatremic complications during hysteroscopic myoma resections using sorbitol-mannitol distending medium and its relationship to operative time, fluid balance, and myoma size, we reviewed all operative hysteroscopic procedures performed by the Section of Reproductive Endocrinology and Fertility at Yale-New Haven Hospital over a 1-year period during which that medium was used. Twenty-six cases were identified of which seven involved hysteroscopic myoma resections. Hyponatremia occurred in four of the seven patients, and in one it was associated with severe posttransurethral prostatic resection (post-TURP) syndrome. The degree of hyponatremia varied roughly in direct proportion to fibroid volume and fibroid volume as a percentage of uterine volume. No relationship was found between the degree of hyponatremia and operating time, estimated submucosal volume, and uterine volume. We conclude that dilutional hyponatremia and the post-TURP syndrome may occur with the use of sorbitol-mannitol distension medium during hysteroscopy. They occur more frequently during operative hysteroscopy to resect myomata, with myoma size and myoma volume expressed as a percentage of uterine volume possibly influencing the degree of hyponatremia.
Abdominal Pain↗
Large bowel-to-pelvic sidewall adhesions associated with chronic pelvic pain.
STUDY OBJECTIVES: To assess retrospectively the prevalence of colon-to-pelvic sidewall adhesions associated with pelvic pain or pelvic endometriosis, and to evaluate prospectively their prevalence compared with controls. DESIGN: A retrospective review of all patients undergoing laparoscopy for chronic pelvic pain between August 1992 and September 1993; and abased on a power analysis, a prospective comparison of women undergoing laparoscopy for chronic pelvic pain with those undergoing laparoscopy for tubal sterilization between October 1994 and December 1995. SETTING: A university-associated teaching hospital. PATIENTS: Fifty women in the retrospective portion, and 30 women (15 in each group) in the prospective portion. MEASUREMENTS AND MAIN RESULTS: Of the 50 women undergoing laparoscopy for pelvic pain, 47 (94%) had either right- or left-sided colon-to-sidewall adhesions, and these adhesions were more common than any other type of intraabdominal adhesion, 94% versus 58%. Thirty-eight (76%) of these women had visual and 25 (50%) histologic evidence of endometriosis. The prospective study revealed that women with pelvic pain had a higher rate of colon-to-sidewall adhesions than controls (93.3% vs 13.3%) and a correspondingly higher rate of visualized endometriosis (73.3% vs 6. 7%). Right-sided paracolic adhesions were both more common than left-sided adhesions (87.7% vs. 46.7%) and were more often extensive than minimal (46.7% vs 6.7%). CONCLUSIONS: Colon-to-sidewall adhesions occur in the majority of patients with chronic pain, whereas they are an uncommon finding in the general population. The lateral gutters are dependent regions of the abdominal cavity that are susceptible to the spread of peritoneal endometriosis or other inflammatory processes, and should be evaluated at diagnostic laparoscopy for chronic pelvic pain.
Chronic Disease↗
Modulation of leukemia inhibitory factor gene expression and protein biosynthesis in human endometrium.
Implantation is the process by which the blastocyst becomes intimately connected with the maternal endometrium/decidua. The independently developing preimplantation blastocyst then becomes dependent on the maternal environment for its continued development. Although the factors involved in the regulation of blastocyst implantation are incompletely understood, recent studies strongly suggest a critical role for leukemia inhibitory factor (LIF) in mice. We showed previously that LIF acts on human trophoblasts to shift their differentiation toward the anchoring phenotype by increasing the synthesis of fibronectin. In the present study, we first evaluated the temporal expression of LIF in the human endometrium in order to gain further insights into the role of LIF in human implantation. We established the LIF is expressed in the endometrium in a menstrual cycle-dependent manner. The most abundant LIF messenger ribonucleic acid (mRNA) levels are observed in the mid- and late-luteal phase samples. LIF mRNA was also present in decidual tissues of first trimester of pregnancy, but levels were lower than those found in the midluteal endometrium. We then investigated the regulation of LIF expression in human endometrial cells in culture by cytokines, steroid hormones, and growth factors. We could not show any direct stimulatory evidence of steroid hormones (estradiol and progestins) on LIF mRNA expression or protein production by endometrial cells in culture. On the other hand, we showed that interleukin-1, tumor necrosis factor-alpha, platelet-derived growth factor, epidermal growth factor, and transforming growth factor-beta are potent inducers of LIF expression in endometrial stromal cells in culture in a concentration- and time-dependent manner. Interferon-gamma acted to inhibit LIF expression induced by these cytokines. In contrast, we found high constitutive and relatively less regulated levels of LIF mRNA in the endometrial gland cells. The timing of the expression of LIF in the endometrium suggests a potential role in the implantation. The regulation of the expression of LIF may have an important role in the physiological and pathological processes involving human implantation.
Adult↗
Endosalpingiosis found at laparoscopy for chronic pelvic pain.
OBJECTIVE: To assess a correlation between endosalpingiosis and pelvic pain. DESIGN: A retrospective analysis of every patient undergoing laparoscopy for chronic pelvic pain at Yale-New Haven Hospital by one surgeon from August 1992 through October 1993 was performed, focusing on those cases with endosalpingiosis. RESULTS: Of 51 laparoscopies performed for chronic pelvic pain, 37 demonstrated visual evidence of implants and pathology specimens were read as either endometriosis or endosalpingiosis in 23 cases. Of those 23 cases, 6 demonstrated endosalpingiosis, and 4 of those 6 demonstrated both endosalpingiosis and endometriosis. In all six cases endosalpingiosis was found in locations consistent with the patients' pelvic pain symptoms, and all six patients experienced relief from their pain symptoms after surgery. CONCLUSIONS: Endosalpingiosis may be found in association with chronic pelvic pain. The pelvic distribution of endosalpingiosis in patients with chronic pain is consistent with that generally found in endometriosis.
Adult↗
Changing hysterectomy patterns after introduction of laparoscopically assisted vaginal hysterectomy.
OBJECTIVE: The objective of this study was to determine whether introduction of laparoscopically assisted vaginal hysterectomy decreases the percentage of women requiring laparotomy for hysterectomy. STUDY DESIGN: A retrospective review of women undergoing hysterectomies from 1990 through 1992 was performed. Type of hysterectomy and total hospital charges were determined. Indication for surgery and complications in the laparoscopically assisted vaginal hysterectomy group were also examined. RESULTS: During the study interval 670 hysterectomies were performed. In 1990 and 1991 abdominal hysterectomies comprised 51.5% and 45.5% of all hysterectomies, respectively. After introduction of laparoscopically assisted vaginal hysterectomy in 1992 the percentage of abdominal hysterectomies declined to 35.6%, whereas the percentage of unassisted vaginal hysterectomies remained stable. The complication rate for patients with laparoscopically assisted vaginal hysterectomy was 16%. Average cost was $11,931 compared with $7031 for abdominal hysterectomy and $5343 for vaginal hysterectomy. CONCLUSION: Laparoscopically assisted vaginal hysterectomy can decrease the number of patients requiring a laparotomy for hysterectomy but at a much greater cost.
Adult↗
The fecundity gene for sheep and man.
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Animals↗
Elevated serum progesterone levels on the day of human chorionic gonadotropin administration in in vitro fertilization cycles do not adversely affect embryo quality.
OBJECTIVE: To assess the effect of an elevated serum P level on the day of hCG administration in an IVF cycle on resulting embryos by evaluating their performance at subsequent frozen ET. DESIGN: A retrospective study. PARTICIPANTS: Ninety-six consecutive patients undergoing frozen ET cycles were studied in a tertiary care center. MAIN OUTCOME MEASURES: Serum obtained on the day of hCG administration in an IVF cycle was assayed for E2 and P by RIA. The main outcome measured was the development of a clinical pregnancy in a subsequent frozen ET cycle. RESULTS: Using a previously described breakpoint in serum P concentration of 0.9 ng/mL (2.86 nmol/L), 8 of 69 (11.6%) frozen ETs in which embryos from low P level IVF cycles were transferred and 7 of 27 (25.9%) frozen ETs of embryos from elevated P level IVF cycles were transferred resulted in the development of clinical pregnancies. Although this does not clearly demonstrate superiority of embryos obtained from elevated P cycles, employing a power calculation, the probability that the pregnancy rate in the elevated serum P group is at least equal to the observed rate in the low P group is 92.8%. CONCLUSION: These data suggest that an elevated serum P level on the day of hCG administration does not adversely affect the quality of oocytes or resulting embryos.
Chorionic Gonadotropin↗
Duplicate cervix and vagina associated with infertility, endometriosis, and chronic pelvic pain.
BACKGROUND: Müllerian anomalies are associated with several gynecologic complications including endometriosis, infertility, and pelvic pain. CASE: A woman with duplicate cervix and a non-communicating longitudinal vaginal septum, but no other uterine anomalies, presented with pelvic pain, secondary infertility, and a long history of endometriosis. She was treated with operative laparoscopy and excision of the vaginal septum. CONCLUSION: A thorough evaluation, including history, physical examination, and appropriate imaging techniques (hysterosalpingography and magnetic resonance imaging) facilitates accurate diagnosis of anatomical defects and any associated disease in cases of unusual müllerian anomalies. An accurate preoperative diagnosis allows a planned, efficient surgical approach.
Abnormalities, Multiple↗
Diagnostic and therapeutic options in endometriosis.
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Endometriosis↗
The prognostic value of serum concentrations of progesterone, estradiol, and luteinizing hormone during superovulation with and without adjunctive leuprolide therapy.
OBJECTIVE: To determine the predictive value of preovulatory serum concentrations of P, E2, and LH for pregnancy achieved with IUI after superovulation with and without adjunctive leuprolide acetate (LA) therapy. DESIGN: Randomized, crossover study of superovulation with and without LA therapy. SETTING: Infertility clinic. PATIENTS: Subfertile patients referred for superovulation and IUI. MAIN OUTCOME MEASURES: Preovulatory serum concentrations of P, E2, and LH on the day of hCG administration; pregnancy. RESULTS: Preovulatory serum concentrations of P, E2, and LH had equivalent predictive value for pregnancy during cycles stimulated without LA therapy. No single parameter was particularly useful in clinical decision making. Threshold P concentrations proposed in other studies as useful in predicting pregnancy did not correlate with cycle fecundity. The predictive value of preovulatory concentrations of P during superovulation with adjunctive LA therapy was significantly worse than P concentrations during superovulation without LA therapy. CONCLUSIONS: Preovulatory serum P, E2, and LH concentrations in superovulation and IUI are not helpful in determining prognosis for pregnancy. The relative utility of predictive parameters may vary for different treatment regimens.
Chorionic Gonadotropin↗
Complications associated with the absorption of hysteroscopic fluid media.
OBJECTIVES: To review the literature concerning complications resulting from absorption of hysteroscopic fluid distension media and to describe methods to treat and prevent these complications. DESIGN: All pertinent literature on fluid distension media used for endoscopy, as well as relevant reports concerning the management of fluid and electrolyte imbalance, was reviewed. RESULTS: The absorption of large volumes of electrolyte-free, low-viscosity fluid may result in volume overload with water intoxication. Volume overload may cause pulmonary edema, and water intoxication may lead to hyponatremia, hypo-osmolarity, and cerebral edema. In contrast, the absorption of dextran-70 may cause volume overload secondary to the oncotic effect of intravascular dextran. Dextran-70 has been associated with anaphylaxis and coagulation disorders. TREATMENT: The use of diuretics is advocated. Urine output must be closely monitored. Judicious correction of electrolyte imbalance will prevent morbidity. PREVENTION: Meticulous attention to intraoperative fluid balance is imperative. A multichannel hysteroscope is necessary to keep intrauterine pressure low. Extensive surgical procedures may need to be performed in stages. CONCLUSIONS: Severe volume overload and electrolyte imbalance may result from fluid absorption during operative hysteroscopy. Most complications may be avoided by closely monitoring fluid balance intraoperatively.
Absorption↗
Fetal growth: a comparison of growth curves with mathematical modeling.
This study compared the use of fetal growth curves with the Rossavik mathematical model in predicting third trimester fetal growth in 27 Hispanic patients. The parameters tested were BPD, HC, AC, and FL. The growth curve method of predicting third trimester fetal growth was significantly more accurate than the mathematical model for three of the four fetal parameters tested: BPD, HC, and FL. We conclude that the mathematical model method offered no advantage over the more commonly used growth curve method for predicting third trimester fetal growth. In addition, growth curves do not require complex calculations and are conceptually simpler and easier to use.
Adult↗
A case of endometrial cancer following endometrial ablation for dysfunctional uterine bleeding.
BACKGROUND: A concern voiced by critics of endometrial ablation is the possibility that cryptic endometrial adenocarcinoma may develop after such ablation. To date, this concern has been theoretical. CASE: A patient presented with vaginal bleeding and was diagnosed with endometrial carcinoma 5 years after ablation of the superficial endometrium. CONCLUSION: The possibility exists for endometrial carcinoma to develop years after endometrial ablation. Careful patient selection, thorough evaluation of any post-procedure bleeding, careful postoperative surveillance, and continued evaluation of the procedure and its long-term efficacy are indicated.
Adenocarcinoma↗
A prospective, randomized trial comparing two different intrauterine insemination regimens in controlled ovarian hyperstimulation cycles.
OBJECTIVE: To compare a single periovulatory intrauterine insemination (IUI) with a regimen employing two IUIs, one before ovulation and one after ovulation, in patients undergoing controlled ovarian hyperstimulation with human menopausal gonadotropins (hMG) combined with human chorionic gonadotropin (hCG). DESIGN: A randomized, prospective trial. PARTICIPANTS: Thirty-one consecutive patients undergoing 49 cycles of controlled ovarian hyperstimulation/IUI were studied in a tertiary care setting. MAIN OUTCOME MEASURES: Ovulation was determined sonographically. The establishment of a clinical pregnancy was defined by either ultrasonographic verification of cardiac activity within an intrauterine fetus, or histologic confirmation of trophoblast in a surgical specimen. RESULTS: Clinical pregnancies developed in 2 of 23 cycles in the single insemination group, compared with 12 of the 23 cycles in the double insemination group. Cycle fecundity was significantly higher for group II (0.522) than for group I (0.087) patients (P = 0.003). CONCLUSION: In hMG/hCG cycles, two IUIs timed as described above are superior to one periovulatory insemination.
Cryopreservation↗