Controlled ovarian hyperstimulation and intrauterine insemination for treatment of infertility

Empirical therapy for subfertility using assisted reproductive technologies recently has gained popularity; however, the cost-effectiveness of these therapies, compared with an untreated control group, has not been established. Similarly, there has been no comparative cost analysis of the utility of controlled ovarian hyperstimulation and IUI in the management of the same condition. Significant PRs in untreated couples with subfertility mandate the design and execution of controlled trials to ascertain the role of controlled ovarian hyperstimulation and IUI in infertility therapy. Various disorders of subfertility have been treated with controlled ovarian hyperstimulation and IUI. The rationale for this therapy is the increase in gamete density at the site of fertilization, as with GIFT and IVF when used for management of the same problems. The live birth rate per initiated cycle and risk of complications are similar to results recently reported for GIFT and IVF. The utility of controlled ovarian hyperstimulation and IUI still remains controversial. When the relatively low direct and indirect costs of controlled ovarian hyperstimulation and IUI are considered, acknowledging the lack of prospective, controlled studies, this procedure appears to be at least as cost-effective as GIFT and IVF.     

Utility of fluoroimmunoassay in detecting luteinizing hormone surges in spontaneous and human menopausal gonadotropin-stimulated menstrual cycles

Luteinizing hormone (LH) levels measured with radioimmunoassay and time-resolved fluoroimmunoassay (FIA) in 274 serum samples correlated highly, with a linear correlation coefficient of 0.934. Through the analysis of serial samples from 43 women undergoing human menopausal gonadotropin stimulation for in vitro fertilization or gamete intrafallopian transfer and seven patients monitored in spontaneous menstrual cycles for receipt of frozen embryos, we demonstrated the utility of FIA in the detection of the LH surge. This LH assay technique, which involves no radioactive isotopes, should facilitate the monitoring of ovulation induction patients in the office/ambulatory setting.     

Residual embryos in failed embryo transfer

One hundred thirteen embryo transfers (ETs) were performed in an in vitro fertilization and ET program of which residual or extruded embryos were found in 17 transfers (15%). Residual or extruded embryos are those embryos found outside the uterine cavity, either at the cervical os, on the vaginal speculum, or remaining in the catheter after an ET. Patients were divided into two groups according to the method of inspection for residual embryos. In group I, microscopic visualization of the transfer catheter alone revealed that 9 of the 67 transfers (13.4%) had 17 residual embryos either at the catheter tip or adherent to mucus on the side of the catheter. In group II inspection of the catheter and cervical wash revealed that 8 of 46 ETs (17.4%) had 15 residual embryos that failed to be transferred during the initial attempt. Six of these 15 (40%) were found in the cervical wash medium. Thus, failure of the proper placement of embryos at the time of transfer may occur frequently. Evaluation of only the transfer catheter may result in a significant underestimation of the problem.     

Disposition of the normal-appearing ovary during surgery intended to cure endometriosis externa. A case report

Management of a normal-appearing ovary at the time of hysterectomy in a patient with endometriosis externa is controversial. Our experience supports the contention that such ovaries should not be conserved at the time of surgery intended to cure endometriosis.     

Distal septic emboli and fatal brachiocephalic artery mycotic pseudoaneurysm as a complication of stenting

The use of percutaneous angioplasty with subsequent intravascular metallic stent placement has gained increasing acceptance over the past decade. Infections of these stents appear to be uncommon; however, the rarity of this complication may in part be the result of a lack of availability of long-term follow-up data. A number of examples of infected cardiac and peripheral vascular stents have been reported, often with fatal consequences. Herein, we report a 74-year-old woman who underwent subclavian and brachiocephalic artery angioplasty and stent placement for symptomatic stenoses. Six months after the initial intervention, the patient returned with restenosis of the stents and underwent repeat angioplasty to restore full patency. Two weeks later, the patient was readmitted with generalized malaise and multiple erythematous, macular lesions on the right forearm and hand. Blood cultures grew Staphylococcus aureus, and a computed tomographic scan of the chest showed a large brachiocephalic artery pseudoaneurysm with surrounding hematoma. Despite prompt surgical intervention, this complication proved ultimately fatal. Infections of metallic endovascular stents are potentially life-threatening complications and must be addressed urgently, including possible surgical intervention.     

Hypertension and diabetes

Hypertension is common in people with diabetes with an estimated prevalence using the new criteria (> or = 140/90) at 70%. The recent large randomized controlled studies in diabetic subjects has clearly shown the benefit of blood pressure lowering with reduction in cardiovascular endpoints and microvascular disease. ACE inhibitors, calcium antagonists, thiazide diuretics and beta-blocking agents have been the agents validated by the trials. The challenge now is to implement antihypertensive therapy to achieve tight blood pressure targets (< or = 140/80), usually requiring dual or even triple therapeutic regimens.     

Asbestos burden in two cases of mesothelioma where the work history included manufacturing of cigarette filters

Asbestos has been used in many applications, but possibly one of the more unique was in the manufacturing of filters for cigarettes. The type of asbestos used in this application was crocidolite. Data from several resources indicate that crocidolite was one of the least utilized types of commercial asbestos in the United States. The present study provides quantitative tissue burden analysis data for two mesothelioma cases where the work histories included manufacturing of cigarette filters that contained crocidolite. The data include the number of asbestos bodies and uncoated fibers per gram of tissue, as well as the dimensions of these structures. The conclusion of the findings indicates that the individuals had an appreciable homogeneous exposure to crocidolite asbestos.     

Impact of anti-hepatitis Bc-positive grafts on the outcome of liver transplantation for HBV-related cirrhosis

BACKGROUND: The present scarcity of organ donors requires consideration of grafts from sources not previously used. Several studies have addressed the use of grafts from donors who have antibodies to the hepatitis B core antigen (anti-HBc+). The aim of this study was to evaluate the impact of the use of anti-HBc+ grafts in patients transplanted for hepatitis B virus (HBV)-related cirrhosis. METHODS: Recipients of first hepatic transplants from donors with antibodies to HBV were identified retrospectively. All patients who had serology suggestive of active HBV and were negative for hepatitis C and D were included in the analysis. The Kaplan-Meier method was used to assess the actuarial recurrence-free survival on patients with graft survival longer than 1.5 months. The stepwise Cox regression model was used to identify independent predictors of HBV recurrence. RESULTS: One thousand seven hundred seventeen first liver transplants were performed at the Thomas E. Starzl Transplantation Institute from September 1, 1990, to December 31, 1999. HBV was the cause of cirrhosis in 112 patients (6.5%). Thirty-three patients had coexistent viral infection (23 HCV and 10 HDV). Fourteen donors (17.2%) were positive for HBV markers, with nine anti-HBc+ and with five both anti-HBc+ and anti-HB surface-positive; of these, 13 anti-HBc+ organ recipients had long-term survival. Nine (69.2%) of these cases were reinfected versus 20 (35.7%) in the group that received grafts from HBV- donors (P<0.05, Fisher's exact test). The mean time to reinfection was shorter in the anti-HBc+ group (2.9 yr vs. 6.4 yr, P<0.005). There were no statistical differences in graft or patient survival between the two groups. HBV prophylaxis with combined lamivudine and hepatitis B immunoglobulin (HBIG) significantly reduced the reinfection rate (P<0.03). Hepatitis Be (Hbe) antigen-positive recipients trended to faster reinfection (not significant). Cox regression analysis revealed that both anti-HBc graft donor status (RR, 2.796; P=0.020) and combination of lamivudine/HBIG (RR, 0.249; P=0.021) are independently associated with reinfection. CONCLUSIONS: The use of anti-HBc+ liver grafts does not affect graft or patient survival. However, patients who receive these organs are 2.5 times more likely to develop HBV recurrence. Lamivudine and HBIG combination decreases HBV recurrence 4-fold.