Overcoming the challenging cervix: techniques to access the uterine cavity

OBJECTIVE: To identify cervical stenosis and review medical, surgical, and radiological modalities to access the uterine cavity. MATERIALS AND METHODS: Computerized searches of Medline and PubMed from 1996 to 2005 were conducted using the key words "cervix," "cervical ripening," and "cervical stenosis." References from identified publications were manually searched and cross-referenced to identify additional relevant articles. We review relevant techniques on how to access the uterine cavity when cervical stenosis is encountered. RESULTS: Many gynecologic procedures require uncomplicated access through the cervix to access the uterine cavity, including hysteroscopy, dilation and curettage, sonohysterogram, hysterosalpingogram, endometrial biopsy, and embryo transfer for in vitro fertilization. These procedures can be quite complicated when a cervix is obstructed. Management techniques described include the medical use of misoprostol and laminaria, intraoperative ultrasound guidance, and operative creation of a new passage. Additionally, techniques for bypassing the obstructed cervix and preventing cervical stenosis have been described. CONCLUSIONS: Cervical stenosis can result in iatrogenic complications. Preoperative identification, cervical ripening agents, osmotic dilators, and the use of ultrasound guidance are useful in overcoming cervical stenosis. It is also key to identify those at risk for cervical stenosis and implement preventative techniques as needed.     

Recruitment and screening policies and procedures used to establish a paid donor oocyte registry

We have reviewed the demographic characteristics of, and report abnormalities noted in, the de-novo growth and development of a paid oocyte donation programme. The personal profiles of all prospective oocyte donors were reviewed. Acceptance or rejection of candidates was based upon screening the results of medical, genetic and psychological testing. A total of 603 candidates initially responded to our advertisement. From this pool, 313 individuals were considered suitable and contacted by telephone. Following further conversation, 176 women were scheduled an entry interview. On completion of the formal screening process, 17.6% (n = 31) of those actually interviewed were denied entry. Thus, from the initial interested parties, only 23% of women wishing to participate in oocyte donation were considered suitable candidates. Given the high attrition rate, we concluded that the need for rigorous and thorough medical, psychological and genetic testing is mandatory for the establishment of a donor registry. Furthermore, professional counselling of prospective donors with respect to the results of tests and the implications of test results with respect to their future medical and reproductive health, are important parts of providing comprehensive care.      

Assessment of wishes regarding disposition of oocytes and embryo management among ovum donors in an anonymous egg donation program

Revealing possible clinical scenarios to potential anonymous donors for their donated oocytes appears to uncover ambivalence in the majority of prospective candidates about their donation and unwillingness in some to proceed. Full disclosure to a prospective donor candidate of the program's policies for directives of donated oocytes and embryo management emphasizes the importance of the informed consent process and how it may affect the decision to donate.     

Serum Progesterone Before and After Human Chorionic Gonadotropin Injection Depends on the Estradiol Response to Ovarian Hyperstimulation During In Vitro Fertilization–Embryo Transfer Cycles

Purpose: Our purpose was to assess if periovulatory serum progesterone is reflective of ovarian responsiveness in controlled ovarian hyperstimulation (COH). Methods: One-hundred forty-two in vitro fertilization–embryo transfer cycles in women using GnRH-a suppression and human menopausal gonadotropin (hMG) stimulation were evaluated. Responses were studied according to ovarian response to hMG and age. Outcome measures included peak serum estradiol, serum progesterone and estrogen/progesterone ratios on the day of hCG injection, number of harvested oocytes, fertilization rates, and delivered pregnancy rates. Results: A periovulatory rise in serum progesterone (>0.9 ng/ml) occurred only among younger women (<40 years old) with a good response (P<0.05). Though the number of oocytes was greater in good responders, fertilization and pregnancy rates were similar among all women regardless of age and ovarian response. Conclusions: Periovulatory levels of serum progesterone vary according to ovarian response to COH. Elevations in progesterone do not appear to be a manifestation of poor responders. Reduced periovulatory progesterone may reflect inadequate steroidogenesis.