Conservative surgical management of uterine myomas

Uterine fibroids are a major gynecologic problem in American women, and several alternatives have been developed. Conservative treatment, with the goal of treating the fibroid but retaining the uterus, is a frequent choice among women who require therapy during their early to middle reproductive years. A variety of conservative surgical approaches exist; each has advantages and disadvantages for the clinician and the patient. Some are well-established techniques, whereas others are still in the investigational stage. None has been evaluated adequately for its effects on future fertility. To this end, it is imperative that investigators continue to evaluate these surgical procedures so that the clinician can provide accurate and comprehensive information when faced with a patient who desires one or more of these approaches. Furthermore, it is critical for the practitioner to stay informed about these procedures so that patients can be given a full complement of options.     

Hysterosalpingography and sonohysterography: lessons in technique

OBJECTIVE: The objectives of this article are to review the examination techniques for hysterosalpingography and saline infusion sonohysterography and to present practical tips to enhance physician performance and minimize patient discomfort during these procedures. CONCLUSION: Optimally performed hysterosalpingography and saline infusion sonohysterography can be relatively comfortable procedures for the patient that provide a great deal of useful diagnostic information.     

Comparison of GnRH antagonists and flareup GnRH agonists in donor oocyte cycles

OBJECTIVE: To compare the flareup GnRH-antagonist (GnRH-ant) and GnRH-agonist (GnRH-a) protocols in oocyte donation cycles, using the donor as her own control. STUDY DESIGN: A retrospective review at a university-based practice of 22 oocyte donors who underwent 29 cycles using recombinant follicle-stimulating hormone (FSH) and GnRH-ant and 28 cycles using flareup GnRH-a with recombinant FSH. Recipients (n=57) were synchronized with estrogen and progesterone supplementation. RESULTS: The total number of recombinant FSH used and days of stimulation were similar between the groups; however, cycle days 5 estradiol (341 +/- 40 vs. 473 +/- 62 pg/mL), peak serum estradiol (1721 +/- 170 vs. 3625 +/- 295 pg/mL) and the number of retrieved MII oocytes (17 +/- 1.5 vs. 29 +/- 7) were significantly higher in the flareup GnRH-a group. Similar fertilization rates, embryos transferred, clinical pregnancy rate/embryo transfer (44%, 11/25; vs. 55%, 15/27), delivered pregnancy rate/embryo transfer (32%, 8/25; vs. 52%, 14/27) and implantation rates (31 +/- 6% vs. 28 +/- 5%) were seen in each group. CONCLUSION: Both the flareup GnRH-a and GnRH-ant are shortened, simplified and efficacious protocols in oocyte donation cycles.     

The addition of norethindrone acetate to leuprolide acetate for ovarian suppression has no adverse effect on ovarian stimulation

Purpose: Our goal was to determine if the addition of norethindrone acetate (NETA) to leuprolide acetate (LA) has an adverse effect on controlled ovarian stimulation (COH) during in vitro fertilization (IVF). Methods: Forty-one consecutive patients undergoing COH and IVF were divided into two groups and evaluated. Group 1 consisted of 18 patients who did not become pregnant following two cycles (one of each protocol). Group 2 consisted of 23 patients who became clinically pregnant following one cycle from either protocol. The standard protocol consisted of LA (1 mg) injected subcutaneously from the first day of menses until day 8 or when ovarian suppression was evident, at which time the dose was halved and COH was initiated. The study protocol was identical except 10 mg of NETA was given orally with LA for the first 8 days. Ovarian stimulation was similar in each protocol. Results: No adverse effect on ovarian stimulation was evident on the addition of NETA to LA. No differences were noted in days of stimulation, peak estradiol (E₂) level attained, peak E₂-to-oocyte ratio, dosage of exogenous gonadotropins, number of aspirated oocytes, fertilization rate, or oocyte and preembryo quality. Conclusions: The addition of NETA does not attenuate COH in women undergoing IVF.     

An unusual case of rebound ovulation during conservative management of an ectopic pregnancy following ovum donation

Summary Conservative medical management of ectopic gestations may be difficult in patients with elevated levels of β-hCG and cardiac activity. This case highlights the difficulty of managing such patients. Doppler flow studies and serum P, if available, should be used and can help determine those patients requiring repeated dosing of methotrexate. Patients using donor gametes and hormonal supplementation who subsequently develop an ectopic gestation may experience “re-bound” ovulation, which further clouds the clinical picture. Careful follow-up using serial blood testing and ultrasound study is essential in the correct interpretation of a potentially confusing clinical picture.