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.     

Operative ultrasound using an echogenic loop snare for intrauterine pathology

A technique for resecting intrauterine tissue was performed in nine women, each of whom had intrauterine pathology on sonohysterogram. The uterine cavity was entered with a 12F intrauterine access catheter with a 3-ml balloon that was placed in the cervical canal or lower uterine segment. A 5F echogenic loop snare was passed through the access catheter and resection was attempted under ultrasound guidance. Biopsy samples underwent pathologic examination for definitive diagnosis. Seven of nine patients had adequate resection or biopsy tissue, but in two the loop snare could not secure the base of the lesion. All procedures were well tolerated. Average operating time was about 27 minutes (range 18-43 min), with no complications. Operative ultrasound makes it possible to resect and biopsy intrauterine pathology. In selected patients, this procedure is a cost-effective alternative to hysteroscopy.     

Basal serum follicle stimulating hormone (FSH) and estradiol levels as predictors of pregnancy in unstimulated donor insemination cycles

Purpose The purpose of this study was to evaluate the utility of basal serum follicle stimulating hormone and estradiol levels in predicting pregnancy in women undergoing artificial insemination with donor sperm for severe male factor infertility.Method A retrospective chart review of 48 women who had at least 2 cycles of artificial insemination with donor sperm and who had undergone testing for basal serum follicle stimulating hormone and estradiol levels prior to or during therapy.Results There was no difference in age or mean basal serum follicle stimulating hormone between women who conceived (clinical pregnancy) and those who did not. Women who conceived had significantly lower mean serum basal estradiol levels (P = 0.02) and significantly fewer numbers of treatment cycles (P = 0.041). The highest pregnancy rate was among those women with normal basal serum follicle stimulating hormone and estradiol levels. Receiver operating characteristic curve analysis revealed basal serum estradiol to be a more reliable predictor of pregnancy than follicle stimulating hormone.Conclusions Basal serum follicle stimulating hormone and estradiol levels may be useful in predicting success with artificial insemination with donor sperm. It may be useful to obtain basal serum follicle stimulating hormone and estradiol prior to initiating artificial insemination with donor sperm.Presented at the 50th Annual Meeting of the American Fertility Society, November 5–10, 1994, San Antonio, Texas.     

Behavioral stress responses in premenopausal and postmenopausal women and the effects of estrogen.

OBJECTIVE: Our purpose was to determine the pattern of reactivity to stress in premenopausal and postmenopausal women and to assess the effects of estrogen. STUDY DESIGN: A behavioral stress test was given to premenopausal (n = 13) and postmenopausal women (n = 36). Biophysical and neuroendocrine responses were measured during and on completion of the stress test. The postmenopausal women were then randomized to placebo or transdermal estradiol treatment for 6 weeks, at which time another behavioral stress test was given. RESULTS: Stress reactivity to math and speech tasks elicited significantly greater systolic blood pressure responses in postmenopausal women compared with premenopausal women (p < 0.05). On retesting, significant biophysical responses that were present during the initial stress testing were still present (p < 0.05) in the placebo group but were blunted with estrogen treatment. Plasma corticotropin, cortisol, androstenedione, and norepinephrine increased during testing to a similar degree in premenopausal and postmenopausal women; this response was maintained after placebo treatment. Postmenopausal women treated with estrogen had blunted responses. CONCLUSION: Significant differences in responses to psychologic stress exist in premenopausal and postmenopausal women. The lack of adaptation may account in part for the increased risk of cardiovascular disease in postmenopausal women. Estrogen appears to blunt the stress-induced response.     

Reproductive Outcome After Sterilization Reversal in Women of Advanced Reproductive Age

Objective: Our objective was to assess the clinical outcome of tubal reversal in women of advanced reproductive age. Methods: A multicenter retrospective chart review of 153 patients who underwent a tubal ligation reversal was carried out. Patients were evaluated according to age. All patients had documented ovulation and a partner with a normal semen analysis by WHO criteria. Outcome measures included rates of clinical pregnancy, ectopic pregnancy, spontaneous abortion, and live birth, and the time to conception. Results: Clinical pregnancy rates were significantly lower in women 40 compared to younger groups. The time to conception was significantly shorter for women <30 compared to women 35. No pregnancies occurred in women 42. Conclusions: Our data support the judicious use of sterilization reversal for infertile women with no male factor through their early forties. Women 42 years should be especially counseled as to the very low success rates.     

Follicular Fluid Insulin-like Growth Factor-I and Insulin-like Growth Factor–Binding Protein-1 and -3 Vary as a Function of Ovarian Reserve and Ovarian Stimulation

Purpose: Follicular fluid concentrations of insulin-like growth factor (IGF)-I, IGF-II, IGF-binding protein (BP)-1, and IGFBP-3 in 57 women undergoing in vitro fertilization and embryo transfer were examined to determine whether levels reflected differences in patients' exposure to gonadotropin stimulation and a diminished ovarian reserve. Methods: Preovulatory follicular fluid was obtained from both gonadotropin-stimulated and unstimulated cycles. Subjects were grouped according to normal or decreased ovarian reserve and whether or not they received gonadotropin stimulation. Results: The mean follicular fluid concentrations of IGF-I and IGFBP-1 were significantly lower in the decreased ovarian reserve group compared with the normal ovarian reserve group, with no change in estradiol or IGF-II levels. This resulted in a decreased molar IGF-I: BP ratio and an increased molar IGF-II:IGFBP-1 ratio. In unstimulated cycles, mean follicular fluid concentrations of IGFs did not differ significantly compared with those in stimulated cycles, whereas concentrations of IGFBP-1 and IGFBP-3 were significantly lower, leading to higher molar ratios of the IGFs to the binding proteins. Conclusions: Follicular fluid IGF and binding proteins vary as a function of ovarian reserve and gonadotropin stimulation. This may reflect either differences in oocyte quality or a suboptimal follicular fluid environment.     

Hydrosalpinges adversely affect implantation in donor oocyte cycles

Hydrosalpinges have been associated with poor in-vitro fertilization (IVF) outcome in some, but not all, studies, perhaps through endometrial effects. To determine whether hydrosalpinges affect IVF outcome via endometrial factors alone, we analysed the results of recipients of donor oocytes with hydrosalpinges, thereby controlling for confounding variables, while isolating the intrauterine environment. We retrospectively analysed 110 patients who underwent 121 donor oocyte cycles in a university-based assisted reproduction programme. Thirteen cycles involving recipients (n = 10) with hydrosalpinges were compared to 108 cycles involving recipients (n = 100) without hydrosalpinges. Pregnancy, implantation, miscarriage, and ectopic pregnancy rates were compared between women with and without hydrosalpinges. There were no significant differences between the hydrosalpinx and no hydrosalpinx groups with respect to donor age, recipient age, or number or grade of embryos transferred. Patients with a hydrosalpinx had significantly lower embryo implantation rates (7.1 versus 19.3%, P < 0.05) and significantly higher miscarriage (75.0 versus 14.9%, P < 0.05) and ectopic pregnancy rates (33.3 versus 0.0%, P < 0.05) than normal controls. We conclude that the presence of a hydrosalpinx adversely affects early pregnancy events by altering the intrauterine environment.