Multiple pregnancies: what action should we take?
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Adult↗
Biomedical subjects
W D Schlaff
Publications and source records attributed to W D Schlaff.
Hydrosalpinx treated with extended doxycycline does not compromise the success of in vitro fertilization.
OBJECTIVE: To determine if extended treatment with doxycycline before and after an in vitro fertilization (IVF) procedure can minimize the detrimental effect of a hydrosalpinx. DESIGN: Retrospective analysis. SETTING: University IVF program. PATIENT(S): Patients undergoing IVF, including 17 with a hydrosalpinx, 25 with adhesions or proximal tubal occlusion, and 22 with endometriosis or unexplained infertility. INTERVENTION(S): Women with a documented hydrosalpinx were prescribed doxycycline 100 mg twice daily starting 1 week before expected retrieval and continued until 6 days after retrieval. No antibiotics were prescribed in the other groups. MAIN OUTCOME MEASURE(S): Implantation rates and IVF outcomes. RESULT(S): Implantation rates were 30% for the doxycycline-treated group of patients with a hydrosalpinx, 27% for the group with tubal occlusion/adhesion, and 24% for the group with endometriosis or unexplained infertility. Eight (47%) of 17 patients with a hydrosalpinx had a live birth, compared with 11 (44%) of 25 for the group with tubal occlusion/adhesion and 12 (55%) of 22 for the group with endometriosis/unexplained infertility. There were no differences between the groups in patient age, number of oocytes retrieved, fertilization rate, or number of blastomeres of the transferred embryos. CONCLUSION(S): No detrimental effect of a hydrosalpinx was evident for patients treated with extended doxycycline. Tremendous cost savings can be realized if treatment with 2 weeks of an inexpensive antibiotic provides outcomes comparable to surgical correction of a hydrosalpinx before IVF.
Adult↗
Update on the medical treatment of endometriosis.
The treatment of women with endometriosis can be a challenge. Therapeutic strategies must be tailored to the individual symptoms, age, and desire for fertility. Medical therapy continues to be based on endocrine treatment, such as oral contraceptives, progestins, danazol, and GnRH agonists. Unfortunately, recurrence rates are high after discontinuation of therapy. Recent clinical research on GnRH analogues plus add-back therapy has produced favorable results. Long-term treatment of patients using this approach has successfully reduced pain while minimizing symptoms of hypoestrogenism and adverse metabolic effects, such as loss of bone mineral density. Currently, GnRH analogues given with add-back therapy seems to be the most effective long-term approach to the treatment of symptomatic endometriosis. In the future, other modalities, such as medicated vaginal rings, inhibitors of steroidogenic enzymes, and GnRH antagonists, will most likely be options.
Contraceptives, Oral↗
Effects of chronic dietary exposure to genistein, a phytoestrogen, during various stages of development on reproductive hormones and spermatogenesis in rats.
Developmental, hormonal, and gametogenic parameters were evaluated in male progeny following chronic dietary exposure to the phytoestrogen genistein. Twenty pregnant rats were fed a diet containing genistein (50 microg/d) from d 17 of gestation, and 12 were fed a control diet without genistein. Four litters each of control and genistein-fed rats were euthanized on d 21. The remaining pups were weaned on d 21 and only male rats were used in this study. On d 21, eight litters of genistein-fed rats were placed on control diet (gestational and lactational exposure alone [GL-G]), and the remaining eight continued on genistein diet (lifelong exposure group [LL-G]). These rats were euthanized (four litters/group) on d 70 or 130 of life. Serum testosterone, which was slightly reduced in genistein-exposed rats on d 21, did not differ among treatment and control groups on d 70 and 130. Serum luteinizing hormone of genistein-exposed rats was reduced on d 21 and 130, but not on d 70. Serum follicle-stimulating hormone did not vary among groups at any age. Treatment-related effects of dietary genistein were not observed on the weights of the testes of 21-d-old rats. Except for a slight decrease in testis weight of GL-G rats at 130 d, no significant effect of dietary exposure was observed on the weight of the testes in any other group. However, epididymal weights were significantly reduced in both treated groups at d 130. Testicular sperm count (on d 70 as well as 130) also was not affected in GL-G or LL-G rats. We conclude that gestational plus lactational exposure to genistein and subsequent dietary exposure to genistein have no adverse effects on gametogenic function in male rats.
Aging↗
Extending the treatment boundaries: Zoladex and add-back.
OBJECTIVE: To review the evidence that add-back hormone replacement therapy (HRT) can ameliorate the metabolic consequences of gonadotropin-releasing hormone (GnRH) agonist treatment in women with symptomatic endometriosis. METHODS: A review of relevant literature. RESULTS: Early studies suggested that add-back HRT maintained bone mineral density (BMD) without reducing the symptomatic benefit of GnRH treatment. Both high-dose progestogen and low dose progestogen plus cyclical etidronate are effective in maintaining BMD. Standard and low dose HRT add-back may be more effective in relieving the hypo-estrogenic side-effects of GnRH agonist therapy. Randomized controlled studies have shown that both low-dose and standard-dose add-back HRT reduce the side-effects of GnRH agonist therapy, and that this benefit extends to 12 months of treatment. CONCLUSIONS: GnRH agonist treatment with add-back HRT seems to offer the hope of improved treatment for women with endometriosis, but the optimum treatment duration and time to start HRT have yet to be defined.
Bone Density↗
Assisted hatching does not enhance IVF success in good-prognosis patients.
PURPOSE: The role of assisted hatching in good-prognosis IVF patients was evaluated in a prospective, randomized, controlled pilot study, which was followed by a retrospective observational series. METHODS: After assisted hatching was proved successful in a mouse embryo study, 20 good-prognosis IVF patients were randomly assigned to either assisted hatching (13) or no assisted hatching (7; the controls). Following this series, 27 good-prognosis IVF patients were retrospectively evaluated to determine the outcome with assisted hatching. RESULTS: In the prospective study, clinical pregnancies resulted from 3 (23%) of 13 patients in the hatching group, compared to 3 (43%) of 7 in the control group. Implantation rates were similar: 9.6% in the hatching group and 10.7% in the controls. In the retrospective series, the 11.1% implantation rate with assisted hatching was significantly less than the 42.9% implantation rate seen with traditional IVF. CONCLUSIONS: Implantation and pregnancy rates are high in young women undergoing traditional IVF. Assisted hatching is not beneficial in these patients.
Adult↗
Goserelin acetate (Zoladex) with or without hormone replacement therapy for the treatment of endometriosis.
OBJECTIVE: To determine whether hormone replacement therapy (HRT) plus goserelin (Zoladex) is as effective as goserelin alone for the relief of pelvic symptoms of endometriosis and to determine whether it reduces both the loss of bone mineral density (BMD) and the physiologic side effects associated with goserelin therapy. DESIGN: Prospective, placebo-controlled study, open label for goserelin therapy and double-blind for HRT. SETTING: Forty-two teaching or community hospitals. PATIENT(S): Premenopausal women with symptomatic endometriosis. RESULT(S): Statistically significant mean decreases from baseline in the total pelvic symptom score and total subjective score were observed by week 24 for all three groups. There were no statistically significant treatment differences for change in total symptom score. Some degree of BMD loss occurred in the three groups; however, the percentage loss was consistently greater in the HRT0 group than in the HRT1 or HRT2 groups. When analyzed separately, no overall age effect on BMD change was seen in women >30 years of age versus women < or = 30 years. The HRT1 and HRT2 groups had fewer occurrences of hot flushes and vaginal dryness than did the HRT0 group. CONCLUSION(S): Goserelin plus HRT is as effective as goserelin alone in relieving pelvic symptoms of endometriosis and attenuates both the loss of BMD and the physiologic side effects of hot flushes and vaginal dryness associated with goserelin therapy.
Adolescent↗
Reproductive sequelae in female rats after in utero and neonatal exposure to the phytoestrogen genistein.
OBJECTIVE: To determine reproductive sequelae in female rats after in utero and lactational dietary exposure to genistein. DESIGN: Experimental animal study. SETTING: University laboratory. ANIMAL(S): Sprague Dawley rats. INTERVENTION(S): Pregnant rats were fed control rat chow or rat chow incorporated with genistein (approximately 50 microg/d) beginning on day 17 of gestation and continuing until the end of lactation (postpartum day 21). Genistein-exposed female pups were divided into two groups on day 21. One group continued to receive a genistein-added diet (G70); the other group was changed to a control diet (Ex-G). At necropsy (days 21 and 70), blood and reproductive tissues were collected. MAIN OUTCOME MEASURE(S): Serum levels of gonadotropins and gonadal steroids and histopathologic examination of the ovaries. RESULT(S): The weight of the ovaries and uterus and serum levels of E2 and progesterone in genistein-exposed rats on day 21 (G21) were significantly reduced compared with control rats. On day 70, serum levels of E2, progesterone, LH, and FSH were similar in all groups. Atretic follicles and secondary interstitial glands were more common in G70 and Ex-G rats compared with control rats. Cystic rete ovarii was observed in some G70 and Ex-G rats. CONCLUSION(S): Our data indicate that in utero and lactational exposure to dietary genistein adversely affects reproductive processes in the adult female rat.
Animals↗
Pronuclear uterine transfer lowers in vitro fertilization success.
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Adult↗
Infertility treatment in women over 40 years of age.
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Adult↗
Diagnosing ovarian torsion with computed tomography. A case report.
BACKGROUND: The diagnosis of adnexal torsion is difficult to make on the basis of symptoms, physical findings or radiologic techniques. Unfortunately, delayed intervention can lead to irreversible damage and loss of the adnexa. This report describes a finding seen on computed tomography (CT) that may increase suspicion of the diagnosis of ovarian torsion. CASE: A 21-year-old woman was admitted with constant abdominal pain and a tender retrouterine mass. Ultrasound failed to provide a definitive diagnosis. CT showed a central, hypodense area consistent with fat and surrounded by a shell of intermediate density. At laparotomy the patient was found to have a necrotic left adnexa due to torsion. Bisection of the adnexal mass confirmed a dermoid cyst with overlying edematous ovarian cortex. CONCLUSION: The observation of a round, hypodense central lesion (dermoid cyst) surrounded by thickened, edematous ovarian cortex on CT is a finding that may aid in the diagnosis of adnexal torsion. The finding is a thickened shell of ovarian cortex surrounding a central mass that has caused the torsion; in this case it was a dermoid cyst.
Adult↗
Neonatal exposure to coumestrol, a phytoestrogen, does not alter spermatogenic potential in rats.
The objective of this study was to determine the effects of neonatal exposure to phytoestrogens on male reproductive function as adults. Male rats were injected either with 100 micrograms coumestrol or DMSO (controls) daily during their first 5 d of life. Pituitary gland, testes, sex accessory organs, and blood were collected on d 60 of life. Serum testosterone, LH, and FSH levels were determined by RIA. Levels of steady-state mRNA for gonadotrophin subunits (LH beta and FSH beta were determined by Northern blot analysis and quantified by a scanning densitometer. Coumestrol had no effect on weights of testes and sex accessory organs, or sperm count. Similarly, there were no significant differences among serum concentrations of testosterone, LH beta and FSH of coumestrol-treated rats and those of controls. Whereas steady state levels of LH beta mRNA in coumestrol-treated rats did not differ from those of controls, steady state levels of FSH beta mRNA increased (37%) in treated animals. However, the augmented FSH beta mRNA expression in coumestrol-treated rats did not negatively affect reproductive potential in male rats. We conclude that neonatal exposure to coumestrol does not alter reproductive organ structure or spermatogenic potential in male rats.
Animals↗
Preprogrammed, unmonitored ovarian stimulation reduces expense without compromising the outcome of assisted reproduction.
OBJECTIVE: To determine if a novel, preprogrammed, unmonitored stimulation protocol could reduce the cost of assisted reproductive technology (ART) without compromising outcome or safety. DESIGN: Prospective, nonrandomized study of unmonitored ART versus traditional monitoring. SETTING: University ART program. PATIENT(S): Infertile women aged < 39 years, with a basal FSH level < 15 mIU/mL (conversion factor to SI unit, 1.00) and regular menstrual cycles, undergoing ART. INTERVENTION(S): Oocyte retrieval was performed at a predetermined time in 72 unmonitored cycles based on age and basal FSH level. No monitoring of any type was performed before retrieval. There were 86 monitored control cycles. MAIN OUTCOME MEASURE(S): The number of oocytes, and embryos; complications including ovarian hyperstimulation. RESULT(S): The total cost for unmonitored ART was significantly less than for monitored cycles. There was no difference between groups for patient age, number of oocytes obtained, or number of metaphase II oocytes. For non-male-factor patients, the number of oocytes fertilized, number of embryos transferred, and the clinical pregnancy rates were comparable. There was one case of severe hyperstimulation requiring hospitalization in the unmonitored group. CONCLUSION(S): This novel, unmonitored ovarian stimulation protocol provides ART at a significantly lower cost than is incurred with traditional monitoring, with no apparent compromise in outcome.
Adolescent↗
Evaluation of synthetic serum substitute versus serum as protein supplementation for mouse and human embryo culture.
PURPOSE: Our purpose was to determine the effect of Synthetic Serum Substitute (SSS) versus serum supplementation on fertilization rates and subsequent development of embryos from patients undergoing IVF. PROCEDURE: Experiment I compared the effects of SSS to human serum on mouse embryo development. Two hundred one-cell B6D2F1 mouse embryos were cultured in 100-microliter droplets of human tubal fluid (HTF) containing either (1) no protein (control; n = 37), (2) 15% serum from women with tubal infertility (n = 44), (3) 15% serum from women with endometriosis (n = 49), (4) 15% fertile donor serum (n = 33), or (5) 15% SSS (n = 37). Experiment II compared the effects of SSS to human serum on the development of embryos from patients undergoing IVF. Thirty-three women were included in this study. A total of 371 oocytes was cultured in HTF containing either (1) maternal or donor serum (n = 140) or (2) 15% SSS (n = 231). Embryo development was evaluated 48 hr after fertilization. RESULTS: In Experiment I, the rate of blastocyst development was evaluated at 48, 72, and 96 hr of culture. Sixty-four and nine-tenths percent of embryos cultured in SSS were morulae at 48 hr of culture (versus 5.4, 0, 8.2, and 6.1 in Groups 1, 2, 3, and 4, respectively). By 72 hr, 29.7% of these embryos had developed into blastocysts (versus 0, 0, 8.2, and 3.0, for Groups 1, 2, 3, and 4, respectively). This percentage increased to a total of 83.7 after 96 hr (versus 27.0, 20.4, 38.8, and 39.4 for Groups 1, 2, 3, and 4, respectively). Forty-three and two-tenths percent of the blastocysts cultured in SSS had hatched from their zonae by 96 hr. With the exception of Group 5, which had a rate of 9.1%, embryo hatching was not observed in any of the groups at the termination of culture (96 hr). In Experiment II there were no differences in cell stage or quality of human embryos cultured in SSS or serum, but fertilization rates tended to be better (P = 0.07) for oocytes inseminated in media containing SSS (70.0%, vs 55.0% for serum). CONCLUSIONS: SSS appears to be a superior protein source for mouse embryo growth and is as good as serum from fertile donors in promoting in vitro human embryo development.
Animals↗
Endoscopic ultrasound. A new instrument for laparoscopic surgery.
OBJECTIVE: Although laparoscopy is an important tool for evaluating pelvic pathology, visualization is limited to the surface of structures. A method of seeing below the surface during laparoscopy could be useful. We report on our early experience with new laparoscopic ultrasound. STUDY DESIGN: Following diagnostic laparoscopy the pelvis is filled with fluid to obtain optimal imaging. A 10-mm ultrasound probe is introduced through the umbilical trocar and the uterus and adnexa examined. RESULTS: High-resolution images can be obtained to delineate such abnormalities as suspected ovarian cysts and uterine myomata. CONCLUSION: Endoscopic ultrasound is a new instrument that allows the surgeon to evaluate and define pelvic pathology suspected at the time of laparoscopy. Endoscopic ultrasound may augment the diagnosis of subtle pathologic findings during laparoscopy.
Female↗
Transcervical gamete and zygote intrafallopian transfer. Does it enhance pregnancy rates in an assisted reproduction program?
OBJECTIVE: To evaluate the role of early tubal transfer procedures, we compared outcomes of transcervical gamete intrafallopian transfer (TC-GIFT) and transcervical zygote intrafallopian transfer (TC-ZIFT) versus in vitro fertilization/embryo transfer during the first two years of our assisted reproduction (AR) program. STUDY DESIGN: Prospective, nonrandomized, concurrent, controlled comparison of TC-GIFT and TC-ZIFT pregnancy outcomes versus those after IVF-ET. All cycles for patients less than age 39 undergoing transfer of at least three viable oocytes, zygotes or embryos in the first two years of our program were included. Patients with normal fallopian tubes underwent TC-GIFT (n = 9) or TC-ZIFT (n = 12), whereas those with tubal compromise underwent IVF-ET (n = 28). RESULTS: Implantation rates were 4.2% for TC-ZIFT, 2.8% for TC-GIFT and 3.7% for combined TC procedures as compared to 7.4% for IVF-ET. Delivery rates were no different for the TC procedures than the IVF-ET procedures (14%). Patients ages, number of oocytes retrieved and number transferred were comparable between the TC and IVF-ET groups. CONCLUSION: TC-GIFT and TC-ZIFT did not enhance the pregnancy outcome as compared to IVF-ET in the first two years of our AR program. Ultrasound-directed tubal catheterization is harder to learn and more difficult and expensive to perform than simple uterine embryo transfer. Since we could not demonstrate an improved outcome for TC transfers even in a new AR program, IVF-ET and laparoscopic GIFT are now our procedures of choice.
Cervix Uteri↗
Assessing the acceptability of Norplant contraceptive in four patient populations.
The object of this study was to review the experience of Norplant implants insertion at the University of Colorado Health Sciences Center with specific attention to the potential impact of source of care and/or clinic site of of insertion. Norplant implants were inserted at four different office sites, namely, adolescent-teen, resident, certified nurse midwife, and faculty physician. The charts of all patients who had Norplant implants inserted between April 1991 and September 1992 were reviewed and we attempted to contact each patient by telephone to assess clinical course and acceptability of Norplant contraceptive. We were able to contact 254 of 414 women (61%) who had Norplant implants inserted. The average length of time since Norplant implants insertion was 13.2 months. The only significant demographic difference between groups was that the adolescent-teen patients were younger, of lower parity, less educated, and were more likely to be single than the other three groups. The overall removal proportion was 14.6%, and removal proportions were not significantly different between any of the four groups. The primary reason for removal was unacceptable bleeding (32% of removers). Only 59% of patients returned for follow-up care. Faculty physician patients were significantly more compliant with follow-up compared to adolescent-teen and resident patients (p < 0.01). Patient retention of Norplant contraceptive is unrelated to age or the clinic setting in which the device was inserted. Since similar side effects are experienced by retainers and removers, it is unclear what other factors prompt women to seek removal. Particularly in the teen and resident groups, follow-up is poor.
Adolescent↗