Serum anti-endometrial antibodies (AEA) have been studied as a marker for endometriosis and implantation failure. We sought to determine if the presence of AEA in the serum of pregnant patients is associated with first trimester pregnancy loss including complete abortion. This is a prospective pilot case control study of 30 patients presenting with first trimester pregnancy loss compared to a control group of 30 first trimester pregnant patients with a normal course for the presence of serum AEA. The control group was selected using propensity matching of patient characteristics. AEA assays were performed by a single operator blinded to clinical status of patients. The mean maternal age in the study and control groups was not statistically significant (26.1 +/- 5.7 vs. 24.2 +/- 4.5 years, p < 0.155). A history of pregnancy loss was not significantly greater in the study group (12/30 = 40.0%) as compared to the control group (8/30 = 26.7%, p < 0.412). In both study and control groups, 40% of the samples tested positive for AEA; therefore, we found no evidence of an association between the presence of AEA and pregnancy loss. These findings in our pilot study suggest that presence of serum AEA does not appear to be a marker for early pregnancy loss.

Adequately controlling pain is a key component of postoperative care after a hysterectomy. The purpose of this study was to evaluate the effects of two intraperitoneal (IP) administered solutions during Laparoscopic Assisted Vaginal Hysterectomy (LAVH), on the amount of postoperative self-administered morphine. In this prospective, randomized, double blinded study, twenty women undergoing LAVH randomly distributed to two treatment groups: (1) 100 ml dexamethasone/ bupivacaine/ gentamicin (DMG) solution: 60 cc injected vaginally at cuff and 40 cc placed topically via laparoscopy over intra-peritoneal postoperative surfaces (IP) and 5 ml bupivacaine or 5 ml saline injected at the laparoscopic incision sites, (2) 100 ml saline solution: 60 cc injected vaginally at cuff and 40 cc placed topically via laparoscopy over intra-peritoneal postoperative surfaces (IP) and 5 ml bupivacaine or 5 ml saline injected at the laparoscopic incision sites. The amount of morphine utilized by the patients was documented from their patient controlled anesthesia (PCA) pump. Patient parameters recorded included perceived pain score, height, weight, age, race, reason for surgery, pre-surgery medications, American Society of Anesthesiologist (ASA) classification, length of the surgery and estimated blood loss (EBL). Age, EBL, length of surgery, and ASA classification were not significantly different between the groups. The postoperative amount of morphine utilized was higher at 4 (p=.02) and 16 hours (p = .04) and tended to be higher at 8, 12 hours (p=.06), and 24 hours (p=.09) in the saline IP group. Overall the saline IP group (n=10) used (median; range) 21.5; 8-82 mg of morphine while the DMG IP group (n=10) used 10.5; 1-23 mg. No participants reported a postoperative infection. This study demonstrates that intraoperative utilization of DMG solution during LAVH enables patients clinically to have less perceived pain and subsequently tend to utilize about half the amount of morphine, helping to avoid the potential harmful side effects and adverse reactions of morphine.

OBJECTIVE:To test the hypothesis that morphology is the best predictor of clinical pregnancy (CP) when employing intrauterine insemination (IUI).STUDY DESIGN:We retrospectively reviewed a registry of 527 couples who collectively underwent 1,027 IUI cycles, testing sperm parameters and other variables with univariate and multivariate analyses for association with CP. With the literature scant regarding the impact of sperm morphology on IUI outcome, we determined semen parameter threshold values in our patient population and compared them to published reference range values. A logistic regression model was used to determine predictors of CP.RESULTS:Fecundity was 12.9% per cycle and fertility was 23.3% by the third attempted cycle. Morphology was the most significant parameter predicting CP with IUI. Motility was also significant when employing our new threshold values. Using receiver operator characteristic curve analysis, values 16% morphology and 69% motility were found to be the optimal threshold values for achieving CP.CONCLUSION:Morphology was the best predictor of CP. When considering IUI, the best chance of clinical pregnancy occurs when both motility and morphology values are above normal thresholds.

OBJECTIVE:To study the impact of surgically verified endometriosis and serum and peritoneal fluid antiendometrial antibodies (AEA) on pregnancy outcomes in gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT) and in vitro fertilization (IVF) patients using assisted reproductive technologies (ART).STUDY DESIGN:Surgical evaluation of endometriosis and collection of serum and peritoneal fluid was performed at the time of laparoscopy. For patients who did not undergo laparoscopy, only serum samples were obtained. Sera and peritoneal fluid were tested by indirect immunofluorescence for AEA.RESULTS:There was no correlation between surgically verified endometriosis, serum or peritoneal fluid AEA and clinical pregnancy in patients undergoing ART. There was no significant difference in surgically verified endometriosis in patients who delivered and those who miscarried (p < 0.0594), whereas serum (p < 0.0223) and peritoneal fluid (p < 0.0032) AEA showed differences. In the total group of 352 ART patients, positive serum AEA was statistically significant in those who miscarried vs. those who delivered (p < 0.0000).CONCLUSION:Endometriosis does not significantly impair the pregnancy potential of ART patients, but it may be associated with miscarriage. The presence of serum and peritoneal fluid AEA correlate better with miscarriage than surgically verified endometriosis.

OBJECTIVE To evaluate the effectiveness of offering double intrauterine insemination (IUI) to clients in our fertility program. STUDY DESIGN In this prospective, nonrandomized study, 595 couples with ovulatory dysfunction, endometriosis, male factor, unexplained, tubal factor and combined diagnoses utilizing clomiphene citrate-hCG (CC-hCG), CC-gonadotropin-hCG (CC-Gn-hCG), Gn-hCG, lupron-Gn-hCG (L-Gn-hCG) or luteinizing hormone (LH) surge monitoring of natural cycles were offered single or double IUI in a total of 1276 cycles. Single IUIs were performed at 36 hours following hCG or the day following LH surge; double IUIs were performed 18 and 36 hours following hCG or the day of and day following LH surge. Single versus double IUI clinical pregnancy outcomes were compared between ovarian stimulation protocols and diagnostic categories. RESULTS One hundred ten clinical pregnancies occurred for 508 couples in 999 single IUI cycles (fecundity, 11.0%); 45 clinical pregnancies for 174 couples occurred in 277 double IUI cycles (16.2%, p < 0.004). The single IUI group was younger than the double IUI group (32.8 vs. 33.7, p < 0.004). Differences for fecundity were noted regarding diagnostic categories between single and double IUI groups (ovulation dysfunction, 12.9% vs 19.5%, p < 0.048, and male factor, 7.9% vs. 17.5%, p < 0.030) and ovulation protocols (CC-Gn-hCG, 13.0% vs. 21.3%, p < 0.031, and L-Gn-hCG, 4.2% vs. 25.0%, p < 0.002). CONCLUSION Double IUI is superior to single IUI overall, especially when comparing Gn-containing ovarian stimulation protocols or within the ovulatory dysfunction and male factor diagnostic categories.

PURPOSE The purpose of the present study is to compare intrauterine insemination (IUI) pregnancy rates (PR) as a function of diagnosis and ovulation protocol utilizing an extended semen transport time. This allowed clients to conveniently collect IUI specimens in the comfort and privacy of their home. A single IUI per treatment cycle was performed. BASIC PROCEDURES Three-hundred-ten consecutive infertilty couples having unexplained, male factor, ovulatory dysfunction, endometriosis, tubal factor or combined diagnostic factors receiving a total of 584 cycles of IUI were included. Ovulation protocols included LH surge, clomiphene citrate (CC)-hCG, CC-gonadotropins(Gn)-hCG, Gn-hCG or leuprolide acetate (L)-Gn-hCG followed 36-42 hours by a single IUI. Pregnancy rates per cycle (fecundity) and per couple (fertility) as a function of diagnosis, ovulation protocol and cycle number were evaluated. In each cycle the couples processed the specimen by adding sperm washing medium at room temperature to the specimen 30 min following collection and allowed it to incubate for two hours prior to IUI during transport. MAIN FINDINGS Overall, fecundity was 11.8% (69/584) and fertility was 22.3% (69/310); respectively by diagnosis was: unexplained 22.6%, 38.8%; male factor 18.8%, 42.9%; ovulatory dysfunction 12.4, 22.6%; endometriosis 5.3%, 11.1%; tubal factor 7.6%,13.3%; and combined factors 9.7%, 20.0%. Unexplained vs endometriosis (P < 0.0001, P < 0.005), tubal factor (fecundity P < 0.008) and ovulatory dysfunction (fecundity P < 0.027) was statistically different. Male factor vs endometriosis (P < 0.011, P < 0.036) was significantly different. Ovulatory dysfunction vs endometriosis was significantly different (fecundity P < 0.027). Pregnancies by ovulation protocol: LH surge 4.5%,10.5%; CC-hCG 9.4%,14.9%; CC-Gn-hCG 13.7%, 23.7%; Gn-hCG 17.5%, 45.3%; L-Gn-hCG 3.5%, 6.7%. For Gn-hCG vs L-Gn-hCG (P < 0.009, P < 0.030) and LH surge (fecundity P < 0.033). CC-Gn-hCG vs CC-hCG (fertility P < 0.050) and L-Gn-hCG (P < 0.033, P < 0.034). Gn-hCG vs CC-hCG (fecundity P < 0.043). CONCLUSIONS We conclude that IUI is effective when utilizing an extended transport time allowing most couples to collect the specimen at home and is most effective when utilizing Gn-hCG therapy. Based on our analysis, endometriosis, tubal factor and combined diagnostic categories should proceed earlier to higher level assisted reproductive technologies.

PROBLEM:The purpose of the present prospective multi-center study is to investigate the relationship between laparoscopic diagnosis of endometriosis and results of a serum antiendometrial antibody (AEA) assay.METHOD OF STUDY:Indirect immunofluorescence detection of AEA was performed on serum specimens from patients presenting with dysmenorrhea or chronic pelvic pain and infertility (n = 2609) utilizing frozen sections of endometrium acquired on cycle days 18-21 from normally cycling women without endometriosis. Diagnostic laparoscopy was performed within 1 year of AEA assay on 527 tested women.RESULTS:The relationship between the serum AEA and laparoscopic verification was characterized by a positive predictive value = 88%, negative predictive value = 86%, sensitivity = 87% and specificity = 87%.CONCLUSION:The AEA assay is a very good screening test for patients suspected of having endometriosis and should be utilized prior to laparoscopy in diagnostic categories of dysmenorrhea or chronic pelvic pain and infertility.

Purpose: The effects of premature luteinization of ovarian follicles as detected by elevated progesterone values on the day of human chorionic gonadotropin induction of ovulation were evaluated in 38 consecutive gamete intrafallopian transfer (GIFT) retrieval cycles.

The purpose of the present study was to investigate the individual and combined effects of low levels of endotoxin and physiological levels of tumor necrosis factor on in vitro fertilization and preimplantation embryo development. B6D2F1 mice were superovulated by utilizing pregnant mare serum gonadotropin and human chorionic gonadotropin. Oocyte-cumulus complexes (3221 oocytes) were collected, pooled, and randomized into control and treatment groups. Sperm were collected from the caudae epididymides of mature male mice and allowed to capacitate. Treatments included culture media supplemented with increasing amounts of endotoxin (0.5, 1.0, and 2.0 ng/ml; sp act, 3000 IU/ng) and/or tumor necrosis factor (1, 10, and 50 pg/ml; sp act, 0.01 IU/pg) throughout the fertilization and preimplantation development process. Percentage cleavage and percentage expanded blastocyst formation were evaluated. No significant effects were observed for percentage cleavage or percentage expanded blastocyst formation in either the endotoxin (E) or the tumor necrosis factor (TNF) groups. The combination of endotoxin and tumor necrosis factor at any of the levels tested did not significantly decrease cleavage; however, percentage blastocyst formation was decreased with any combination of TNF and E (P<0.05−P<0.001). We conclude that TNF and E exert significant synergistic effects which are detrimental to in vitro preimplantation embryonic development.

The purpose of this investigation was to attempt to develop a process, utilizing a murine model, which would allow more efficient harvesting from the intact ovary and maturation in vitro of germinal vesicle (GV) oocytes. The recovery process yielded 25.5±4.5 (\(\overline X \)±SE) cumulusfree GV oocytes per animal. Treatment groups included culture medium (CM) supplemented with either estradiol (E2), follicle stimulating hormone (FSH), human chorionic gonadotropin (hCG), or prolactin (PRL). Among the hormone-free controls 83.2±1.6% of oocytes underwent GV breakdown, whereas 25.3±2.6% developed to the first polar body stage (PB-1) following 18 hr of incubation (n=29 trials). Oocytes progressing to the PB-1 stage were inseminated in vitro. In vitro fertilization (IVF) of pooled in vitro matured (IVM) PB-1 oocytes (judged by two-cell formation) was 19.9%, which was significantly lower than in the group of in vivo matured oocytes (74.7%). E2 significantly increased the percentage of GV breakdown (control, 76.8±2.5%; E2 at 10 ng/ml, 92.9±2.5%,P<0.001; E2 at 100 ng/ml, 93.7±2.1%,P<0.001; and E2 at 1 μg/ml, 86.7±3.3%,P<0.05) but not PB-1 formation. Neither FSH nor hCG significantly increased GV breakdown or PB-1 formation. Prolactin treatment resulted in an increased percentage of PB-1 formation (control, 25.3±2.5%; PRL at 2 μg/ml, 35.0±2.9%; and PRL at 20 μg/ml, 34.1±1.9%;P<0.01), fertilization (control, 15.3±5.1%; PRL, 33.6±8.5;P<0.01), and subsequent development (control, 3.5±2.3%; PRL, 18.8±5.6%;P<0.01). We conclude that recovery and IVM of GV oocytes is feasible, however, further work is necessary to define optimal conditions.

Bacterial endotoxins have been correlated with increased fragmentation of early cleavage-stage human embryos and decreased pregnancy rates in human in vitro fertilization programs. The purpose of the present study was to test the direct effects of increasing concentrations of endotoxins on in vitro fertilization and development of mouse embryos to the blastocyst stage. Sexually mature B6D2F1 female mice were superovulated and oocytecumulus complexes were collected from the oviducts and randomized into control and treatment groups. Oocytes (n=867) were inseminated with capacitated sperm. Treatments included Ham's F-10 supplemented with 3 mg/ml bovine serum albumin and increasing amounts of endotoxin (0.35, 0.64, 0.92, 1.5, 2.08, 3.21, 6.07, and 11.79 ng/ml). Percentage cleavage, percentage fragmentation at the four-cell stage, and percentage expanded blastocyst formation (of cleaved embryos) were evaluated. Statistically significant decreases in cleavage at 6.07 ng/ml (P<0.05) and blastocyst formation at 11.79 ng/ml (P<0.05) of endotoxin were observed. Fragmentation at the four-cell stage was significantly increased at 3.21 ng/ml (P<0.05) of endotoxin. We conclude that the levels of endotoxin necessary to decrease murine preimplantation development significantly is higher than that reported for human embryos.