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Objective: To compare the pharmacokinetics of a long-acting FSH analog containing the hCG-beta carboxyterminal peptide (recombinant hFSH-CTP) with native recombinant hFSH and describe the pharmacodynamics of recombinant hFSH-CTP after SC injection in female rhesus monkeys., Design: Rhesus monkey study., Setting: Academic research environment., Animal(s): Ten female rhesus monkeys., Intervention(s): Recombinant hFSH and recombinant hFSH-CTP were administered via a single SC or IV dose to rhesus monkeys, and serial phlebotomy was performed (n = 2 and n = 4 for SC recombinant hFSH and recombinant hFSH-CTP, respectively; for IV dosing, n = 1 in each group). An additional two monkeys were pretreated with SC ganirelix and received SC recombinant hFSH-CTP after confirmation of pituitary suppression., Main Outcome Measure(s): Plasma disappearance rate of recombinant hFSH and recombinant hFSH-CTP and serum estradiol levels., Result(s): The elimination half-life of recombinant hFSH-CTP was twofold and fourfold longer than that for recombinant hFSH after SC and IV dosing, respectively. The absorption half-life was approximately threefold longer for recombinant hFSH-CTP than for recombinant hFSH after SC administration. Recombinant hFSH-CTP stimulates estradiol secretion for 5-7 days after an isolated SC dose., Conclusion(s): Addition of the hCG-beta carboxyterminal peptide to hFSH-beta results in an FSH analog with longer absorption and elimination half-lives compared with native hormone. This analog is capable of prolonged ovarian stimulation in rhesus monkeys after an isolated SC injection.

Objective: To describe the establishment of an embryo donation program using a large oocyte donor registry to produce embryos., Design: Descriptive study., Setting: A university-based practice., Patient(s): Embryos were obtained either through traditional donation from couples who underwent IVF-ET (n = 8) or through ovum donation (n = 15) with embryos produced by the program. In select cases, ovum donors were inseminated either with donor sperm selected following an advance directive from the patient or couple (n = 13) or with sperm designated by an IVF medical advisory board (n = 11)., Intervention(s): Donated embryos or donor oocyte/donor sperm embryos were provided to patients with backgrounds and physical attributes compatible with the embryonic phenotype. In some of the cycles, fresh ET was performed, with embryos shared among two, three, or four couples (n = 18); in other cycles, embryos were cryopreserved and transferred later (n = 21)., Main Outcome Measure(s): Clinical and ongoing-delivered pregnancy rates., Result(s): The mean (+/-SD) numbers of embryos for cycles in which fresh ET and frozen ET was performed were 3.1+/-0.7 (range, 2-5) and 3.6+/-0.2 (range, 3-5), respectively. The clinical and ongoing-delivered pregnancy rates were 44.4% (8/18) and 33.3% (6/18), respectively, for cycles in which fresh ET was performed and 57.1% (12/21) and 47.6% (10/21), respectively, for cycles in which frozen ET was performed., Conclusion(s): Embryo donation is an alternative approach to assisted reproduction that meets the needs of single and lesbian women as well as older and less affluent couples. It is a cost-effective and efficacious means of achieving pregnancy.

Objective: To report a case of cryptic 21-hydroxylase deficiency identified at the time of ovum donation in a patient with Turner's syndrome., Design: Case report., Setting: University IVF practice., Patient(s): A 28-year-old woman with Turner's syndrome who presented for ovum donation., Intervention(s): Four cycles of donor IVF., Main Outcome Measure(s): Pregnancy, endometrial appearance, progesterone, and 17-hydroxyprogesterone values., Result(s): The patient failed two fresh and two frozen ET cycles with donated oocytes. The appearance of the endometrium suggested elevated progesterone before progesterone supplementation. An elevated progesterone was detected but not suppressed by leuprolide acetate. Progesterone was suppressed by adding dexamethasone. The diagnosis of cryptic 21-hydroxylase deficiency was confirmed biochemically., Conclusion(s): Patients with Turner's syndrome reportedly have poorer outcomes with donor IVF than other women. They also have an increased incidence of carrying a defective 21-hydroxylase gene. We suggest that some of the poorer outcomes may be explained by the presence of elevated progesterone and recommend evaluation of possible congenital adrenal hyperplasia in patients with Turner's syndrome who want oocyte donation.

Objective: To determine if human chorionic gonadotropin (hCG) can be absorbed from the uterine cavity in the absence of an embryo., Design: Prospective study., Setting: University-based assisted reproduction program., Patient(s): Eight functionally agonadal patients (age range, 33-46 years) who were taking hormone replacement therapy so that they could receive donated oocytes., Intervention(s): Intrauterine instillation of 50 microL of hCG (10,000 IU) during a mock cycle before an attempt at oocyte donation., Main Outcome Measure(s): Spot urine measurements of different hCG epitopes (intact beta, beta-core, and free beta) at timed intervals (12, 20, 44, and 68 hours after instillation)., Result(s): All hCG epitopes were detected in the urine at the first sampling interval, and levels decreased in subsequent sampling intervals. Measurement of the serum hCG level confirmed that systemic absorption had occurred and that the urine measurements were not a result of specimen contamination through the cervix., Conclusion(s): hCG may be systemically absorbed into the blood through the uterine cavity, even in the absence of implantation, and its metabolites may be measured with use of highly sensitive urinary assays.

Objective: To describe the reproductive and obstetric outcomes of women > or = 50 years attempting pregnancy using donor oocytes., Setting: The IVF program at the University of Southern California., Patients: Thirty-six postmenopausal women aged 50 to 59 years, mean 52.3 +/- 2.6 years (mean +/- SD) were screened medically, reproductively, and psychologically and enrolled in a trial of oocyte donation., Interventions: Recipients underwent hormone replacement therapy using oral micronized E2 and IM administered P. Oocytes were provided by designated gamete donors (mean age 30.5 +/- 4.4 years). Embryos (4.3 +/- 1.2) were transferred transcervically., Main Outcome Measures: Rates for embryo implantation, spontaneous abortion, ongoing and delivered pregnancies, as well as the gestational age at delivery, birthweights, complications, and postpartum outcomes., Results: Forty-five aspirations resulted in 22 pregnancies (48.9%): 3 preclinical, 2 ending in spontaneous abortion, and 17 viable pregnancies (37.8%). The embryo implantation rate was 20.6%. Nine of 17 pregnancies (52.9%) were multiple gestations (6 twins; 1 triplet; and 2 quadruplets, selectively terminated to twins). All pregnancies delivered beyond 32 weeks: mean gestational age for singletons was 38.4 +/- 1.9 weeks (range 35 to 41 weeks); mean gestational age for twins was 36.3 +/- 1.4 weeks (range 34 to 38 weeks); the triplet pregnancy delivered at 32 weeks. Complications occurred in eight patients; gestational hypertension (n = 7), preterm labor (n = 3), gestational diabetes (n = 2), and pre-eclampsia (n = 1). One infant was trisomy-21., Conclusion: Patients > or = 50 years experience similar pregnancy rates after oocyte donation as younger women and are at equal risk for multiple gestation. Antenatal complications were experienced by the majority of patients, underscoring the importance of high risk obstetric surveillance and care.

Objective: To determine whether angiotensin-converting enzyme (ACE) inhibition would affect ovarian steroid synthesis in the oocyte donors undergoing controlled ovarian hyperstimulation (COH)., Setting: The IVF program of the University of Southern California., Design: Prospective matched clinical trial., Patients: Twelve oocyte donors were studied in 28 hyperstimulation cycles., Interventions: Donors underwent a standard COH protocol. Follicle aspiration was performed 34 hours after administration of hCG. After the procedure, seven donors were administered the ACE inhibitor, captopril, 6.25 mg orally twice daily for 4 days. The remaining patients served as controls., Main Outcome Measures: Serum E2, P, plasma prorenin, active renin, and angiotensin II (Ang II)., Results: Angiotensin II increased after aspiration in both groups but was significantly lower in those receiving captopril. Peak P in the captopril group was significantly lower than controls (81.8 +/- 27.8 versus 208.5 +/- 23.9 ng/mL [conversion factor to SI unit, 3.180]). Peak E2 was significantly higher (2,222.4 +/- 875.3 versus 425.6 +/- 490.4 pg/mL [conversion factor to SI unit, 3.671]). Active renin and Ang II correlated with P., Conclusions: In stimulated cycles, inhibition of Ang II production appears to raise serum E2 and lower P levels. Angiotensin II, therefore, may have a role in the regulation of ovarian steroid synthesis.

Objective: To evaluate the natural history of multiple implantation in a donor oocyte program., Design: Retrospective review of clinical pregnancies resulting from donor oocytes with analysis of serial vaginal ultrasound examinations beginning 21 days after embryo transfer., Setting: University of Southern California IVF program (USC-IVF)., Main Outcome Measures: Number of implantation sites lost during gestation, furthest development of the gestation, and clinical symptoms of those experiencing loss., Results: Sixty-two of 101 patients (61%) who became pregnant had multiple implantations, 41 (41%) with two sacs, 12 (12%) with three sacs, 6 (6%) with four sacs, and 3 (3%) with five sacs. Overall 28% of implantations sites were lost spontaneously. Rates of loss were similar for multiple implantations. The majority (62%) of these nonviable sacs did not develop beyond a gestational sac. All patients with three or more implantation sites had ongoing pregnancies through the first trimester. The probability of pregnancy loss after visualization of fetal heart motion was 5.7%. Few patients who underwent a natural self reduction of sacs were symptomatic., Conclusions: There is a significant self-reduction in multiple implantation sites in a donor oocyte program. This may obviate the need for a selective reduction procedure. Patients should be followed for up to 10 weeks after ET before committing to a selective reductive procedure.

Objective: To determine pharmacokinetic and endometrial effects of vaginally delivered micronized P., Design: Functionally agonadal estrogen-replacement recipients received either micronized P administered vaginally or bi-daily IM injections of P. Hourly blood samples were obtained, from baseline to 6 hours after the initial dose of P and again on simulated cycle day 21 when transvaginal ultrasound (US) measurements and tissue samples of the endometrium were performed. Blood and tissue samples were assayed for P. Endometrial histology, estrogen receptor (ER) and P receptor (PR) contents were evaluated., Setting: University of Southern California School of Medicine, Los Angeles, California., Participants: Twenty functionally agonadal and four normally ovulating women., Main Outcome Measure: Delivery differences were assessed by [1] endometrial P concentrations; [2] USs; [3] histologic datings; [4] ER and PR contents, and [5] serum P levels., Results: Endometrial P concentrations were higher with vaginally administered P than endometrial concentrations observed in normal ovulatory women or women who consistently had the highest serum P after IM administration (11.50 +/- 2.60 versus 1.40 +/- 0.40 versus 0.30 +/- 0.10 ng/mg protein [36.56 +/- 8.27 versus 4.45 +/- 1.27 versus 0.95 +/- 0.32 nmol/L], respectively). After 7 days of P, no differences between either treatment regimen and control groups were detected by histologic, ultrasonographic, or immunocytochemical receptor analyses., Conclusion: Vaginal micronized P enhances P delivery to the uterus compared with a standard IM regimen and results in a synchronous secretory endometrial histology in agonadal women preparing for embryo donation.

Despite careful screening and the adherence to strict protocol, approximately 2% of initiated cycles of oocyte donation were found to be complicated by difficulties incurred by oocyte donors. The risk of these adverse events appeared to be limited to the initial trial of donation with experienced donors being more reliable. Thus, surveillance of the cycle's progress should be maximal during this time. Both donors and recipients need to be aware of the unique problems posed by oocyte donation to provide full informed consent. This includes the possibility for unplanned pregnancies when discontinuing the donors' usual method of contraception. These mishaps underscore the importance of reminding patients that cycle success cannot be guaranteed, and unexpected complications cannot be entirely avoided.

Objective: To evaluate sperm preincubation in tes and tris (TEST)-yolk buffer as a potential enhancing agent of fertilizing capacity of sperm during human in vitro fertilization (IVF)., Design: Oocytes obtained during IVF were divided into two groups: one group fertilized with TEST-yolk buffer-treated sperm and the other group with standard-prepared sperm., Setting: The University of Southern California IVF Program., Patients: Thirty-nine couples with suspected male factor infertility undergoing IVF., Interventions: Preinsemination incubation of sperm in TEST-yolk buffer for 24 hours., Main Outcome Measures: Fertilization rates in vitro., Results: TEST-yolk buffer-treated sperm fertilized 140 of 241 oocytes (58%), whereas control sperm fertilized 108 of 251 oocytes (43%). Of four couples who had previously failed to fertilize during IVF, one fertilized with both specimens and three fertilized with TEST-yolk buffer-treated sperm only., Conclusions: TEST-yolk buffer pretreatment of sperm for 24 hours results in higher fertilization rates during IVF among suspected male factor patients.

Objective: To describe the clinical experience of our center with in vitro fertilization (IVF) in unstimulated cycles and to provide a comparison to stimulated cycles., Design: Spontaneous ovulatory cycles were triggered with human chorionic gonadotropin in the midcycle, and 78 aspirations for IVF were performed, with the remainder of the IVF cycle proceeding in a standard manner., Setting: The IVF program of the University of Southern California and the California Medical Center, Los Angeles, California., Patients: Spontaneously ovulatory women (n = 46) with predominantly pelvic factor as their principal cause of infertility, under the age of 40, and no male factor., Interventions: Human chorionic gonadotropin administration in midcycle, follicle aspiration, IVF, and embryo transfer., Main Outcome Measures: Embryo implantation and pregnancy., Results: Seventy-eight follicle aspirations resulted in 11 clinical (14%) and 9 ongoing (12%) pregnancies. The per embryo implantation rate was 13% clinical and 11% ongoing. There was no decrease in per cycle pregnancy rates (PRs) for up to three unstimulated cycles., Conclusions: Unstimulated IVF is a viable alternative to stimulated cycles with PRs approximately one half those of stimulated cycles. It is reasonable to offer patients up to three cycles of unstimulated IVF without expecting a decrease in PRs.

Study Objective: To assess the clinical utility of measuring urinary pregnanediol glucuronide in random samples in an infertility practice., Design: Samples of urine were collected from patients approximately 3 weeks from their last menstrual period to ascertain if ovulation had occurred. Each sample was tested for specific gravity before analyzing for pregnanediol glucuronide. Simultaneous venipuncture was performed to compare results from the urinary assay to quantitative measures of serum progesterone (P)., Setting: All patients were randomly sampled., Patients: Three hundred ninety women undergoing pituitary down regulation with leuprolide acetate were chosen for study because they routinely initiate medication after documentation of ovulation., Outcome Measures: The performance of the urinary pregnanediol glucuronide was evaluated as to its sensitivity, specificity, predictive value, and test efficiency compared with a serum measurement of 2.5 ng/mL and 10.0 ng/mL., Results: The performance characteristics of the pregnanediol glucuronide assay were directly related to the hydration status of the patient at the time of sample collection. Regardless of urine specific gravity, if pregnanediol glucuronide was qualitatively detected (greater than 3 micrograms/mL), serum P was greater than 2.5 ng/mL. However, in cases in which pregnanediol glucuronide was undetected (less than 3 micrograms/mL), results were only accurate when the specific gravity was greater than or equal to 1.020. When comparing urinary pregnanediol glucuronide values to serum greater than 10 ng/mL, both specificity and predictive value of a positive test decreased because of increased numbers of false-positive results., Conclusions: The enzyme immunoassay measurement for pregnanediol glucuronide may replace the use of serum P in documenting the ovulatory status of many patients. However, all specimens must be checked for specific gravity and if less than 1.020, a serum P should be used to ensure accuracy.

In summary, oocyte and pre-embryo donation may be used to establish pregnancy in women with galactosemia and ovarian failure. Reported is the first pregnancy after pre-embryo donation to a woman with classical galactose-1-phosphate uridyl transferase deficiency. Despite disturbances in galactose metabolism, the endometrial lining responded normally to exogenous hormone replacement and was receptive to pre-embryo implantation. Pregnancy support was provided by exogenously administered oral E2 and IM P for the initial 100 days, at which time placental hormone production solely maintained the gestation.

The outcome of a series of pre-embryo transfers to 31 women with ovarian failure is described. Twenty six fertile women functioned as nonanonymous donors, providing oocytes for in vitro fertilization after undergoing controlled ovarian hyperstimulation and transvaginal ultrasound directed oocyte aspiration. Recipients, 24 to 44 years of age, received hormone replacement therapy before pre-embryo transfer (ET). A mean of 13.7 +/- 1.1 oocytes were obtained per aspiration resulting in the transfer of 4.5 +/- 0.2 pre-embryos to each recipient couple. Twenty-five of 47 ET resulted in pregnancy (53.2% per ET); 5 preclinical, and 20 clinical, of which 18 are ongoing or delivered. The overall implantation rate per individual transferred fresh pre-embryo was 21.1%. We conclude that oocyte donation is a safe and highly efficient means of achieving pregnancy for women with ovarian failure.

The purpose of this study was to analyze follicular fluid (FF) samples for steroid levels from stimulated and unstimulated cycles triggered with human chorionic gonadotropin (hCG) and to assess the influence of controlled ovarian hyperstimulation and luteinizing hormone/hCG on these levels. Spontaneous ovulatory cycles were monitored with serial ultrasound examinations, and hCG 10,000 IU was given when the lead follicle was mature. Fourteen FF samples yielding fertilizable oocytes were compared with 13 FF samples from controlled ovarian hyperstimulation cycles. Progesterone (P) was higher in controlled ovarian hyperstimulation than in unstimulated cycles (9.0 +/- 1.2 micrograms/mL versus 4.4 +/- 0.6 microgram/mL; mean +/- SEM), whereas estradiol (E2) was lower (0.8 +/- 0.1 microgram/mL versus 1.3 +/- 0.2 microgram/mL), resulting in a higher P:E2 ratio (15.5 +/- 3.3 versus 4.4 +/- 0.7). Androstenedione (A), testosterone (T), and T:E2 ratios were all higher in unstimulated than controlled ovarian hyperstimulation cycles. We conclude that controlled ovarian hyperstimulation is associated with increased FF P, decreased FF E2, T, and A levels, and decreased T:E2 ratios, suggesting altered steroidogenesis and enhanced follicular aromatase activity.

The use of gonadotropin-releasing hormone agonists as adjuncts to ovulation induction for in vitro fertilization (IVF) has resulted in increases in oocyte recovery rates. Along with increased oocyte number, greatly increased estradiol (E2) levels have been found. We sought to determine the clinical effect of very high E2 levels on the outcome of IVF cycles. Estradiol levels were measured in 141 patients undergoing controlled ovarian hyperstimulation with leuprolide acetate and human menopausal gonadotropin for IVF. Whereas the number of oocytes recovered and fertilized and the number of embryos available for cryopreservation were directly proportional to the E2 level, the fertilization rate and embryo cleavage rates were unrelated to the E2 level. When the patients were grouped in thirds according to E2 levels, pregnancy rate (PR) was highest in the patients with the highest E2 levels (E2 greater than 2,777 pg/mL, PR = 37%). One mild, one moderate, and one severe case of ovarian hyperstimulation syndrome occurred in patients with E2 greater than or equal to 3,000 pg/mL (n = 21), but in general, high E2 levels were attained with few complications. We conclude that high E2 levels are not detrimental to the pregnancy outcome of IVF. Our experience further suggests that cycles with E2 levels of less than or equal to 5,000 pg/mL need not be canceled and can proceed to oocyte recovery and embryo transfer.

A 35-year-old woman with chronic anovulation and bilateral tubal disease was found during infertility evaluation to have grade I endometrial carcinoma confined to an endometrial polyp. She was treated with polypectomy and endometrial curettage followed by high-dose progestagens for 6 months. Endometrial curettage at 3 and 6 months of therapy indicated regression of the lesion and the patient subsequently achieved successful pregnancy with IVF.

To study the effects of controlled ovarian hyperstimulation (COH) on endometrial receptivity during human in vitro fertilization (IVF), we compared embryo implantation data obtained from our nonanonymous donor oocyte program with those obtained from standard IVF. To control for embryo quality, IVF patient characteristics were matched to those of the oocyte donors with regard to age and previous gravidity. All cycles were performed in an identical manner, using standardized ovarian stimulation protocols, transvaginal follicle aspiration, fertilization and culture in vitro, and transcervical embryo transfer. A similar number of oocytes per cycle were obtained, fertilization rates were similar, and similar numbers of embryos were transferred in both groups. Transferred embryos had similar numbers of blastomeres and were morphologically judged to be of similar quality in both groups. Implantation rates per individual embryo were significantly higher in donor than in standard IVF (35% versus 10.7%) as were ongoing per embryo implantation rates (23% versus 8%). Clinical and ongoing pregnancy rates per cycle were likewise higher in the donor group than in the standard IVF group (67% versus 39%, and 61% versus 30%, respectively). We conclude that COH inhibits embryo implantation after IVF by decreasing endometrial receptivity, which is an important factor in IVF pregnancy success.

In an attempt to increase the number of fertilized ova recoverable by uterine lavage, the authors superovulated ovum donors using a combination of clomiphene citrate and human menopausal gonadotropin. Six women underwent seven lavage cycles with uterine flushes performed 96, 120, 144, and 168 hours after ovulation and artificial insemination. Ova were recovered from three women between 96 and 144 hours after ovulation. However, no ova were recovered from the other three donors, two of whom were later noted to be pregnant. Retained pregnancies occurred despite postlavage administration of high-dose contraceptive pills, endometrial aspiration, and, in one case, RU 486. None of the infertile women became pregnant as a result of the trial. The authors conclude that, although superovulation may increase ovum production, without reliable contragestion, such practice is unsafe for ovum donors undergoing uterine lavage.

We report this country's first nonsurgical donor ovum transfer pregnancy in a functionally agonadal woman who had received chemotherapy and radiation for Hodgkin's lymphoma. For women with ovarian failure, nonsurgical uterine lavage and ovum transfer may provide an opportunity for motherhood that was not possible previously.

The occurrence of an incarcerated small bowel hernia through a subumbilical laparoscopic incision site is a rare event. The obstruction occurred 7 weeks after laparoscopy and 1 week after bilateral tuboplasty through a Pfannenstiel incision. Following laparoscopy, the possibility of a bowel obstruction should be entertained in any patient presenting with signs consistent with this diagnosis regardless of the intervening period of time.

Transvaginal ultrasound-directed oocyte retrieval was performed on eight women functioning exclusively as gamete donors for 10 patients with ovarian failure. Donors included sisters, personal friends, and compensated participants selected by the recipient couple. Oocyte donors underwent controlled ovarian hyperstimulation and transvaginal oocyte aspiration. Thirteen initiated cycles resulted in 11 embryo transfers and six ongoing pregnancies. There were no complications, and all donors stated a willingness to undergo the procedure again. The use of nonanonymous oocyte donation appears both efficacious and efficient and is recommended as an option for achieving pregnancy in women with ovarian failure.

Two patients are presented who developed vulvar edema after intraperitoneal instillation of Hyskon. Regardless of the route of extravasation, Hyskon's high molecular weight and osmotic effects may lead to further soft tissue swelling. Correct diagnosis warrants the exclusion of wound infection, hematoma, or seroma. Special attention to ensuring peritoneal closure may lessen the risk for the development of this complication.

17 beta-estradiol (E2)-and/or crystalline progesterone (P)-impregnated polysiloxane vaginal rings and cylinders were tested as a system for endometrial priming in functionally agonadal women awaiting donor embryo transfer. Endometrial tissue was obtained by a transcervical biopsy procedure on simulated cycle day 26. The adequacy of the replacement regimen was judged by endometrial histologic dating, scanning electron micrographs, receptor content, and circulating E2 and P serum concentrations. Endometrial dating was consistent with cycle day 26. Electron micrographs showed normal surface characteristics. E2 and P receptor concentrations were within the normal range. Serum E2 levels were midfollicular, 105 +/- 12.8 pg/ml (mean +/- SEM), and midcycle, 254 +/- 28.6 pg/ml. P levels during the simulated follicular phase were undetectable (less than 0.2 ng/ml) but rose to a mean peak level of 17.3 +/- 1.8 ng/ml. The steroid-impregnated polysiloxane vaginal ring and cylinder system provided continuous and sustained hormone release, morphologically and endocrinologically normal endometrium, serum levels of E2 and P within the normal range for the entire menstrual cycle, and a convenient and physiologic therapeutic alternative to oral, vaginal, or intramuscular steroid replacement.

Unruptured tubal pregnancies diagnosed at laparoscopy were treated with either methotrexate/citrovorum factor (MTX/CF) (n = 21) or observation (n = 5). Entry criteria required that the ectopic pregnancy be visualized, less than or equal to 3 cm in diameter, with intact serosa and no active bleeding. Treatment selection was based upon preoperative levels of beta-human chorionic gonadotropin (beta-hCG), with MTX/CF given to subjects exhibiting a plateaued or rising pattern and observation alone given to those with falling levels. Twenty-five of 26 ectopic pregnancies resolved without need of laparotomy. Two subjects received blood transfusions and one required a second operation for intra-abdominal bleeding. In both cases, fetal cardiac activity was noted pretreatment on ultrasound. The authors conclude the following: (1) MTX/CF may be safely used to treat selected unruptured ectopic pregnancy; (2) many ectopic pregnancies resolve spontaneously; and (3) ectopic pregnancies that form fetal elements, as evidenced on ultrasound, should not be managed medically.

We conclude that the acceptability of using a sister for gamete donation is high among couples desiring ovum donation. On the contrary, couples undergoing AID generally rejected the concept of using the husband's brother as a known donor. Thus, although similar in concept, disparity exists regarding the use of siblings for gamete donation. Though the use of sibling gamete donation may provide a short-term solution to the dwindling supply of acceptable gamete donors, the long-term acceptability of such practice remains unknown.

We successfully synchronized two functionally agonadal women with a single oocyte donor who underwent controlled ovarian hyperstimulation and transvaginal aspiration. Pregnancies were simultaneously established in these recipients; the need for freezing supernumerary preembryos was obviated, and substantial cost reduction was realized by the patients.

Seven women with unruptured tubal pregnancies diagnosed on laparoscopy were treated with methotrexate and citrovorum rescue. Criteria for inclusion in the study were that the level of human chorionic gonadotropin (hCG) be plateaued or rising, that the ectopic pregnancy not exceed 3 X 3 cm, that the tubal serosa be intact, and that there be no active bleeding. The women were followed with serial measurements of hCG, complete blood counts, and liver function tests. All women responded to a single course of therapy. The median time to resolution (from the first day of treatment to when the hCG was undetectable) was 31 days (range, 5 to 50 days). Follow-up hysterosalpingograms were available for five women. Four women demonstrated tubal patency, and one showed a unilateral occlusion on the side of the ectopic. One woman was found to have an intrauterine pregnancy prior to the scheduled time of hysterosalpingogram.

After four unsuccessful attempts at multiple follicular induction with exogenous gonadotropins, a patient underwent two attempts at IVF in spontaneous cycles triggered with hCG. The second attempt resulted in the transfer of three embryos and a successful singleton intrauterine pregnancy. We believe that unstimulated IVF is a viable option for patients with ovulatory cycles. It should be considered in cases of failed hyperstimulation, and may become a primary treatment option in the future.

We obtained a single serum P measurement in 70 subjects at risk for an EP. Retrospectively, a P less than 15 ng/ml was 100% predictive of either an EP or otherwise nonviable IUP, while P greater than 15 ng/ml would have ruled out an EP in all cases. Because of this high degree of diagnostic accuracy, we speculated on the clinical utility of an outpatient D and C for those patients in our series having a P less than 15 ng/ml. Laparoscopy would be reserved for those cases without identifiable chorionic villi on frozen section of curettings. Following this course of management could have potentially diagnosed all EPs at the first ER visit without disruption of a single normal IUP in our series. This sequence could have expedited the diagnosis of EP by up to 14 days compared with a standard hCG/US protocol. This report describes a promising new test for the early detection of EP. The findings, however, require confirmation in a prospective trial before widespread clinical implementation.

To aid in the clinical decision making involved with persistent ectopic gestation, a total of 329 operative procedures for tubal gestation were reviewed. Six of 114 (5.3%) cases treated conservatively had persistent trophoblastic activity. The decline in serum beta-human chorionic gonadotropin (hCG) and progesterone (P) at 3 and 6 days postoperatively was similar in the "persistent ectopic" and the "resolved ectopic" groups. However, beyond day 6 both beta-hCG percentage of baseline and P level were significantly higher in the "persistent ectopic" (greater than 22.6 +/- 6.6%, greater than 3.4 +/- 0.7 ng/ml, respectively) than the "resolved ectopic" group (less than 2.7 +/- 0.8%, less than 0.2 +/- 0.05 ng/ml, respectively). Four patients underwent a second operation, whereas two were managed expectantly. These data suggest that the diagnosis of persistent ectopic gestation is best made by an initial measurement of serum beta-hCG or P at 6 days postoperatively, and at 3 day intervals thereafter. The choice of management may be determined by various factors including serum beta-hCG and patient's symptoms.

Reported is the first triplet gestation following oocyte donation to an agonadal woman. The transfer of five ova resulted in implantation of all five, with continued embryonic development in three. Pregnancy support was provided by exogenously administered oral E2 and intramuscular P for 100 days, at which time placental hormone production solely maintained the gestations.