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Insufficient progesterone, effect possibly more on immune factors rather than adequate endometrial development, can be an easy remedial cause of infertility by simply supplementing the luteal phase with either vaginal or intramuscular or oral (dydrogesterone) progesterone. Progesterone will also help to reduce miscarriage rates when follicle maturing drugs are used for those with regular menses but follicular maturation defects, or women with recurrent miscarriages. One mechanism of action seems to be related to production of an immunomodulatory protein, the progesterone-induced blocking factor either in the cytoplasm or in the circulation. PIBF inhibits cytotoxicity of natural killer cells. Cancer cells may 'borrow' the same mechanism to escape NK cell immunosurveillance.

Purpose: To determine the impact of embryo quality on multiple birth rates., Materials and Methods: A retrospective review of in vitro fertilization-embryo transfer (IVF-ET) cycles over ten years was performed. The data was stratified by number of embryos transferred (two vs three) and by percentage of embryos with < 6 vs > or = 6 blastomeres., Results: Pregnancy rates (PRs) increase with the greater number of embryos with a higher blastomere count. However transferring more embryos with less blastomeres does not lower the risk of multiple births., Conclusions: Couples should consult the table, e.g. presented here, so they can make their best choice of how many embryos to transfer considering the importance of a higher pregnancy rate vs the risk of the complication of multiple births.

Purpose: To report the second case of amenorrhea related to endometrial compaction apoptosis syndrome., Materials and Methods: A female with secondary amenorrhea was evaluated with sonography, hysteroscopy, serum estradiol and progesterone levels, serum luteinizing hormone (LH), follicle stimulating hormone (FSH), and endometrial biopsy., Results: Initially she was found to be ovulatory. However she did not menstruate despite the development of adequate endometrial thickness and a normal secretory endometrial biopsy. Hysterosalpingogram failed to detect synechial. Subsequently she developed hypogonadotropic hypogonadism, but she still failed to menstruate despite estrogen followed by progesterone., Conclusions: Amenorrhea can occur despite secretory endometrial changes without a uterine abnormality.

Purpose: To determine if the additional burden of low percentage motility reduces the chance that sperm with low hypoosmotic swelling (HOS) test scores will achieve a pregnancy following in vitro fertilization (IVF) with intracytoplasmic sperm injections (ICSI)., Methods: Couples undergoing IVF-embryo transfer (ET) and ICSI for low HOS tests (< 50%) were retrospectively identified. The percentage motility was divided into deciles. Pregnancy rates were determined according to the deciles of motility., Results: No differences in clinical or live delivered pregnancy rates per transfer were found in even the very lowest percent motility category., Conclusions: The added complicating factor of low percentage motility added to sperm with low HOS test scores does not reduce the effectiveness of IVF with ICSI.

Purpose: To determine if sperm motility and hypo-osmotic swelling (HOS) test scores are associated. Furthermore the study would determine if the chance of having a subnormal HOS test increases as motility levels decrease. Finally the study would determine if age, motility, and HOS test scores are independent factors or if they interact., Materials and Methods: A retrospective analysis of males of all ages with a normal sperm concentration of > 20 x 10(6)/ml is presented. Males were evaluated separately according to age (< 40 vs > or = 40 years) for percent progressive motility and HOS test scores. The percent motility was assessed according to percentage in deciles., Results: A significantly higher percentage of males with low motility have low (< 50%) HOS test scores irrespective of age. The odds ratio of males < 40 years having an abnormal HOS test score is 6.73 times higher and is 8.23 times higher for males > or = 40 years. As age increases, there is a significantly larger proportion of males with abnormal HOS test scores (6% to 13%)., Conclusions: Factors that cause an abnormality in the functional integrity of the sperm membrane, as evidenced by a low HOS test score, can also have a negative effect on motility.

Purpose: To present a novel approach to prevent miscarriage by treatment with sympathomimetic amines., Materials and Methods: Two women undergoing in vitro fertilization-embryo transfer (IVF-ET) with a history of recurrent miscarriage even in IVF-ET cycles were treated with dextroamphetamine sulfate prior to their next IVF-ET cycles., Results: Both women successfully completed their first trimester. One woman delivered a live baby and one had neonatal death related to prematurity secondary to severe pre-eclampsia., Conclusions: Sympathomimetic amines therapy may prove to be an effective therapy to prevent recurrent miscarriage especially in women who have failed despite progesterone therapy, and where no other etiologic factors have been determined.

Purpose: Sympathetic nervous system hypofunction has been found to be associated with motility disorders of the bowel, including gastroparesis, pseudointestinal obstruction, and esophageal motility disorders. These disorders respond to sympathomimetic amine therapy. The purpose of this study was to see if this therapy could be effective in treating pathological constipation., Materials and Methods: Dextroamphetamine sulfate 15 mg extended release capsules was prescribed to an 18-year-old young woman who had severe constipation with a bowel movement every two to three weeks and sometimes every five to six weeks who did not respond to standard therapy and where no definite etiology was determined., Results: Two hours after her first dosage of the sympathomimetic amine, she had a bowel movement and has had regular bowel movements ever since., Conclusions: Sympathomimetic amine therapy seems to help severe constipation refractory to standard therapy.

Purpose: To determine the relative confounding effect of diminished oocyte reserve on the chance of successful pregnancy in non-in vitro fertilization-embryo transfer (IVF-ET) cycles., Materials and Methods: Matched controlled study comparing pregnancy outcome in women aged < or = 37 years with severely decreased oocyte reserve as manifested by a day 3 serum follicle stimulating hormone (FSH) > or = 15 mIU/ml compared to women with normal oocyte reserve (serum FSH < or = 8 mIU/ml). Couples were excluded if they did not have tubal patency or a semen analysis that required IVF-ET. Only couples that tried at least three natural cycles (unless pregnancy occurred first) were included., Results: The live delivered pregnancy rates within a maximum of five cycles of luteal phase support with progesterone (P) or at most mild FSH stimulation, or intrauterine insemination for mild male factor or cervical factor was 33.3% (8/24) with increased day 3 FSH and 62.5% (16/24) for the normal group (p = 0.08, Fisher's exact test)., Conclusion: Women with marked oocyte depletion are half as likely to conceive with assisted reproductive techniques compared to women with normal oocyte reserve.

Purpose: To determine if the addition of luteinizing hormone (LH) to follicle stimulating hormone (FSH) stimulation for controlled ovarian hyperstimulation (COH) protocols using gonadotropin releasing hormone (GnRH) antagonists improves pregnancy rates following in vitro fertilization-embryo transfer (IVF-ET)., Materials and Methods: All IVF-ET cycles using a GnRH antagonist were evaluated according to whether FSH was used exclusively or if LH was added. The cycles were further stratified according to age (< or = 39 and 40-42 years) and according to good responders (> or = five oocytes retrieved) or poor responders (< or = four oocytes)., Results: Combining all data, a significantly higher clinical and live delivered pregnancy rates were found in those adding LH (34.7% and 32.3%) vs those taking all FSH (33.4% and 25.8%). The only subgroup not showing this effect was the women aged 40-42 years with diminished oocyte reserve., Conclusions: LH should be added not only to COH protocols using GnRH agonists but also those using GnRH antagonists.

Purpose: To determine if pregnancy rates following embryo transfer are reduced if the endometrial echo pattern in the late proliferative phase is isoechogenic (IE) vs triple line (TL)., Methods: Pregnancy and implantation rates were compared according to TL vs IE pattern in the late proliferative phase in women having in vitro fertilization-embryo transfer (IVF-ET), frozen ET, and transfer of embryos derived from donor oocytes., Results: There was no difference in pregnancy rates with IE vs TL pattern with fresh or frozen ET or in donor egg recipients. The degree of ovarian reserve did not affect the pregnancy rates according to endometrial echo pattern., Conclusions: The presence of an IE pattern in the late proliferative phase should not influence the treating physician to either cancel the cycle and withhold human chorionic gonadotropin (hCG) injection or freeze all embryos and defer transfer.

Purpose: To determine the pregnancy rate following the exclusive transfer of twice frozen twice thawed embryos., Materials and Methods: All day 3 transfers of exclusive twice frozen-twice thawed embryos were retrospectively identified over a 13-year time-period. The cryopreservation technique used a simplified slow cool freezing protocol. Embryos could have been originally cryopreserved at the 2 pronuclear or multi-cell stage., Results: Survival rates were 83.3%. The live delivered pregnancy rate was 18.1% (15/83). The implantation rate was 13.1% (22/168)., Conclusions: These data suggest that twice frozen twice thawed embryos should not be discarded but either transferred alone if they are the only embryos left, or mixed with frozen embryos that have never been thawed. Though the live delivered pregnancy rates are inferior to fresh embryo transfer the marked reduction in cost and avoidance of the risk of ovarian hyperstimulation justifies their transfer.

Purpose: To evaluate the empirical use of progesterone (P) in the luteal phase for unexplained infertility., Methods: Clinical and live-delivered pregnancy rates in three treatment cycles were compared in women with unexplained infertility vs women taking follicle maturing drugs for women completely anovulatory or those who release the oocyte before the follicle is mature., Results: There was insufficient power to show a significant difference in the 19.5% live-delivered pregnancy rate found in women with a mean length of infertility duration of 2.1 years who just used P in the luteal phase vs the 30.1% rate seen in women with clear-cut ovulatory defects treated with follicle-maturing drugs in the follicular phase and P in the luteal phase., Conclusions: Though a larger study would possibly show a lower pregnancy rate in those women with unexplained infertility empirically treated with P vs the women with ovulation defects, the empirical use of P allows easy treatment without the side-effects of follicle-maturing drugs, e.g., hostile cervical mucus, vasomotor symptoms or ovarian cysts. The study was not designed to determine if empirical use of follicle-maturing drugs with P support for unexplained infertility would be more effective than P supplementation alone.

Purpose: To determine if isolation of sperm by nuclear characteristics using high magnification offers any advantage over the normal morphologic methods when performing intracytoplasmic sperm injection (ICSI) in refractory cases in which the male partner had an abnormal DNA fragmentation index., Materials and Methods: Women aged < or = 39 with failure to have a successful conception after three consecutive embryo transfers whose male partner had a DNA fragmentation index > 30% were randomly assigned to isolation of sperm for ICSI by a new high magnification procedure to evaluate nuclear morphology and the usual method with normal magnification where nuclear characteristics were not seen. Women 40-43 were not randomized and were given the option after hearing pros and cons., Results: Overall the live delivered pregnancy rates were similar in the high vs normal magnification groups (33.3% vs 36.3%)., Conclusions: Isolation of sperm with normal nuclei with high magnification does not offer any advantage over conventional IVF for refractory cases where the male partner has a high DNA fragmentation index.

Purpose: To evaluate the possibility that dihydrotestosterone (DHT) may play a role in the etiology of some people's migraine headaches., Methods: Finasteride 5 mg daily was given to a young woman with chronic migraines., Results: The chronic migraine headaches almost completely disappeared shortly following therapy. However, symptoms returned shortly after stopping the finasteride due to dry eyes., Conclusions: DHT may be an etiologic factor in causing migraines since finasteride suppresses DHT secretion. Alternatively, the benefit could be related to some other property of finasteride possibly by increasing testosterone which may compete with estrogen at the blood vessel level.

Purpose: To determine the relative role of aneuploidy vs embryo apoptosis as the etiologic factor of poor pregnancy rates with advancing age., Materials and Methods: A retrospective review of chemical vs clinical vs live delivery pregnancy rates in women aged 40-42, 43-45, and > or = 45 years is reported. The data were further stratified according to oocyte reserve based on day 3 serum follicle-stimulating hormone (FSH) < or = 11 mIU/ml vs >12 mIU/ml., Results: For women aged 40-42 years there were no differences in live delivery pregnancy rates in women with normal vs decreased egg reserve (DOR). There were no differences in live delivery pregnancy rates in women aged 40-42 years vs 43-44 years with normal oocyte reserve; however despite no differences in clinical pregnancy rates in women aged 43-44 years with normal vs DOR, the live delivery pregnancy rates were markedly lower in the group with DOR. In contrast, there were very low chemical pregnancy rates in women aged > or = 45 years., Conclusions: As seen in younger women, there does not appear to be any increased risk of meiosis errors in women aged 40-42 years with DOR compared to women of the same age with normal reserve. Low pregnancy rates in women aged 43-44 years with DOR is related to meiosis errors. In contrast the very low chemical pregnancy rates found in women aged > or = 45 years despite embryo transfer (ET) suggest embryo apoptosis is mostly responsible for poor pregnancy rates in this very advanced reproductive age group.

Purpose: To determine the confounding effect, if any, of poor motility of sperm that are already compromised by an abnormal hypo-osmotic swelling (HOS) test on pregnancy outcome following in vitro fertilization-embryo transfer (IVF-ET) and intracytoplasmic sperm injection (ICSI)., Materials and Methods: Clinical and live-delivered pregnancy and implantation rates were retrospectively evaluated in first cycles of couples undergoing IVF-ET with ICSI where the HOS test was < 50% according to deciles of subnormal percentage motility (< 50%) and compared to those with normal motility > or = 50%., Results: The combination of very poor motility and low HOS test scores did diminish pregnancy rates following IVF with ICSI., Conclusions: The only part of fertilization of the oocyte that ICSI does not overcome is phase 2 of oocyte activation. Based on these data, the combination of very low percentage motility and low HOS test scores do not adversely affect pregnancy outcome following IVF with ICSI.

Purpose: To determine if intrauterine insemination (IUI) improves pregnancy rates in couples with a correctable ovulatory defect but a male partner with an apparent normal semen analysis and a normal postcoital test., Materials and Methods: A prospective evaluation of clinical live delivered pregnancy rates following the first cycle where follicular maturation was demonstrated naturally or with a follicle maturing drug. The couples were given the option of IUI., Results: The live delivered pregnancy rates per IUI cycle were similar with intercourse only vs addition of IUI (18.7% vs 21.4%)., Conclusions: There is no evidence to support the notion that IUI improves pregnancy rates in circumstances where the semen analysis and postcoital tests are normal.

Purpose: To determine if the use of gonadotropin releasing hormone (GnRH) agonists (a) or antagonists (ant) allow better pregnancy rates when used in controlled ovarian hyperstimulation protocols in women of advanced reproductive age. Furthermore the study aimed to determine if the status of ovarian oocyte reserve has a confounding effect., Materials and Methods: A 12-year retrospective review was performed on all in vitro fertilization-embryo transfer (IVF-ET) cycles in women aged 40-44. Pregnancy rates were determined according to whether a GnRH-a or GnRH-ant was used. The data were also stratified according to normal or low oocyte reserve., Results: There was no significant difference in pregnancy rates according to whether a GnRH-a or GnRH-ant was used in women with normal oocyte reserve. Though a large majority of the women used a GnRH-ant, there was a 9% live pregnancy rate vs 0% in the women using a GnRH-a., Conclusion: Since it is unlikely that a larger study will ever be conducted, it is probably wise to use a GnRH-ant for the controlled ovarian hyperstimulation regimen in women aged 40-44 with diminished oocyte reserve.

Purpose: To find a case that will support the concept that mild elevation of serum follicle stimulating hormone (FSH) levels in late follicular phase may interfere with the release of the oocyte from the follicle., Materials and Methods: Oocyte release was determined in a woman in a complete natural cycle vs cycles where a boost of very low dose FSH was given, human chorionic gonadotropin (hCG) 10,000 units or leuprolide acetate 1 mg every 12 hours x two doses was given in FSH stimulated cycles., Results: Oocyte release occurred in all natural cycles vs none of the mildly stimulated cycles., Conclusions: Mild changes in the FSH level in the late luteal phase may affect the production of certain FSH dependent factors needed to release the oocyte.

Purpose: To determine if defective oocytes or sperm may be a common etiologic factor in unexplained infertility., Materials and Methods: A retrospective comparison of fertilization rates and pregnancy rates from infertile donors with unexplained infertility trying to conceive with in vitro fertilization-embryo transfer (IVF-ET) and their respective recipients, who shared the other half of the oocytes with the recipient's male partner for financial compensation was performed. Pregnancy rates from donors and recipients were also compared to other donor recipient pairs sharing oocytes from infertile donors with tubal or male factor or financially-compensated donors providing oocytes to two recipients., Results: Pregnancy rates from infertile donors with unexplained infertility were comparable not only to their respective recipients but to other donor/recipient pairs that received oocytes from donors with tubal or male factor or financially-compensated donors. Fertilization rates were somewhat reduced in the infertile donors., Conclusions: Abnormal embryos resulting from an oocyte or sperm defect do not appear to be a common cause of unexplained infertility. The possibility does exist that sperm may be an etiologic factor in reduced fertilization potential, which not only could be obviated by conventional oocyte insemination, but could be further improved by intracytoplasmic sperm injection (ICSI).

Purpose: To present the first gonadotropinoma presenting as pseudo-menopause in a teenager., Methods: Human menopausal gonadotropins (hMG) were given to a 37-year-old woman whose hypergonadotropic amenorrhea with estrogen deficiency as a teenager was changed to hypogonadotropic amenorrhea by the growth and prolactin secretion of a macroprolactinoma., Results: The patient responded multiple times, and every time to stimulation with hMG and each time produced several dominant follicles. She delivered two babies including conception at age 40., Conclusions: The fact that this woman could respond consistently to hMG 20 years after the diagnosis of premature menopause, it is clear that initially the etiology of the extremely high LH and FSH levels in an estrogen-deficient 18-year-old was the presence of gonadotropinoma secreting inert LH and FSH. Since serum prolactin was measured the first time at age 37, it is not clear whether the endogenous biologically active gonadotropine were suppressed by replacement of the gonadotroph cells with tumor cells or suppression of endogenous gonadotropins by hyperprolactinoma.

Purpose: To further investigate the efficacy of treatment of interstitial cystitis that had been refractory to standard treatment with sympathomimetic amines., Methods: Dextroamphetamine sulfate sustained release capsules up to 30 mg per day were prescribed in women with refractory painful bladder syndrome/interstitial cystitis in six new cases. The patients were carefully evaluated for relief of symptoms., Results: All six women found marked relief in their painful bladder syndrome in a rather short length of time. The benefit persisted as long as the therapy was maintained. Temporary cessation resulted in prompt return of symptoms, but resumption of sympathomimetic amines again allowed good relief of bladder pain and related symptoms., Conclusions: Because of very few side-effects and no drug dependence in the dosage used, sympathomimetic amines should be considered for first-line therapy.

Purpose: To determine the relative effect of age vs ovarian oocyte reserve on miscarriage rates., Materials and Methods: Miscarriage rates (loss of pregnancy established by ultrasound) from pregnancies achieved through in vitro fertilization-embryo transfer (IVF-ET) were evaluated according to four age groups (< or = 35, 36-39, 40-42, and 43-44 years) and four day 3 serum follicle-stimulating hormone (FSH) groups (< or = 11, 12-14, 15-17, and > 17 mIU/ml). All cycles were supplemented with progesterone in the luteal phase., Results: With each advancing age group irrespective of the FSH levels, there was a progressive increase in miscarriage rates. In contrast, no difference in miscarriage rates were seen as FSH levels increased (and thus ovarian reserve decreased) in women up to 42 years of age. Only in the group aged 43-44 years was there an association with diminished oocyte reserve and miscarriage., Conclusions: Since low FSH stimulation protocols were purposely used for the group with diminished oocyte reserve, the data are consistent that the conclusion regarding poor oocyte quality in women with diminished oocyte reserve was mostly iatrogenic and related to the use of high-dosage FSH stimulation trying to create more oocytes for retrieval.

Recommendations for the use of heparin for preventing miscarriage are recently rapidly changing based on evidenced based prospective studies. At present either heparin or low molecular weight heparin (LMWH) is recommended for the antiphospholipid syndrome (APS). However criteria for diagnosing APS have become much stricter. The exact timing of the heparin is still being evaluated since it is not clear if the main therapeutic effect is in inhibition of thrombosis when the heparin could be started at the time in the first trimester when the platelets become thrombophilic or does its main role in improving implantation in which it would be started shortly before or shortly after ovulation. Possibly heparin is superior to LMWH in improving the implantation process though more studies are needed to corroborate or refute this suggestion. At present inherited thrombophilias are not considered a cause of first trimester miscarriage and thus measuring these factors are not recommended. There is no evidence that heparin has any benefit in preventing miscarriage from unexplained causes. Heparin is effective alone and there does not appear to be any extra benefit from adding aspirin (or even aspirin may negate some of its benefits)., (© 2012 John Wiley & Sons A/S.)

Purpose: To determine if the presence of a lower percentage of metaphase II eggs during oocyte retrieval leads to a lower fertilization rate of these metaphase II eggs since they may be more likely to be not quite fully mature, and to determine if transfer of embryos made from these eggs leads to lower pregnancy and implantation rates., Methods: Fertilization and pregnancy rates determined according to deciles of percent of metaphase II eggs beginning with <30%., Results: Though there was no difference in fertilization rates when comparing those with <60% metaphase II eggs vs a 60%, there were significantly higher clinical and live delivered pregnancy rates and implantation rates when there were a 60% of the eggs retrieved that were metaphase II., Conclusions: An inferior pregnancy outcome with a lower percentage of metaphase II eggs despite similar fertilization rates is consistent with the hypothesis that subtle full maturation defects may result in pregnancy failure despite embryo transfer.

Purpose: To determine if the sharing of oocytes by an infertile woman with an egg recipient for financial advantages has any negative impact on the success rate for the donor., Methods: A matched controlled study was performed comparing pregnancy outcome of women undergoing in vitro fertilization-embryo transfer (IVF-ET) but sharing half of their eggs with a recipient vs women undergoing IVF-ET but not sharing oocytes., Results: Even though more women sharing oocytes deferred fresh transfer and cryopreserved the embryos because of a greater likelihood of ovarian hyperstimulation syndrome, there was no difference in pregnancy rates between the two groups after their first embryo transfer whether it was with fresh or frozen-thawed embryos., Conclusions: Sharing of oocytes by a woman undergoing IVF-ET does not jeopardize her chance of a successful outcome following embryo transfer.

Purpose: To test the hypothesis that very advanced reproductive age leads to an increased risk of zona pellucida hardening by comparing fertilization rates and rates of failed fertilization with conventional oocyte insemination vs intracytoplasmic sperm injection (ICSI)., Methods: Women aged > or = 45 were given the option of ICSI vs conventional oocyte insemination in circumstances where there was no male factor present. They were advised of the theoretical benefit of ICSI overcoming zona hardening but also advised that ICSI might lower pregnancy rates and is more costly., Results: There were 364 cycles evaluated and 74% chose ICSI. The failed fertilization rates were similar--28.4% (66/232) for ICSI vs 26.5% (35/132) for conventional insemination. The fertilization rates were similar 56.0% with ICSI vs 50.9% with conventional oocyte insemination., Conclusion: Based on similar fertilization and failed fertilization rates in women aged > or = 45 undergoing IVF-ET, zona hardening does not appear to be a consequence of reproductive aging.

Purpose: To determine if any single abnormal semen parameter is associated with low hypoosmotic swelling (HOS) test scores., Methods: A retrospective review evaluating males with single sperm defects of sperm concentration, % progressive motility, morphology using strict criteria, and antisperm antibodies. The percentage of these males with HOS test scores < 50% was then determined., Results: By far the abnormal semen parameter most associated with a subnormal HOS test was poor motility., Conclusions: Though we believe that the simple inexpensive HOS test should be performed routinely when performing semen analysis, it is especially important to evaluate in males with poor motility since simple intrauterine insemination will not allow pregnancies.

Purpose: To determine if the use of Embryo glue improves implantation and pregnancy rates following embryo transfer (ET) in women who failed to conceive in three previous attempts., Methods: A matched controlled study was performed in women undergoing IVF-ET, donor oocyte recipients and women using their own oocytes having fresh or frozen ETs. A woman having Embryo glue was matched with the very next woman not using glue within six months of age and having the same number of previous failed ETs., Results: Embryo glue did not seem to improve pregnancy or implantation rates. In fact, in evaluating fresh embryo transfers there was a significantly higher live delivered pregnancy rate in the women not using Embryo glue (39.3%) vs those using the glue (14.3%)., Conclusions: Embryo glue does not improve pregnancy outcome in women failing in previous IVF cycles.

Purpose: To corroborate or refute the claim that intracytoplasmic sperm injection (ICSI) can overcome the problem found after conventional insemination of oocytes with sperm with low hypoosmotic swelling (HOS) tests of forming embryos with low implantation potential., Methods: Matched couple pairs sharing one pool of oocytes were identified where one of the male partners had a low HOS test score and the other one with a normal one. Intracytoplasmic sperm injection was always used in those with low HOS test scores (i.e., < 50%) vs ICSI only used for semen abnormalities in the normal HOS group., Results: There were no differences found in either fertilization rates or clinical or live delivered pregnancy rates or implantation rates between these groups., Conclusions: Intracytoplasmic sperm injection can completely negate the adverse effect that fertilization with sperm with subnormal HOS scores has on embryo implantation potential.

Purpose: To determine if in a population of women with diminished oocyte reserve as evidenced by day 3 serum follicle stimulating hormone (FSH) levels > 12 mIU/ml women with lower dehydroepiandrosterone sulfate (DHEA-s) levels produce fewer oocytes or have lower pregnancy rates following in vitro fertilization-embryo transfer (IVF-ET) compared to women with higher levels., Methods: The women were divided into poor responders (producing < or = 4 oocytes) following oocyte retrieval or good responders (> or = 5 oocytes). Mean DHEA-s levels were compared in poor vs good responders and in the subgroups of those who conceived vs those who did not conceive., Results: The data clearly showed no association with low DHEA-s levels and response to controlled ovarian hyperstimulation or pregnancy rates., Conclusions: In women with elevated serum FSH low DHEA levels do not suggest that supplementation with DHEA would improve response or pregnancy rate. These data do not preclude the possibility that there is a small subset of women with normal oocyte reserve who also fail to respond to controlled ovarian hyperstimulation for some unknown reason and the problem could be remediable by DHEA supplementation.

Purpose: To determine if males with low hypoosmotic swelling (HOS) test scores may have normal vitality tests., Methods: Retrospective nine-year review of initial semen analyses evaluating vitality and HOS tests., Results: Only 12.5% (45/361) of males with low HOS test scores have low vitality., Conclusions: WHO seems to treat vitality and HOS as equal tests. We disagree and find that structural defects of the sperm membrane are much less common than functional impairment of the sperm membrane. Since a male with an HOS test score < 50% will rarely achieve a pregnancy with intercourse, intrauterine insemination, or IVF with conventional insemination it is important to check for the HOS test not viability because the HOS test can be easily corrected with ICSI.

Purpose: To determine if there is an increased frequency of abnormal hypoosmotic swelling (HOS) tests when testing semen in males of advanced reproductive age., Methods: Ten-year retrospective review according to six age groups (< or = 29.9, 30-34.9, 35-39.9, 40-44.9, 45.0-49.9, and > or = 50)., Results: Compared to males < 35 years old, the frequency of HOS scores < 50% doubles in males 45-49.9 and quadruples in males > or = 50., Conclusions: Males with low HOS scores despite having no problem with fertilization of the oocytes rarely achieve a pregnancy because of embryo implantation defects unless intracytoplasmic sperm injection (ICSI) is performed. Thus at least one abnormality seen in sperm of males of advanced reproductive age is correctable by performing in vitro fertilization with ICSI.

Purpose: To determine the relative pregnancy rates following frozen embryo transfer according to the reason for deferring fresh embryo transfer and freezing all embryos., Method: A retrospective review over a 10-year time period of all in vitro fertilization (IVF) cycles that deferred fresh transfer and cryopreserved all embryos related to risk of ovarian hyperstimulation syndrome or if there was inadequate endometrial thickness. Pregnancy rates according to the reason for freezing were then compared., Results: The clinical and live delivered pregnancy rates following frozen embryo transfer in women < or = age 39 was 42.8% and 31.9%, respectively for women deferring for risk of ovarian hyperstimulation syndrome vs 28.7% and 21.8% for those freezing for inadequate endometrial thickness (p = 0.01 and p = 0.07, respectively)., Conclusion: Embryo cryopreservation may not be a complete panacea for problems of inadequate endometrial thickness.

Purpose: To compare pregnancy rates following fresh vs frozen embryo transfer into gestational carriers., Methods: Choice of deferring fresh embryo transfer and cryopreserving the embryos vs fresh transfers was not randomized but based on circumstances. The cryopreservation protocol used a simplified slow cool technique avoiding the planar programmable freezer and using a one-step removal of the cryoprotectant., Results: The live delivered pregnancy rate was 51.0% (49/96) for fresh embryo transfer vs 34.3% for transfers of frozen thawed embryos in gestational carriers not having a fresh embryo first., Conclusions: Using the simplified slow cool cryopreservation protocol with a one-step removal of cryoprotectants pregnancy rates are comparable to what is found in women of similar ages undergoing controlled ovarian hyperstimulation followed by IVF-ET. However, when transferring to a gestational carrier the live delivered pregnancy rates are 50% higher with fresh embryo transfer.

The hypothesis set forth is that the basis for a great many chronic debilitating conditions that involve almost all of the physiologic systems of the body may have as the underlying cause and a common link between them, i.e., hypofunction of the sympathetic nervous system. The hypothesis considers that one of the main functions of the sympathetic nervous system is to diminish cellular permeability. Thus sympathetic hypofunction may lead to absorption of chemicals and toxins into tissues that were supposed to be impervious leading to inflammation and other adverse consequences which then cause a wide variety of symptoms. These symptoms may include pain or diminished muscular function leading to various pain syndromes or conditions related to diminished muscular function. Furthermore since the sympathetic nervous system is involved in body homeostasis and temperature regulation, sympathetic nervous system hypofunction could lead to disorders in these areas, e.g., vasomotor symptoms and edema. This defect in sympathetic nervous system has a genetic predisposition but relatives, e.g., siblings or children may manifest in a different manner which suggests some influence of external factors causing one physiological system to be more prone than another to malfunction under conditions of sympathetic hypofunction. Evidence to support this hypothesis has been provided by a large number of published anecdotes demonstrating the quick and long lasting considerable improvement in symptoms following treatment with the sympathomimetic amine dextroamphetamine sulfate (with return of symptoms if treatment is temporarily ceased thus diminishing the likelihood of spontaneous remission) despite failure to respond to a plethora of other pharmacologic agents and other therapies over many years. The physiological systems with various chronic disorders that have responded included the gastrointestinal system, skin, genitourinary system, the nervous system, the musculoskeletal system, the temperature regulation system, peripheral vasculature system, and the endocrine system. Despite the multitude of very convincing anecdotal reports showing its efficacy (and to date no reports refuting this hypothesis), there has only been one controlled study which showed the benefit of dextroamphetamine sulfate on edema and weight gain in diet-refractory patients. The flaw to date for general acceptance of this hypothesis is that most positive studies are coming from one clinical center. Furthermore, more controlled studies are needed. There has been a recent interest amongst physiologists and recent studies have been published confirming a deficiency of sympathetic nerve fibers in some of these disorders which hopefully will encourage more research into other physiologic systems leading to corroboration of this hypothesis., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To determine if there is a certain age when the uterus is somewhat less receptive to successful pregnancy despite the transfer of embryos from donated oocytes., Study Design: We conducted a retrospective evaluation of donor oocyte recipient cycles according to specific ages. The recipients used an oral/vaginal graduated estradiol regimen followed by intramuscular and vaginal progesterone. Only recipients sharing oocytes with either the donor or another recipient were included., Results: Evaluating the pregnancy rate by each year of age from 40-49 following transfer of embryos derived from donor oocytes showed no trend for lower pregnancy rates up to age 49. In fact the highest live delivery pregnancy rates (though not significant) were found at ages 47 (64.3%) and 49 (63.6%). The live delivered pregnancy rates for recipients < or = 39 was 52.5% vs. 55.6% for women > or = age 46. The live delivered pregnancy rate was 34.6% for women > or = age 50. The pregnancy and implantation rates were similar whether the source was infertile women sharing half their oocytes or compensated donors., Conclusion: The uterus does not seem to have a diminished capacity for implantation up to the age of 49, but it may be slightly less receptive after age 50.

Purpose: To investigate if the late follicular phase echo pattern is associated with pregnancy outcome in donors vs recipients., Methods: Infertile donors sharing eggs with recipients were retrospectively evaluated. The endometrial echo pattern was evaluated on the day of human chorionic gonadotropin injection in donors and on the day before progesterone was given to recipients., Results: Almost twice as many donors conceived when the triple-line pattern was found compared to isoechogenic (IE) (51.5% or 52/101 vs 27.3% or 6/22) but there were inadequate numbers in the IE group to show a significant difference. There was not even a trend for a difference in recipients (55.2%, 37/67 vs 53.8%, 14/26)., Conclusions: The trend in this study for higher pregnancy rates in COH cycles with triple-line isoechogenic pattern in the late follicular phase will prompt a study of a larger group of patients undergoing IVF-ET in the modern era. If confirmed one treatment option would be to freeze and defer transfer to an estrogen/progesterone cycle.

Purpose: To show that even a twin pregnancy is possible following embryo transfer despite a very thin endometrium., Methods: Two embryos derived from donor oocytes were transferred into a 47-year-old woman despite a peak endometrial thickness of 4 mm., Results: She delivered viable dichorionic twins at 30 weeks in a pregnancy complicated by HELLP syndrome., Conclusions: Anecdotal case reports are important to establish precedents to allow patients to make decisions when presented with treatment options. A third precedent of a successful pregnancy with endometrial thickness of only 4 mm is presented. Without precedent she would have chosen embryo freezing and subsequent transfer into a very expensive gestational carrier if thin endometrium persisted.

Purpose: To demonstrate the physiologic changes in adiponectin levels during the first vs second half of pregnancy., Methods: Sixty-six females with uncomplicated pregnancies and normal pre-gestational BMI had serum adiponectin levels obtained at various gestational ages. Thirty-one samples were obtained during the first half of their pregnancy vs 35 in the second half. Thirty-three healthy non-pregnant females with comparable ages and BMI were controls., Results: Mean adiponectin levels were 9.55 microg/dl (95% CI 8.2-10.77) vs 9.48 microg/dl (95% CI 8.44-10.66) in the control group in the first half of pregnancy (p = NS). We noted a 21% reduction in mean adiponectin levels (7.51 microg/dl) during the second half of pregnancy (p = 0.03) compared to the first half of pregnancy., Conclusion: Early pregnancy does not affect adiponectin levels. However, there is a significant reduction in adiponectin levels during the second half of pregnancy.

Purpose: To determine any differences in pregnancy rates if frozen-thawed embryos are transferred to a gestational carrier if the source of oocytes came from infertile women trying to conceive vs a paid egg donor., Methods: Gestational carriers were used because of uterine problems or health issues. If there was adequate ovarian egg reserve, controlled ovarian hyperstimulation followed by oocyte retrieval was performed on the infertile woman. Otherwise an egg donor was used., Results: No differences in clinical and ongoing delivered pregnancy rates were found but a trend for higher implantation rates in the paid donors was evident., Conclusions: The trend for higher implantation rates when a paid donor was the source of oocytes may be age-related (35.9 for infertile women vs 29.5 for paid donors). The pregnancy results with frozen embryos were sufficient to allow women to proceed with oocyte retrieval if time is of the essence even if a gestational carrier has not as yet been found.

Purpose: To determine if there is any association of serum progesterone (P) level at the time of human chorionic gonadotropin (hCG) injection and pregnancy outcome in in vitro fertilization (IVF) cycles using gonadotropin releasing hormone (GnRH) antagonists for controlled ovarian hyperstimulation (COH)., Methods: A retrospective analysis of IVF cycles over a six and a half-year period where either cetrorelix or ganirelix was used with COH and at least two embryos were transferred. Female partners were < or = 35. Four different serum progesterone (P) ranges were evaluated from < or = .5 ng/ml to 1.9 ng/ml; P was measured by ELISA., Results: There was no significant difference in pregnancy rates or even a trend in that direction with increasing serum P levels with either GnRH antagonist., Conclusions: At least with COH cycles using GnRH antagonists and where serum P is measured by ELISA there does not seem to be any disadvantage of higher serum P levels up to 2 ng/ml at the time of hCG in IVF-ET cycles.

Purpose: To determine if a successful pregnancy is possible following in vitro fertilization embryo transfer (IVF-ET) in a woman of advanced reproductive age with diminished egg reserve., Methods: In vitro fertilization-embryo transfer with intracytoplasmic sperm injection (ICSI) was performed for a 45-year-old woman with a peak serum follicle stimulating hormone (FSH) level of 29 mIU/ml and a history of failing to conceive in five previous IVF-ET cycles at a younger age. A minimal FSH stimulation protocol was used., Results: A fresh transfer of a 7-cell embryo was performed on day 3. A successful pregnancy and delivery ensued., Conclusion: This case report establishes a precedent that a successful pregnancy following IVF-ET is possible in a woman whose serum FSH is > 15 mIU/ml, and is age 45. Of course, there is no implication that accomplishing this again in another woman with similar circumstances would be likely.