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P-168 Abnormal ovulation in women with endometriosis
endometriosis by laparoscopy were identified (273 treatment cycles. Patients with abnormal semen parameters were excluded. Through examination of medical records the reproductive history, ASRM endometriosis stage, and total dose of luprolide was recorded. Cumulative dose of luprolide was divided into four groups: Treatment A (>90 days of suppression), Treatment B (10-90 days suppression), Treatment C (< 10 days suppression) and Treatment O (no luprolide suppression). All patients received ovarian stimulation with human menopausal gonadotropins and received hCG, 10,000 units after discontinuation of menotropins. Patients undergoing IVF were scheduled for oocyte retrieval 36 hours after hCG. Dividing embryos were returned at the 2-8 cell stage. Patients undergoing nonIVF cycles were scheduled for intrauterine insemination or encouraged to have intercourse within 36 hours ofhCG. Luteal phase support was given with hCG (1500-5000 IU) or progesterone (50-100 mg IM or 400 mg vaginally) Groups were compared using Student's t test, Fisher's Exact test or two tailed ANOVA with Tukey posttests, with p<0.05 termed significant, as appropriate. Results: Among patients undergoing IVF no significant difference was seen between treatment groups with regard to age, cycle length, or number of HMG vials used. There were no differences between groups in number of mature follicles, number of oocytes fertilized, and number of erabryos returned. As designed, a significant difference was seen between groups with regard to days on luprolide, as well as an increase in the number of days of stimulation required, and peak serum estradiol levels as the number of days of suppression increased. Among non IVF cycles, no significant difference was seen between groups with regard to cycle length. Peak serum estradiol, or number of mature follicles. As luprolide suppression increased, there was a significant increase in the number of days of stimulation required and the number of vials of HMG employed. Among patients undergoing IVF, increasing days ofluprolide suppression led to increased cycle fecundity (Treatment: A 38% (9/21), B 35% (12/34), C 19% (2/16), O 0% (0/ 4)) A similar increase was seen in patients undergoing non-IVF cycles (Treatment A: 21% (9/28), B 7% (1/15), C 9% (3/32), O 6% (7/123)). Groups were combined (Treatment A/B vs Treatment C/O) to compare by endometriosis stage. No difference in cycle fecundity was seen between stages of endometriosis in either the IVF or Non IVF groups. An increasing trend of pregnancies was seen among all stages, though, as the number of days of suppression increased. Conclusion: Addition of luprolide suppression to stimulation protocols appears to improve pregnancy rates. The effect may be dose related. Future prospective studies with specific doses and lengths of ovarian suppression before stimulation may be beneficial in elucidating the final recommendations. P-167 Is U l t r a s o u n d - T i m e d H u m a n C h o r i o n i c Gonadotropin A d m i n i s t r a t i o n U s e f u l in S c h e d u l i n g Intrauterine I n s e m i n a t i o n W h e n a L u t e i n i z i n g H o r m o n e S u r g e is N o t D e t e c t e d ? A. Auyeung, T. C. Philp0tt. R. R.
Odem. Div of Reproductive Endocrinology, Dept of OB/ GYN, Washington University School of Medicine, St. Louis, MO. Objectives: To compare the pregnancy rates ofintrauterine insemination (IUI) in clomiphene citrate (CC)-stimulated cycles following a detectable endogenous luteinizing hormone (LH) surge to those IUI's performed in the absence of a detectable LH surge after transvaginal sonography (TVS)-timed human chorionic gonadotropin (hCG) administration. Design: A retrospective review of all CC-IUI cycles from January 1993 to February 1997 in the Division of Reproductive Endocrinology at Washington University School of Medicine. Materials and Methods: Three hundred sixty-eight patients treated with 1,016 CC-IUI cycles were included. Patients were excluded if they had tubal disease, stage III or IV endometriosis, significant mullerian fusion defects, absence of a tube or ovary, or never detected an LH surge while on CC. Also excluded were cycles with multiple IUI's or incomplete data on date of menstrual period or IUI, CC dosage, motile sperm count, or cycle outcome. LH surges were detected using commercially available kits. Cycles without detectable LH surge up to 9 days after the last dose of CC were assessed with TVS and hCG 10,000 units injected intramuscularly if a dominant follicle were present, IUI was performed approximately 24 hours after LH surge detection and 36 hours after hCG administration. The major outcome measure was a positive pregnancy test. The data were analyzed using a one-sided Fisher's exact test with Yate's correction. Results: Nine hundred eighty-five cycles had detectable LH surges which led to 86 pregnancies. Thirty-two IUI's with no detectable LH surge were scheduled based on TVS-timed hCG administration, resulting in no pregnancies. There was a trend towards statistical significance between these two groups (p = 0.056). Analysis ofinsemination cycles with -> 10 million motile sperm showed a statistically significant 81 pregnancies out of 731 LH positive cycles and no pregnancies out of 30 LH negative (hCG timed) cycles (p ~ 0.05). Conclusions: The absence of a detectable LH surge likely represents suboptimal follicular development and is associated with a low pregnancy rate. The additional expense of TVS, hCG and IUI in a LH negative cycle and the low probability of success make it reasonable to postpone IUI until an LH positive cycle on CC is achieved, or other therapeutic alternatives are identified. P-168 A b n o r m a l O v u l a t i o n in W o m e n With E n d o m e t r i o s i s . J. H. McBean, J. Blackman, J. R. Brumsted. Division of Reproductive Endocrinology, University of Vermont College of Medicine, Burlington, VT. Objective: The pathophysiology ofendometriosis-related infertility is uncertain. We hypothesis that derangements in periovulatory events may result in an environment that is not conducive to normal fertilization and implantation. This study was designed to identify and define endocrinoAbstracts
$173
logic abnormalities in the late follicular (FP) and early luteal phases (LP) of women with endometriosis. Design: Women with moderate and severe endometriosis (n = 6) and fertile controls (n = 4) were studied in a single menstrual cycle for the presence of urinary luteinizing hormone (uLH), ultrasound (U/S) evidence of ovulation and serum levels of LH(sLH), 17-fl estradiol(E) and progesterone(P). Materials and Methods: Monitoring began 4 days prior to expected ovulation and was continued for 9 days after the LH surge. The daily hormonal data were normalized around the day of first detected uLH surge (LHO). The U/ S criteria for ovulation were the presence of at least 2 of the following: decrease in follicular diameter, free fluid in the cul-de-sac and/or the appearance of intrafollicular echoes. P secretion was compared using Integrated P(IP) defined as the sum of daily P levels on LH+I-7, and the day of peak P. Periovulatory events were compared using peak sLH, integrated LH(ILH) defined as the sum of sLH over 3 days (LH-1,0, + 1), peak E and E at uLH surge. Values were compared using the Student's t-test and Mann-Whitney test where appropriate, (*p<.05 was considered significant). Results: There were no differences between the 2 groups with regard to age, cycle length or duration of LP or FP. However, women with endometriosis exhibited more variation in both the FP length (Range 10-20 vs 10-12 days) and the day of LH surge (Range = 9-20 vs 10-12). Abnormalities in ovulation are suggested by significant differences in peak E, E at uLH surge, ILH, peak sLH and U/ S findings. The mean follicular diameter at LH surge was smaller in women with endometriosis (16.5 _+ 5 vs 20 + .5 mm) and only ~ women with endometriosis had evidence of follicular rupture compared to 4 of the controls. P production is delayed in women with endometriosis with the day of peak P occurring 2 to 4 days later than in controls.
Endo Control
Peak P (ng/ml)
IP (ng/ml)
Day of Peak P
11.8 +_ 3 9.9 _ .8
39.5 +_ 3 40.8 _+ 2
LH + 7-~+9" LH + 5
Endo Control
Endo Control
Peak E (pg/ml)
E at LH Surge
262 _+ 97* 185 _+ 47
219 _ 97* 151 _+ 35
ILH (IU/ml)
Peak LH (IU/ml)
72 +_ 30* 44 _+ 17
41 _ 15" 27 _+ 9
Conclusions: We conclude that women with moderate to severe endometriosis display a variety of abnormalities associated with ovulation and luteinization. This may be a factor in the pathogenesis of endometriosis-related infertility by disrupting the normal hormonal transition from S174
Abstracts
the FP to the LP with resulting abnormalities in oocyte release and P production.
P-169 Doppler Blood Flow Studies Are of Limited Value in Assessing Ovarian Viability Following Torsion. E. C. Ditkoff, L. Jackson, I. Timor, S. R. Lindheim. Dept of Ob/Gyn, College of Physicians and Surgeons, Columbia University, Columbia Presbyterian Medical Center, New York, NY. Objectives: Adnexa sparing is appropriate if viability is noted following torsion intraoperatively. Our purpose was to determine whether preoperative assessment of doppler blood flow helps predict adnexal viability compared to clinical impressions intraoperatively. Design: A retrospective study in a major university medical center. Materials and Methods: A chart review searching for reproductive aged women having an oophorectomy for adnexal torsion following preoperative doppler blood flow exam was carried out. Eleven such women were identified. All underwent doppler blood flow with either the ATL 3000 or the Toshiba 270A ultrasound device preoperatively. Following the ultrasound exam, these 11 patients underwent oophorectomy and the surgeons recorded their impression regarding the status of adnexal viability. Excised adnexa were evaluated by a pathologist without knowledge of the blood flow studies prior to surgery. Sensitivity, specificity, predictive value and efficiency of doppler blood flow and adnexal appearance were calculated to test the accuracy of these in assessing viability of the ovaries following torsion.
Sensitivity Specificity Predictive value (+) test Predictive value ( - ) test Efficiency
Doppler Blood Flow
Adnexal Appearance
78% 50% 78% 82% 64%
63% 67% 83% 63% 73%
Conclusions: In summary, our data illustrate assessing ovaries for viability following torsion is difficult. Doppler blood flow studies do not help in predicting adnexal viability. Neither doppler ultrasound evaluation or clinical impression are definitive in evaluating ovarian viability following torsion.
P-170 Triggering Ovulation With GnRH Agonist, to Avoid Ovarian Hyperstimulation, Frequently Results in Profound Corpus Luteum Insufficiency. R.A. Bennett, 1A. Vidali, J. Walker, D. Navot. Department of OB/ GYN Reproductive Endocrinology, New York Medical College, Valhalla, NY., The Center for Human Reproduction, Westwood, New Jersey and 1College of Physicians and Surgeons of Columbia University, New York.
Odem. Div of Reproductive Endocrinology, Dept of OB/ GYN, Washington University School of Medicine, St. Louis, MO. Objectives: To compare the pregnancy rates ofintrauterine insemination (IUI) in clomiphene citrate (CC)-stimulated cycles following a detectable endogenous luteinizing hormone (LH) surge to those IUI's performed in the absence of a detectable LH surge after transvaginal sonography (TVS)-timed human chorionic gonadotropin (hCG) administration. Design: A retrospective review of all CC-IUI cycles from January 1993 to February 1997 in the Division of Reproductive Endocrinology at Washington University School of Medicine. Materials and Methods: Three hundred sixty-eight patients treated with 1,016 CC-IUI cycles were included. Patients were excluded if they had tubal disease, stage III or IV endometriosis, significant mullerian fusion defects, absence of a tube or ovary, or never detected an LH surge while on CC. Also excluded were cycles with multiple IUI's or incomplete data on date of menstrual period or IUI, CC dosage, motile sperm count, or cycle outcome. LH surges were detected using commercially available kits. Cycles without detectable LH surge up to 9 days after the last dose of CC were assessed with TVS and hCG 10,000 units injected intramuscularly if a dominant follicle were present, IUI was performed approximately 24 hours after LH surge detection and 36 hours after hCG administration. The major outcome measure was a positive pregnancy test. The data were analyzed using a one-sided Fisher's exact test with Yate's correction. Results: Nine hundred eighty-five cycles had detectable LH surges which led to 86 pregnancies. Thirty-two IUI's with no detectable LH surge were scheduled based on TVS-timed hCG administration, resulting in no pregnancies. There was a trend towards statistical significance between these two groups (p = 0.056). Analysis ofinsemination cycles with -> 10 million motile sperm showed a statistically significant 81 pregnancies out of 731 LH positive cycles and no pregnancies out of 30 LH negative (hCG timed) cycles (p ~ 0.05). Conclusions: The absence of a detectable LH surge likely represents suboptimal follicular development and is associated with a low pregnancy rate. The additional expense of TVS, hCG and IUI in a LH negative cycle and the low probability of success make it reasonable to postpone IUI until an LH positive cycle on CC is achieved, or other therapeutic alternatives are identified. P-168 A b n o r m a l O v u l a t i o n in W o m e n With E n d o m e t r i o s i s . J. H. McBean, J. Blackman, J. R. Brumsted. Division of Reproductive Endocrinology, University of Vermont College of Medicine, Burlington, VT. Objective: The pathophysiology ofendometriosis-related infertility is uncertain. We hypothesis that derangements in periovulatory events may result in an environment that is not conducive to normal fertilization and implantation. This study was designed to identify and define endocrinoAbstracts
$173
logic abnormalities in the late follicular (FP) and early luteal phases (LP) of women with endometriosis. Design: Women with moderate and severe endometriosis (n = 6) and fertile controls (n = 4) were studied in a single menstrual cycle for the presence of urinary luteinizing hormone (uLH), ultrasound (U/S) evidence of ovulation and serum levels of LH(sLH), 17-fl estradiol(E) and progesterone(P). Materials and Methods: Monitoring began 4 days prior to expected ovulation and was continued for 9 days after the LH surge. The daily hormonal data were normalized around the day of first detected uLH surge (LHO). The U/ S criteria for ovulation were the presence of at least 2 of the following: decrease in follicular diameter, free fluid in the cul-de-sac and/or the appearance of intrafollicular echoes. P secretion was compared using Integrated P(IP) defined as the sum of daily P levels on LH+I-7, and the day of peak P. Periovulatory events were compared using peak sLH, integrated LH(ILH) defined as the sum of sLH over 3 days (LH-1,0, + 1), peak E and E at uLH surge. Values were compared using the Student's t-test and Mann-Whitney test where appropriate, (*p<.05 was considered significant). Results: There were no differences between the 2 groups with regard to age, cycle length or duration of LP or FP. However, women with endometriosis exhibited more variation in both the FP length (Range 10-20 vs 10-12 days) and the day of LH surge (Range = 9-20 vs 10-12). Abnormalities in ovulation are suggested by significant differences in peak E, E at uLH surge, ILH, peak sLH and U/ S findings. The mean follicular diameter at LH surge was smaller in women with endometriosis (16.5 _+ 5 vs 20 + .5 mm) and only ~ women with endometriosis had evidence of follicular rupture compared to 4 of the controls. P production is delayed in women with endometriosis with the day of peak P occurring 2 to 4 days later than in controls.
Endo Control
Peak P (ng/ml)
IP (ng/ml)
Day of Peak P
11.8 +_ 3 9.9 _ .8
39.5 +_ 3 40.8 _+ 2
LH + 7-~+9" LH + 5
Endo Control
Endo Control
Peak E (pg/ml)
E at LH Surge
262 _+ 97* 185 _+ 47
219 _ 97* 151 _+ 35
ILH (IU/ml)
Peak LH (IU/ml)
72 +_ 30* 44 _+ 17
41 _ 15" 27 _+ 9
Conclusions: We conclude that women with moderate to severe endometriosis display a variety of abnormalities associated with ovulation and luteinization. This may be a factor in the pathogenesis of endometriosis-related infertility by disrupting the normal hormonal transition from S174
Abstracts
the FP to the LP with resulting abnormalities in oocyte release and P production.
P-169 Doppler Blood Flow Studies Are of Limited Value in Assessing Ovarian Viability Following Torsion. E. C. Ditkoff, L. Jackson, I. Timor, S. R. Lindheim. Dept of Ob/Gyn, College of Physicians and Surgeons, Columbia University, Columbia Presbyterian Medical Center, New York, NY. Objectives: Adnexa sparing is appropriate if viability is noted following torsion intraoperatively. Our purpose was to determine whether preoperative assessment of doppler blood flow helps predict adnexal viability compared to clinical impressions intraoperatively. Design: A retrospective study in a major university medical center. Materials and Methods: A chart review searching for reproductive aged women having an oophorectomy for adnexal torsion following preoperative doppler blood flow exam was carried out. Eleven such women were identified. All underwent doppler blood flow with either the ATL 3000 or the Toshiba 270A ultrasound device preoperatively. Following the ultrasound exam, these 11 patients underwent oophorectomy and the surgeons recorded their impression regarding the status of adnexal viability. Excised adnexa were evaluated by a pathologist without knowledge of the blood flow studies prior to surgery. Sensitivity, specificity, predictive value and efficiency of doppler blood flow and adnexal appearance were calculated to test the accuracy of these in assessing viability of the ovaries following torsion.
Sensitivity Specificity Predictive value (+) test Predictive value ( - ) test Efficiency
Doppler Blood Flow
Adnexal Appearance
78% 50% 78% 82% 64%
63% 67% 83% 63% 73%
Conclusions: In summary, our data illustrate assessing ovaries for viability following torsion is difficult. Doppler blood flow studies do not help in predicting adnexal viability. Neither doppler ultrasound evaluation or clinical impression are definitive in evaluating ovarian viability following torsion.
P-170 Triggering Ovulation With GnRH Agonist, to Avoid Ovarian Hyperstimulation, Frequently Results in Profound Corpus Luteum Insufficiency. R.A. Bennett, 1A. Vidali, J. Walker, D. Navot. Department of OB/ GYN Reproductive Endocrinology, New York Medical College, Valhalla, NY., The Center for Human Reproduction, Westwood, New Jersey and 1College of Physicians and Surgeons of Columbia University, New York.