The effects of ibuprofen on ovulation

P-240 Physico-chemical differences between recombinant LH (Luveris威) vs hMG. Eleonora Giudice, Carlo Emanuele Giartosio. Inst di Ricerca Cesare Serono, Ardea, Italy. Objective: The currently available pharmaceutical preparations of luteinising hormone (LH) derive either from biotechnological products (recombinant human LH, r-hLH) for which the human gene has been inserted in the genome of eukaryotic cells, or from human urine collection and treatment (human menopausal gonadotropin, hMG). The products of urinary derivation are commonly added with human chorionic gonadotropin (hCG) to compensate for the lack of a sufficient level of LH. Although hCG and hLH can bind with the same receptors, their pharmacokinetic and pharmacodynamic properties are quite distinct. Furthermore, the urinary contaminants in hMG, absent in recombinant products, are potentially bioactive when injected in patients. Design: The physico-chemical differences between these two products have been studied by various physico-chemical techniques, such as total protein assay by colorimetric methods, gel electrophoresis (SDS-PAGE), both with staining and immunoblotting detection methods, reverse phase high performance liquid chromatography (RP-HPLC), and immunoassay. Materials/Methods: The protein assay has been carried out by the Bradford method using bovine serum albumin (BSA) as standard. The SDSPAGE analysis has been developed either by silver staining or by Western blotting, using PcAbs specific for LH and chains. The RP-HPLC analysis has been carried out on a C4 column by a linear gradient of acetonitrile in an aqueous 0.1M triethylammonium phosphate buffer pH 6, with detection at 214 nm. The immunoassays for LH and hCG have employed the DELFIA威 kits specific for LH and hCG. Results: The data obtained have shown that: 1) The electropherogram of r-hLH (Luveris威) presents only the bands related to the LH protein, as confirmed by comparing the gel with that of the hMG, which portrays a very broad and heterogeneous body of protein components, in which LH is only a minor constituent. 2) The chromatographic profile obtained for r-hLH (Luveris威) shows the peak pattern typical of luteinising hormone protein and devoid of hCG, as clearly confirmed by structural studies, whereas the profile generated by the hMG shows a very unresolved cluster of protein compounds. 3) The immunoassay data have shown that while r-hLH (Luveris威) contains only LH protein, the hMG samples are added with significant amounts of hCG. 4) The specific activity of r-hLH (Luveris威) is of about 20,000 IU/mg, while that of hMG ranges from less than 100 to about 3,000 IU/mg. Conclusions: The above data set confirms the higher purity and homogeneity of the recombinant product in regard to the urinary preparations. The r-hLH (Luveris威) has confirmed a specific activity in line with the highly purified preparations described in literature. The hMG on the other hand presents a specific activity as low as to be justified only by a high level of nonrelated impurities, so that when administering LH by this preparation the patient is exposed to a very significant amount of non-LH related urinary proteins. Supported by: Istituto di Ricerca Cesare Serono.

P-241 What is the appropriate evaluation for recurrent spontaneous abortion? A survey of the national collaborative maternal-fetal and reproductive medicine networks. Patrick S. Ramsey, Michael P. Steinkampf. Univ of Alabama at Birmingham, Birmingham, AL. Objective: Among women with recurrent spontaneous abortion (RSA), a specific cause is identified in fewer than half of all patients evaluated. The purpose of this study was to characterize testing patterns and potential areas of research for RSA among experienced clinical investigators in the field of reproductive medicine in order to guide future research in this common yet challenging problem. Design: Prospective survey study. Materials/Methods: We surveyed the principal investigators (PIs) of two centers funded by the National Institute for Child Health and Development which perform clinical trials in reproductive medicine: The National Collaborative Reproductive Medicine Network (RMN; 9 centers, 11 investigators), whose PIs are reproductive endocrinologists; and the Maternal-Fetal Medicine Units Network (MFMU; 13 centers, 26 investigators), whose PIs

FERTILITY & STERILITY威

are perinatologists. Survey questions included standard general workup for RSA as well as potential areas for future research (infection or inflammation, thrombophilias, impaired glucose intolerance/insulin resistance, and diminished ovarian reserve). Responses were coded as “used clinically,” “high/moderate interest for future research,” or “low/no interest for future research.” Statistical analyses were performed using the Fisher exact test Results: A total of 19 investigators responded to the survey (RMN: 10, MFMU: 9). More than 90% of all investigators routinely obtained maternal/ paternal karyotype analysis and uterine anatomy assessment for the evaluation of RSA, but other tests were less uniformly obtained (mid-luteal phase progesterone levels {32%}, endometrial biopsy {33%}, thyroid function testing {58%}, prolactin levels {50%}). RMN members were more likely to obtain levels for thyroid stimulating hormone (RMN: 90%, MFMU: 22%; p ⫽ 0.006) and mid-luteal progesterone (RMN: 60%, MFMU: 0%; p ⫽ 0.01) than MFMU members. Testing for lupus anticoagulant and anticardiolipin IgG antibody was performed by all investigators, but routine testing for other thrombophilias was reported by only 28% of respondents. Only 16% reported routine testing of women with RSA for diminished ovarian reserve or impaired glucose intolerance/insulin resistance. No significant differences were noted between the RMN and MFMU investigators with regard to these additional routine tests. Among the areas of research proposed for RSA, 94% of the entire study group indicated high/moderate research interest for the evaluation of thrombophilias, 83% for infection/ inflammation, 61% for impaired glucose intolerance/insulin resistance, and 63% for diminished ovarian reserve. No significant differences were noted in the level of research interest for the above categories between RMN and MFMU investigators. Conclusions: Subtle testing pattern differences for the workup of recurrent pregnancy loss exist between the investigators of the RMN and MFMU. Substantial research interest exists regarding the role of infection/inflammation, thrombophilias, impaired glucose intolerance/insulin resistance, and diminished ovarian reserve in the pathophysiology of recurrent pregnancy loss. Supported by: NICHD U10 HD33172 (MPS).

P-242 The effects of ibuprofen on ovulation. Sabrina Stewart, Allison M. Case, Olufemi A. Olatunbosun, Roger A. Pierson. Univ of Saskatchewan, Saskatoon, SK, Canada. Objective: To determine whether low doses of ibuprofen inhibit ovulation. Secondary objectives were to assess the effect of ibuprofen on follicular diameter, endometrial thickness and pattern. Design: Pilot study performed as a randomized trial of two doses of ibuprofen with comparison to historical controls. Materials/Methods: Women aged 18 – 45 years with regular menstrual cycles (n⫽47) were enrolled between Sept 2001 and Dec 2001. The historical controls were 50 women participating in a study of ovarian folliculogenesis. Subjects were assigned to 18 mm or 20 mm follicle groups and then randomized to receive one or two doses of ibuprofen (400mg). The resulting 4 groups were 18(1), 18(2), 20(1), and 20(2). Transvaginal ultrasonography was initiated on day 12 and then intermittently until assigned follicular diameter was attained, day 2 post-randomization and then daily until ovulation was documented. At each examination mean follicular diameter, endometrial thickness and pattern were recorded. Serum progesterone levels were obtained 7 days post-randomization. Results: Of the 47 women enrolled, 5 failed to reach assigned follicular diameter, 1 was excluded due to an abnormal finding on initial day 12 ultrasound and there was 1 protocol violation, resulting in 40 women whose data were analyzed. All study participants ovulated. The preovulatory follicular diameter was greater in the 18(2) group [24.9 ⫾ 0.3 mm] and 20(2) [26.3 ⫾ 1.3 mm compared with controls [21.3 ⫾ 0.3 mm] (p ⬍0.001). Preovulatory follicle diameter also was greater in the 18(2) group than in the 18(1) group [24.9 ⫾ 0.3 mm vs 21.4 ⫾ 0.8 mm; (p ⬍0.001)] and there was a similar tendency in the 20(2) vs 20(1) groups [26.3 ⫾ 1.3 mm vs 23.0 ⫾ 1.4 mm; (p ⫽ 0.07)]. No differences were found in preovulatory endometrial thickness [control 10.3 ⫾ 0.3 mm, 18(1) 10.2 ⫾ 0.8 mm, 18(2) 9.9 ⫾ 0.9 mm, 20(1) 10.8 ⫾ 0.8 mm, 20(2) 9.7 ⫾ 0.5 mm; (p ⫽ 0.95)] nor were there differences in endometrial thickness [control 10.4 ⫾ 0.3 mm, 18(1) 9.6 ⫾ 0.5 mm, 18(2) 9.5 ⫾ 0.6 mm, 20(1) 10.8 ⫾ 0.6 mm, 20(2) 11.2 ⫾ 0.9 mm; (p ⫽ 0.32)] on the day of ovulation. No differences were observed in

S195

preovulatory (p ⫽ 0.59) or ovulatory endometrial pattern (p ⫽ 0.62). Progesterone levels were similar among groups (p ⫽ 0.24). Conclusions: Low doses of ibuprofen in the peri-ovulatory period do not inhibit ovulation but may be associated with increased preovulatory follicular diameter. The clinical significance of this finding has yet to be elucidated. Supported by: Support of this research was obtained through a grant from the Clinical Teaching and Research Fund of the College of Medicine of the University of Saskatchewan.

P-243 Comparison of monopolar and bipolar resectoscopes for endomyometrial resection ablation for abnormal uterine bleeding. Michael Lee Moore, Mel I. Cohen, Grace Y. Liu. Advanced Women’s Health Institute, Denver, CO. Objective: To compare endomyometrial resection ablation (ERA) outcome parameters in patients undergoing monopolar ERA (MERA), or ERA with a bipolar resectoscope (BERA). Design: Review of prospective surgical outcomes data-base. Materials/Methods: Patients undergoing ERA from February, 1999, to February, 2002. Women with abnormal uterine bleeding were offered ERA if they no longer desired reproduction and had no indication for operative laparoscopy. Patients were entered into a prospective data-base to track surgical parameters and patient outcome. Data was tracked peri-operatively, and post operatively at 6 weeks, 6 months and annually. Results: 111 cases were available for review, 58 MERA and 53 BERA. There was no statistical difference in operative time (MERA, 22 ⫾ 2 min vs. BERA, 26 ⫾ 2 min, p ⫽ NS). Differences were found in calculated fluid deficit (MERA, 452 ⫾ 8 cc vs. BERA, 1594 ⫾ 73 cc, p ⬍0.001) and additional operative procedures (MERA, 22 (38%) vs. BERA, 36(68%), p ⬍0.05. Operative complications occurred in 4 (7%) MERA cases. Two patients required 30 cc balloons post operatively to tamponade bleeding, one case was terminated due to excessive glycine absorption, and one case was cancelled secondary to perforation. Four (8%) BERA complications were reported. Two patients with fluid overload required diuretic in order to complete ablation, one patient required a 30 cc balloon to tamponade bleeding, and one cancellation for perforation occurred. Amenorrhea rates were calculated by life table actuarial analysis and were similar (MERA 83% vs. BERA 86%, p ⫽ NS). Conclusions: BERA is comparable to MERA in operative time and amenorrhea rate. Cancellation due to fluid overload can be avoided with BERA.

P-244 Pipelle endometrial biopsy in the diagnosis of ectopic pregnancy. Clarisa R. Gracia, Kurt T. Barnhart, Beth Reindl, James Wheeler. Univ of Pennsylvania, Philadelphia, PA; Univ of Washington, Seattle, WA. Objective: As previously demonstrated, the diagnosis of presumed ectopic pregnancy is inaccurate in 40% of cases; therefore uterine curettage (D&C) is necessary for diagnosis. However, D&C is inconvenient, expensive, and associated with a small risk of complications. Minimally invasive endometrial biopsy techniques such as the pipelle biopsy do not require anesthesia, are safe and up to 50 times less expensive than D&C. Pipelle biopsy has been shown to be nearly as sensitive as D&C in cases of suspected endometrial cancer. The objective of this study was to determine the accuracy of endometrial pipelle biopsy in the diagnosis of chorionic villi in patients at risk for ectopic pregnancy. Design: Blinded prospective clinical trial. Materials/Methods: From 4/99 to 5/00, 32 clinically stable pregnant women presenting with pain and/or vaginal bleeding were recruited at a university hospital. Inclusion criteria required that no definite intrauterine or ectopic pregnancy be visualized by transvaginal ultrasound and that quantitative hCG values be either greater than the discriminatory zone or plateaued. Patients were scheduled for D&C as part of routine care. An endometrial pipelle biopsy was performed while under anesthesia prior to D&C. Ectopic pregnancy was diagnosed when no chorionic villi were isolated from either biopsy technique on frozen section and there was a rise in subsequent hCG value. Clinicians were not informed of results by

S196

Abstracts

sampling technique. Treatment of ectopic pregnancy involved methotrexate or laparoscopy. Pipelle and frozen section results were compared to final pathologic diagnoses. Results: 32 patients were enrolled. 10/32 (31%) were found to have chorionic villi consistent with a miscarriage and 22/32 (69%) had none detected. Compared to D&C, pipelle biopsy had a sensitivity of 30% (95%CI: 6.7 to 65.2), a specificity of 100% (95%CI: 84.5 to 100), a positive predictive value of 100% (95%CI: 29.2 to 100), and a negative predictive value of 76% (95%CI: 56.5 to 87). Comparing the initial frozen section results from both sampling techniques to the final pathology, frozen section had a sensitivity of 87.5% (95%CI: 47.3 to 99.7), a specificity of 100% (95%CI: 83.1 to 100), a positive predictive value of 100% (95%CI: 59 to 100), and a negative predictive value of 95.3% (95%CI: 76.1 to 99.8). Ten patients with ectopic pregnancy were treated via laparoscopy, 11 received methotrexate, and 1 patient’s hCG declined normally without treatment. Conclusions: Sampling of the endometrium is essential when ectopic pregnancy is suspected to distinguish an ectopic pregnancy from a miscarriage. If endometrial sampling is not performed, at least one third of women will be incorrectly treated for an ectopic pregnancy. We found that endometrial pipelle is not a substitute for uterine curettage. Pipelle sampling has a poor sensitivity and an unacceptable predictive value for the detection of chorionic villi and therefore is not an adequate method to distinguish between ectopic pregnancy and miscarriage. While D&C with permanent section remains the standard of care in the diagnosis of ectopic pregnancy, frozen section of D&C tissue appears to be an acceptable diagnostic technique on which to base initial management. Until a more sensitive, noninvasive technique for endometrial sampling is developed, D&C is required for the definitive diagnosis of ectopic pregnancy. Supported by: NIH Grant R01HD3645501A1.

P-245 Ultrasound measurement of decidual thickness in early clinical pregnancy is not associated with pregnancy outcome in infertility patients with polycystic ovarian syndrome (PCOS) but may be predictive for other infertility diagnoses. Seth Feigenbaum, Nydia Lovell, Dobie Edmunds, Nancy Zinn, Mary Balmana-Jeffrey, Carrie Vanderwagen. The Permanente Medical Group, Kaiser Medical Ctr, San Francisco, CA. Objective: Endovaginal sonographic (EVS) measurement of decidual thickness (DcT) has been used to predict pregnancy outcome in patients with threatened abortion. It has been shown that DcT of PCOS women in early pregnancy is significantly less than in women with other infertility diagnoses. The objective of this study was to determine whether DcT in early clinical pregnancy is predictive of pregnancy outcome (miscarriage (SAB) vs. live-born) in PCOS patients compared with other infertility diagnoses. Design: Prospective cohort study in a tertiary REI teaching center. Materials/Methods: 163 consecutive patients with viable pregnancy at time of EVS at 6w 3d to 7w 2d by adjusted LMP were included. PCOS patients were oligo-anovulatory, had failed clomiphene citrate alone, had evidence of either hyperandrogenism and/or hyperandrogenemia, and all had PCO-appearing ovaries on EVS. Comparison infertility patients were ovulatory, had one or more diagnoses of unexplained infertility, mild male factor, pelvic factor or mildly diminished ovarian reserve, and had undergone controlled ovarian hyperstimulation. Patients with total motile inseminates between 5–20 million/ml underwent washed IUI. A comparison group of single heterosexual and lesbian women receiving frozen donor semen was included. Decidual thickness was measured using a 5 mHz endovaginal transducer (Acuson 128). The gestational sac was photographed in a magnified sagittal view at a point 180 degrees from the probable implantation site. The DcT was recorded by an independent observer. Pregnancy outcome was determined by reviewing medical records. Data were analyzed using SAS. Chi-square was used to analyze classification versus outcome data, and ANOVA was used for continuous variables. Significance for p ⬍0.05 was tested using two-tailed distributions. Results: Average age of PCOS patients ⫽ 33.1 y.o.; non-PCOS ⫽ 36.7 (p ⬍0.001). 100% of patients had DcT measured and pregnancy outcome ascertained. For both infertility groups combined, the decidual thickness was 4.9 mm, SD 1.6. Patients who delivered (Del) had a DcT of 5.1 mm, SD 1.7; patients who subsequently had miscarriage (SAB) had a DcT of 4.8 mm, SD 1.4 (p ⫽ n.s.). Within the PCOS group, those who delivered had

Vol. 78, No. 3, Suppl. 1, September 2002