.,;;(itters-to-the-editor "Pa~l G.M~DonoJlgh~ M.D.
Vol. 53, No.2, February 1990
FERTILITY AND STERILITY
Printed on acid-free paper in U.S.A.
Copyright © 1990 The American Fertility Society
Donor Insemination Program Management
To the Editor: In their thoughtful article on donor insemination programs, Hummel and TalbertI refer to the practice of mixing husband and donor semen for insemination, but do not comment on the rationale for this. While advising against this practice on the grounds it may compromise the fertilizing ability of the donor sperm, no mention is made of what this is attempting to accomplish. Presumably it represents an effort to foster the belief that the husband may be the biological father. If this is important to the couple, it may suggest a failure to consider thoroughly the issues of using donor sperm. Is it an attempt to dilute the implications of donor sperm, and if so, should this be encouraged? This practice also leads to consideration of issues regarding anonymous versus known donors and the difficulty of maintaining secrecy over time. 2 It would seem that mixing husband and donor sperm is to be avoided on both medical as well as psychosocial grounds.
Anthony E. Reading, Ph.D. Center for Reproductive Medicine UCLA School of Medicine Los Angeles, California July 24,1989 REFERENCES 1. Hummel WP, Talbert LM: Current management of a donor insemination program. Fertil Steril51:919, 1989 2. Back KW, Snowden R: The anonymity of gamete donor. J Psychosom Obstet Gynecol9:191, 1988
Reply of the Author: I thank Dr. Reading for his thoughtful letter questioning the validity of mixing husband and donor sperm for AID. As a practical matter, mixing is not done in the AID program at The University of North Carolina Hospitals. However, couples are obviously free to engage in coitus around the time of AID, and no effort is made to restrict such activity. The authors, however, are aware of no data in the gynecological or psychiatric literature documenting a detrimental psychological effect of mix382
Letters-to-the-Editor
ing donor and husband sperm. The paper referenced to in the foregoing letter is consistent with other publications pertinent to this subject-no data. Despite the absence of data, it is axiomatic that couples should accept the concept of donor sperm before initiating treatment, and couples who demonstrate any ambivalence should be encouraged to obtain psychiatric or psychological counseling to fully resolve the issues in their own minds before initiating therapy.
Luther M. Talbert, M.D. Reproductive Endocrinology University of North Carolina School of Medicine at Chapel Hill Chapel Hill, North Carolina September 5, 1989 REFERENCES 1. Back KW, Snowden R: The anonymity of the gamete donor. J Psychosom Obstet Gynecol 9:191, 1988
Editorial Comment
Dr. Talbert never uses three words when two will suffice- "no data." What would happen to editors and journals if all of us were humble and secure enough to echo that refrain? Paul G. McDonough, M.D., Editor, Letters Conservative Management of Ectopic Gestation
To the Editor: We read with interest the article "Conservative Management of Ectopic Gestation."! We were surprised, however, at the exceedingly strong statement made by Dr. Vermesh in regard to laparoscopic treatment of cornual (interstitial) gestation: he advises surgeons that laparoscopy is never warranted due to a high risk of uncontrollable bleeding without any supporting data to this effect. Yet, in two cases, we have successfully performed laparoscopy to treat (interstitial) ectopic pregnancy. In these cases, the amount of bleeding was very minimal and the procedure took less time than when it was performed in cases of ampullary ectopic pregnancies. Weare also aware of two other cases in which this method of intervention was chosen. 2,3 No complications occurred with any of these four Fertility and Sterility
patients. We find laparoscopic treatment of cornual gestation to be as safe and effective as when it is performed for an ampullary ectopic condition. The key is intravenous infusion of one ampule of pitocin (10 U) in 1,000 cc oflactated Ringer's (the same approach as if it was a vaginal delivery or Csection). This method would contract the muscularis layers of the tube and uterus, making easier both the separation of the placenta from the implantation site and the control of bleeders. In most of the ectopic gestations treated by this route, this approach eliminates the need for injection of dilute pitressin. The author points out that vasopressin, when administered intravascularly, can lead to pronounced increases in blood pressure. Indeed, injecting vasopressin has been shown to lead to alterations (both increases and decreases) of blood pressure rates, and the expected rise of pressure could be offset by dose dependent decreases of cardiac output,4 and even severe hypotension and shock. 5 However, again, this depends on the strength of the dilution, the site of injection (intravascular or not), and the rate of injection, as well as the cardiovascular condition of the patient. If these criteria are considered, we believe that laparoscopic treatment of ectopic pregnancy can be employed with confidence. The limiting factor is not necessarily the location, size, or condition of the tube, rather, it is the skill and experience of the surgeon and availability of proper instrumentation.
treatment of ectopic pregnancy was just emerging as an alternative to laparotomy, and the scarce information about this procedure dictated my comments and conclusions. An abundance of recent data (including our own) has demonstrated that laparoscopic treatment of ectopic pregnancy is as safe and effective, and in some respects, superior to laparotomy. However, there is as yet no published information regarding the efficacy and safety of laparoscopic treatment of interstitial pregnancy. Recently, Confino et al. l have successfully treated two cases of interstitial pregnancy with laparotomy and conservative surgery. They employed dilute vasopressin locally, and ligated the ipsilateral uterine artery, the round ligament, the ovarian ligament, the tubal mesosalpingeal anastomotic arch, and the uterine wall above and below the interstitial pregnancy. From their report, it is apparent that conservative management of interstitial pregnancy is difficult to accomplish. A laparoscopic approach may be at least as difficult as laparotomy, even if performed by a very skilled and experienced surgeon, and hemorrhage from the highly vascularized cornual area may be uncontrollable. The fact that a procedure is technically possible should not make it acceptable. Laparoscopic treatment of interstitial pregnancy should remain a medical anecdote unless a clinical trial demonstrates its advantage over other methods.
Michael Vermesh, M.D. Women's Hospital Los Angeles, California September 13, 1989
Camran Nezhat, M.D. Farr Nezhat, M.D. The Fertility and Endocrinology Center Atlanta, Georgia May 9, 1989
REFERENCES 1. Contino E, Friberg J, Gleicher N: Conservative manage-
REFERENCES 1. Vermesh M: Conservative management of ectopic gesta-
tion. Fertil SteriI51:559, 1989 2. Wheeler J: Personal Communication 3. Mahnes H: Personal Communication 4. Cowley A W, J r: Vasopressin and blood pressure regulation. Clin Physiol Biochem 6:150, 1988 5. McLaughlin D: Personal Communication
ment of interstitial pregnancy (Abstr.) Presented at the 44th Annual Meeting of The American Fertility Society, Atlanta, Georgia, October, 1988. Published by The American Fertility Society, in the program supplement, 1988, pOO
Uniform Assessment of Success Rates with Assisted Reproductive Technology*
To The Editor: Reply of the Author: I appreciate the interest and comments of Drs. Cam ran and Farr Nezhat concerning my review article that appeared in the Modern Trends section. When this review was written (1987), laparoscopic Vol. 53, No.2, February 1990
The recent VI World Congress of In Vitro Fertilization (IVF) and Assisted Reproductive Technology held in Jerusalem in April 1989 has reemphasized the worldwide interest in the success rates of IVF and related new reproductive technologies. Letters-to-the-Editor
383
Vol. 53, No.2, February 1990
FERTILITY AND STERILITY
Printed on acid-free paper in U.S.A.
Copyright © 1990 The American Fertility Society
Donor Insemination Program Management
To the Editor: In their thoughtful article on donor insemination programs, Hummel and TalbertI refer to the practice of mixing husband and donor semen for insemination, but do not comment on the rationale for this. While advising against this practice on the grounds it may compromise the fertilizing ability of the donor sperm, no mention is made of what this is attempting to accomplish. Presumably it represents an effort to foster the belief that the husband may be the biological father. If this is important to the couple, it may suggest a failure to consider thoroughly the issues of using donor sperm. Is it an attempt to dilute the implications of donor sperm, and if so, should this be encouraged? This practice also leads to consideration of issues regarding anonymous versus known donors and the difficulty of maintaining secrecy over time. 2 It would seem that mixing husband and donor sperm is to be avoided on both medical as well as psychosocial grounds.
Anthony E. Reading, Ph.D. Center for Reproductive Medicine UCLA School of Medicine Los Angeles, California July 24,1989 REFERENCES 1. Hummel WP, Talbert LM: Current management of a donor insemination program. Fertil Steril51:919, 1989 2. Back KW, Snowden R: The anonymity of gamete donor. J Psychosom Obstet Gynecol9:191, 1988
Reply of the Author: I thank Dr. Reading for his thoughtful letter questioning the validity of mixing husband and donor sperm for AID. As a practical matter, mixing is not done in the AID program at The University of North Carolina Hospitals. However, couples are obviously free to engage in coitus around the time of AID, and no effort is made to restrict such activity. The authors, however, are aware of no data in the gynecological or psychiatric literature documenting a detrimental psychological effect of mix382
Letters-to-the-Editor
ing donor and husband sperm. The paper referenced to in the foregoing letter is consistent with other publications pertinent to this subject-no data. Despite the absence of data, it is axiomatic that couples should accept the concept of donor sperm before initiating treatment, and couples who demonstrate any ambivalence should be encouraged to obtain psychiatric or psychological counseling to fully resolve the issues in their own minds before initiating therapy.
Luther M. Talbert, M.D. Reproductive Endocrinology University of North Carolina School of Medicine at Chapel Hill Chapel Hill, North Carolina September 5, 1989 REFERENCES 1. Back KW, Snowden R: The anonymity of the gamete donor. J Psychosom Obstet Gynecol 9:191, 1988
Editorial Comment
Dr. Talbert never uses three words when two will suffice- "no data." What would happen to editors and journals if all of us were humble and secure enough to echo that refrain? Paul G. McDonough, M.D., Editor, Letters Conservative Management of Ectopic Gestation
To the Editor: We read with interest the article "Conservative Management of Ectopic Gestation."! We were surprised, however, at the exceedingly strong statement made by Dr. Vermesh in regard to laparoscopic treatment of cornual (interstitial) gestation: he advises surgeons that laparoscopy is never warranted due to a high risk of uncontrollable bleeding without any supporting data to this effect. Yet, in two cases, we have successfully performed laparoscopy to treat (interstitial) ectopic pregnancy. In these cases, the amount of bleeding was very minimal and the procedure took less time than when it was performed in cases of ampullary ectopic pregnancies. Weare also aware of two other cases in which this method of intervention was chosen. 2,3 No complications occurred with any of these four Fertility and Sterility
patients. We find laparoscopic treatment of cornual gestation to be as safe and effective as when it is performed for an ampullary ectopic condition. The key is intravenous infusion of one ampule of pitocin (10 U) in 1,000 cc oflactated Ringer's (the same approach as if it was a vaginal delivery or Csection). This method would contract the muscularis layers of the tube and uterus, making easier both the separation of the placenta from the implantation site and the control of bleeders. In most of the ectopic gestations treated by this route, this approach eliminates the need for injection of dilute pitressin. The author points out that vasopressin, when administered intravascularly, can lead to pronounced increases in blood pressure. Indeed, injecting vasopressin has been shown to lead to alterations (both increases and decreases) of blood pressure rates, and the expected rise of pressure could be offset by dose dependent decreases of cardiac output,4 and even severe hypotension and shock. 5 However, again, this depends on the strength of the dilution, the site of injection (intravascular or not), and the rate of injection, as well as the cardiovascular condition of the patient. If these criteria are considered, we believe that laparoscopic treatment of ectopic pregnancy can be employed with confidence. The limiting factor is not necessarily the location, size, or condition of the tube, rather, it is the skill and experience of the surgeon and availability of proper instrumentation.
treatment of ectopic pregnancy was just emerging as an alternative to laparotomy, and the scarce information about this procedure dictated my comments and conclusions. An abundance of recent data (including our own) has demonstrated that laparoscopic treatment of ectopic pregnancy is as safe and effective, and in some respects, superior to laparotomy. However, there is as yet no published information regarding the efficacy and safety of laparoscopic treatment of interstitial pregnancy. Recently, Confino et al. l have successfully treated two cases of interstitial pregnancy with laparotomy and conservative surgery. They employed dilute vasopressin locally, and ligated the ipsilateral uterine artery, the round ligament, the ovarian ligament, the tubal mesosalpingeal anastomotic arch, and the uterine wall above and below the interstitial pregnancy. From their report, it is apparent that conservative management of interstitial pregnancy is difficult to accomplish. A laparoscopic approach may be at least as difficult as laparotomy, even if performed by a very skilled and experienced surgeon, and hemorrhage from the highly vascularized cornual area may be uncontrollable. The fact that a procedure is technically possible should not make it acceptable. Laparoscopic treatment of interstitial pregnancy should remain a medical anecdote unless a clinical trial demonstrates its advantage over other methods.
Michael Vermesh, M.D. Women's Hospital Los Angeles, California September 13, 1989
Camran Nezhat, M.D. Farr Nezhat, M.D. The Fertility and Endocrinology Center Atlanta, Georgia May 9, 1989
REFERENCES 1. Contino E, Friberg J, Gleicher N: Conservative manage-
REFERENCES 1. Vermesh M: Conservative management of ectopic gesta-
tion. Fertil SteriI51:559, 1989 2. Wheeler J: Personal Communication 3. Mahnes H: Personal Communication 4. Cowley A W, J r: Vasopressin and blood pressure regulation. Clin Physiol Biochem 6:150, 1988 5. McLaughlin D: Personal Communication
ment of interstitial pregnancy (Abstr.) Presented at the 44th Annual Meeting of The American Fertility Society, Atlanta, Georgia, October, 1988. Published by The American Fertility Society, in the program supplement, 1988, pOO
Uniform Assessment of Success Rates with Assisted Reproductive Technology*
To The Editor: Reply of the Author: I appreciate the interest and comments of Drs. Cam ran and Farr Nezhat concerning my review article that appeared in the Modern Trends section. When this review was written (1987), laparoscopic Vol. 53, No.2, February 1990
The recent VI World Congress of In Vitro Fertilization (IVF) and Assisted Reproductive Technology held in Jerusalem in April 1989 has reemphasized the worldwide interest in the success rates of IVF and related new reproductive technologies. Letters-to-the-Editor
383
