Positive hCG Test Research Articles

Normal Production of Human Chorionic Gonadotropin in Menopause

To the Editor: A positive test for the presence of human chorionic gonadotropin (hCG) before menopause is an indication of pregnancy.1 A positive hCG test in menopausal women poses a diagnostic cha...

Diagnosis and Management of Hepatic Ectopic Pregnancy

We present a case in which an adnexal mass caused symptoms that eventually lead to the identification of a primary hepatic pregnancy. A young woman presented with abdominal pain, a positive hCG test result, an empty uterus, and a pelvic mass. Diagnostic laparoscopy revealed a cystic adnexal mass. An exploratory laparotomy with ovarian cystectomy identified a mature teratoma but no evidence of pregnancy in the pelvis. Because the patient's quantitative hCG level continued to increase without evidence of an intrauterine pregnancy, a dilation and curettage was performed which yielded no products of conception. An ultrasound examination and magnetic resonance imaging identified an 11-week ectopic pregnancy with fetal cardiac activity located in the maternal liver. This was treated with fetal injections of methotrexate and potassium chloride under ultrasound guidance and subsequent maternal intramuscular injection of methotrexate. The patient tolerated these interventions well, and subsequent ultrasound examinations showed absent fetal cardiac activity and decreasing fetal size. Serial hCG tests were followed up to zero, and the patient's liver enzyme levels remained normal. With persistently rising hCG levels and no pregnancy identified in the uterus or pelvis, there should be a thorough evaluation of the entire pelvis and abdomen. Magnetic resonance imaging is a useful tool for locating such an ectopic pregnancy. Once identified, decisions regarding surgical versus medical management must take risk of adverse outcomes into consideration. This report reveals an 11-week hepatic pregnancy managed conservatively with fetal potassium chloride and maternal methotrexate administration.

P-53: Efficacy of elective single embryo transfer (eSET) on blastocyst transfer and patient attitudes toward eSET to reduce multi-pregnancies

Reducing the multiple pregnancy rate is an urgent issue in the field of in vitro fertilization and assisted reproduction technology (ART). Policies relating to elective single embryo transfer (eSET) are a potent strategy to curtail multi-pregnancies without decreasing the pregnancy rate. However, not all patients offered eSET necessarily accept such a policy. We studied whether an eSET policy could decrease the multi-pregnancy rate without decreasing the pregnancy rate and whether patient attitudes toward eSET could affect outcomes of the protocol. Retrospective analysis of a university based IVF program. Two hundred and twenty one fresh IVF/ICSI/blastocyt transfer and thawed blastocyt transfer cycles in unselected cases were analyzed. The study was divided into two time periods depending on which transfer policy was implemented. Period I: December 2002 to December 2003 (N=64), under a two embryo transfer (TET) policy. Three hundred and forty two embryos were cultured for 5 days. Two embryos, or one embryo when two embryos were not available, were transferred after evaluating the grade of embryos by the criteria proposed by Gardner for blastocysts. Criteria for eSET were determined by embryo quality, patient age, and the number of ET. Period II: February 2004 to March 2006 (N=157), under an eSET policy. While 29 cycles were offered for eSET, 18 cycles accepted eSET and 11 cycles selected TET. Seventy nine cycles were SET (62 fresh embryo cycles, 17 thawed embryo cycles), and 78 cycles were TET (49 fresh embryo cycles, 29 thawed embryo cycles). The retrieved and fertilized oocytes in both periods were cultured in sequential medium for blastocysts under 37°C/5%CO2/5%O2/90%N2 for 5 days. Pregnancy was defined as a positive serum hCG test and a sac seen on an ultrasound scan. Statistical analysis was performed using Χ-square methods. P<0.05 was considered significant. Subjects in the periods were similar regarding patient age (mean 34.3 -34.5, range 26-46 years), other demographic characteristics, and embryo quality scores. In period I, the pregnancy rate per embryo transfer was 39.1%, and the implantation rate per embryo was 26.5%. A significantly high pregnancy rate and the implantation rate could be reached following the transfer of two 3AA or higher blastocysts (65.0% vs. 27.3%, 45% vs. 16.4%; p<0.01 respectively). The over all multi-pregnancy rate was 24%, but was critically high, 38.5%, following transfer of two 3AA or higher blastocysts. These data were used to determine the criteria for eSET; (1) more than two 3AA or higher blastocysts, (2) age less than 36 years, and (3) less than three failed ET cycles. In period II, following eSET, the pregnancy rate was 66.7% (12/18) and the multi-pregnancy rate was 0% (0/12). In patients who declined eSET, choosing TET instead, while the pregnancy rate was similar, 81.8% (9/11), the multi-pregnancy rate was significantly high, 44.4% (4/9, p<0.05). However, the over all pregnancy rate in period II did not decrease compared with that in period I (37.6% vs. 39.1%), while the multi-pregnancy rate decreased by half (11.9 % vs. 24.0 %). When all patients offered eSET accepted the policy, the over all multi-pregnancy rate significantly decreases to 5% (3/59, p<0.05) without reducing the pregnancy rate. Patient attitudes toward eSET are a critical factor for decreasing the numbers of multi-pregnancies.

Frozen embryo transfers: implications of clinical and embryological factors on the pregnancy outcome

Frozen embryo transfers are characterized by impaired pregnancy outcome and increased incidence of pregnancy loss as compared with fresh IVF/ICSI embryo transfers. In this study, we performed a retrospective analysis of clinical and embryological factors that potentially influence the outcome of frozen embryo transfer. We reviewed the outcome of 1242 frozen embryo transfers with respect to the age of the woman, the method of fertilization, embryo quality before and after freezing and the number of embryos transferred. The pregnancy (positive hCG) and clinical pregnancy rates were 25.8 and 21.1%, respectively. A total of 107 (33.3%) of the 321 pregnancies identified by a positive hCG test miscarried either before (18.4%) or after (15%) the clinical recognition of gestational sac(s). The delivery rate for the frozen embryo transfers analysed was 17.2%. Our data revealed that the delivery rate after frozen embryo transfer was dependent on both the woman's age and the quality of embryos transferred, at the same time being unaffected by IVF/ICSI treatment. In addition, the increased woman's age at IVF/ICSI treatment was identified as the only parameter elevating the biochemical pregnancy rate, whereas the clinical abortion rate was found to be unrelated to the clinical or embryological parameters studied.

Parameters predicting the implantation rate of thawed IVF/ICSI embryos: a retrospective study

Single embryo transfer is becoming increasingly popular in IVF/ICSI. More IVF/ICSI cycles therefore include freezing of high quality embryos, and the cumulative effect of such cycles becomes more important. To improve the results obtained using frozen–thawed embryos, the predictive value of embryo and patient characteristics was analysed retrospectively. Excess embryos were frozen on day 2 according to routine procedures and thawed 24 h before transfer. The women were either treated with oestradiol/progesterone, or the transfer took place after a natural cycle. Of 1777 embryos thawed, 1360 survived (survival rate 76.5%). In the 410 transfer cycles, 819 embryos were transferred, giving 109 positive serum HCG tests and 69 clinical pregnancies. The implantation rate was 10.4%. Five parameters were positively related to implantation: (i) four or more cells at the freezing time (day 2); (ii) resumption of mitosis after thawing; (iii) more than six cells at transfer (day 3); (iv) assisted hatching and (v) child in a previous fresh cycle. The relative predictive value of these parameters may be a guideline for the selection of embryos used for transfer. Assisted hatching may become routine in freeze–thaw cycles if its utility is confirmed in subsequent studies.

Evaluation of Frozen Thawed Embryo Outcome After Transportation to a Long-Term Storage Facility Versus In-House Storage Facility

Objective: The objective of this study was to evaluate the outcomes of frozen embryo transfers (FET) on the embryos that were cryopreserved and transported to a long-term storage facility and then brought back later for FET cycles as compared to the outcomes of embryos that were cryopreserved and thawed in house. This comparison was carried out as further quality control of our procedures for remote site embryo banking. Design: Retrospective comparative study. Materials and Methods: All the embryos that were used for this study were cryopreserved at blastocyst stage and the protocol for freezing and thaw were a modified protocol as described by us earlier (ASRM 2004, abstract # P-58). Frozen embryos were stored in liquid nitrogen (LN2) and monitored. For transportation to our chosen remote site cryo laboratory (Reprotech Ltd, Roseville, MN) dry shippers were used that were previously saturated with LN2 and embryos were shipped in dry shipper by overnight courier. For QC purpose these shippers contain a cryoguard indicator vial. Vial content is green as long as temperature inside the shipper is -120oC and if for some reason temperature falls, it will turn red. These shippers are good to maintain the temperature for at least a week and they are checked intermittently for any leaks or deviations from the required storage temperature. Results: We have analyzed 18 FET cycles that were cryopreserved at our facility and sent for long-term storage to use later for FET. A total of 63 blastocysts thawed and 47 blastocysts were transferred from September 2003 until March 2005. Out of 18 FET, 12 cycles had a positive HCG test and eight are clinically pregnant (44%). Clinical pregnancy is defined as the presence of fetal heart beat by ultrasound. Our in house clinical pregnancy rate for FET during the period evaluated was 40%. Conclusion: Based on these data we conclude that there is no difference in clinical pregnancy rate for the embryos that were sent for long-term storage versus in house storage, if a strict QC is maintained throughout storage and transportation. Sending embryos to a cryobank for the storage could be an attractive option for ART centers where space constraint is a problem. Remote storage out sources the daily inventory and LN2 monitoring work. A significant liability in storing these preimplantation embryos for long-term are also outsourced. INTRODUCTION Long-term storage of embryos generated by ART laboratories in a remote cryobank could be an attractive option for many ART laboratories where space constraint is a problem. It has some other advantages as well because it can significantly eliminate the inventory maintenance and continuous liquid nitrogen monitoring. We have evaluated this option of sending the embryos to a remote cryobank keeping in consideration the stringent quality control procedures practiced during these transfers and storage. We also compared the clinical pregnancy rate obtained after transferring these embryos in frozen embryo transfer (FET) cycles after bringing them back to our laboratory with our ongoing clinical pregnancy rate in FET cycles of those embryos that remained in our laboratory. MATERIALS AND METHODS All the embryos that were used for this study were cryopreserved at the blastocyst stage and the protocol for freezing and thaw were modified protocol as described by us earlier (Srivastava et al, 2004, Veeck et al, 2004). Only expanding, expanded, hatching or hatched blastocysts with well-defined inner cell mass and a cohesive trophectoderm were frozen on day 5, 6 and 7. Frozen embryos were stored in liquid nitrogen (LN2) and monitored. For transportation to our chosen remote site cryo laboratory (Reprotech Ltd, Roseville, MN) dry shippers were used that were previously saturated with LN2 and embryos were shipped in dry shipper by overnight courier. For QC purpose these shippers contain a cryoguard indicator vial. The vial content is green as long as the temperature inside the shipper is less than -120oC and if for some reason the temperature rises, it will turn red. These shippers are good to maintain the temperature for at least a week and they are checked intermittently for any leaks or deviations from the required storage temperature. TABLE: Comparison of clinical pregnancy rate between remotely stored embryos and in-house stored embryos Total FET cycles analyzed when frozen embryos were sent earlier to cryobank and later brought back to our laboratory: (From 09/03 to 02/05): 18 Total blastocysts thawed: 63 Total blastocysts transferred: 47 Number of FET cycles with positive HCG: 12 Number of cycles with clinical pregnancy: 8 Clinical pregnancy rate: 44%

P110: Transvaginal Color Doppler (TVCD) in evaluation of patients with positive Human Chorionic Gonadotropin (hCG) test (in excluded intrauterine pregnancy)

Purpose: To determine the diagnostic role of TVCD in patients with positive hCG test in cases when intrauterine pregnancy is excluded. To definite the correlation of the TVCD findings with the level of hCG. Material and methods: 101 patients with positive hCG test were examined. These included: Ectopic pregnancy (EP-27.7%), recent spontaneous abortion (RSA-9.9%), molar pregnancy (MP-31.7%), hemorrhagic or ruptured corpus luteum cyst (OH/OR-14.9%), ovarian torsion (OT-15.8%). Results: The negative hCG test excluded developing EP. The exception was a chronic EP (17.7%), when the level of test was correlated with vascularity of the EP. In clinically suspected EP cases, when hCG >2000 mIU/mL and TVCD failed to disclose intrauterine gestational sac, the patient had an EP or RSA. When hCG <2000 mlU/ml, serial hCG test was performed (on 48 h. intervals) and the TVCD was repeated once the discriminatory level was reached. In cases of MP with ‘‘snow storm’’ sign, high vascularization and low RI/PI, a hCG was not decreased (uncommonly increased). After the MP extraction the abovementioned findings were correlated with hCG level. In cases of OH, OR, OT the increased level of hCG was not so significant, as clinical manifestation (pelvic pain) and TVCD findings. Conclusion: The TVCD has significant role in management of patients with positive hCG test.

Progesterone supplementation during early gestations after IVF or ICSI has no effect on the delivery rates: a randomized controlled trial

The aim was to study whether prolongation of luteal support during early pregnancy influences the delivery rate after IVF. Dual centre study including 303 women who achieved pregnancy after IVF or ICSI was used. All were treated with the long protocol using GnRH agonists and given luteal support with 200 mg vaginal progesterone three times daily during 14 days from the day of transfer until the day of a positive HCG test. The study group (n = 150) withdrew vaginal progesterone from the day of positive HCG. The control group (n = 153) continued administration of vaginal progesterone during the next 3 weeks of pregnancy. The number of miscarriages prior to and after week 7 of gestation was seven (4.6%) and 15 (10.0%) in the study group and five (3.3%) and 13 (8.5%) in the control group respectively. The number of deliveries was 118 (78.7 %) in the study group and 126 (82.4 %) in the control group. The differences were not significant. Prolongation of progesterone supplementation in early pregnancy has no influence on the miscarriage rate, and thus no effect on the delivery rate. Progesterone supplementation can safely be withdrawn at the time of a positive HCG test.

Progesterone supplementation during early gestation after in vitro fertilization has no effect on the delivery rate

Objective: To compare the delivery rate with IVF or ICSI in women who did and did not receive progesterone supplementation in the first 3 weeks after a positive hCG test result. Design: Retrospective study. Setting: Fertility Clinic, Rigshospitalet University Hospital, Copenhagen, Denmark. Patient(s): 200 pregnant women who did not receive progesterone (intervention group) and 200 pregnant women who received progesterone for 3 weeks after a positive hCG result. Intervention(s): In the study group, vaginal progesterone therapy was withdrawn on the day of positive hCG result. In the control group, treatment with progesterone, 600 mg/d, was continued for 3 weeks after a positive hCG result. Both groups received 600 mg of progesterone starting on the day of embryo replacement until testing positive for pregnancy 14 days after embryo transfer. Main Outcome Measure(s): Delivery rate. Result(s): The number of deliveries was 126 in the study group and 128 in the control group. Conclusion(s): The delivery rate was the same in pregnant women who received and those who did not receive progesterone for 3 weeks after a positive hCG result. Progesterone supplementation for more than 2 weeks after embryo transfer may therefore yield no benefit in terms of pregnancy.

Does pronuclear morphology and/or early cleavage rate predict embryo implantation potential?

A total of 340 patients referred for in-vitro fertilization was included in a retrospective, comparative study in which zygotes were studied regarding alignment and polarization of nucleolar precursor bodies (NPB) and also early cleavage in relation to implantation and pregnancy rates for the 680 transferred embryos. At assessment of the pronucleus 18–19 h after sperm injection, NPB were checked for alignment/polarization. Twenty-six hours after sperm insemination the zygotes were assessed for early cleavage. At embryo transfer the two embryos with the best morphological score, irrespective of polarization and early cleavage, were selected for transfer. The overall rate of positive HCG tests 17 days after embryo transfer was 42% and the implantation rate 23%. Fourteen percent of the patients received two embryos with polarized NPB, with a positive HCG test of 51%. Embryo transfer with early-cleaved embryos was carried out in 21% of the cycles, with a pregnancy rate of 45%. Embryos with polarized NPB and/or early cleavage were transferred in 34% of the cycles, with a pregnancy rate of 51%, compared with a pregnancy rate of 38% when none of the embryos fulfilled these criteria (P-value 0.02). In this study the pregnancy rate was significantly higher when one or two embryos were polarized and/or early cleaved. It is concluded that in a cohort of morphologically good embryos, assessment for alignment/polarization of NPB and/or early cleavage can, together with conventional morphological criteria, serve as a simple non-invasive method for selection of embryos with high implantation potential.

Ectopic pregnancy F16Natural course of ectopic pregnancy evaluated by transvaginal sonography

BackgorundSome of the cases with ectopic pregnancy (EP) may have spontaneous resolution without any treatment. Our aim of this study was to survey natural course of EP with serial sonographic assessment.MethodAll patients with EP from 1995 to 2000 were recruited. Inclusion criteria were 1. Positive hCG test, 2. Adnexal mass, suggestive of EP depicted by transvaginal sonography, 3. No fetal activity, 4. Pelvic fluid less than 300 mL, 5. Minimal symptoms, 6. Conservative management might be profitable to the patients, and 7 Informed consent. Under Hospitalization, the patients underwent at least one sonographic examination per day. When the amount of intraperitoneal hemorrhage proved to be increasing during the follow‐up, surgical treatment was performed.ResultsOf 34 cases with ectopic pregnancy, 13 cases with tubal pregnancy had emergency laparotomy immediately after admission. One case with cervical pregnancy was treated with methotrexate. Other 20 cases were enrolled in this study. Of the cases, 10 had laparotomy because of increasing intraperitoneal hemorrhage and/or worsening symptoms. In other 10 cases, spontaneous regression of the mass and decline of hCG level were confirmed. They could be discharged without any surgical treatment.ConclusionExpectant management was successful in 10 (50.0%) of the patients, in which natural course of EP was followed by transvaginal sonography.

Soluble HLA levels in early pregnancy after in vitro fertilization

Intact pregnancy can be interpreted as a state of maternal immunotolerance toward an haploidentical fetus. Soluble HLA (sHLA) molecules increase during episodes of allograft rejection and are discussed as candidates to modulate immune responses. We questioned whether after in vitro fertilization (IVF) the subsequent intact pregnancy, early abortion, or tubal pregnancy influence the courses sHLA serum levels. Therefore, serum samples of 65 IVF patients were assayed by ELISA for sHLA-I, sHLA-G, and sHLA-DR concentrations preovulatorily and after a positive HCG test weekly until the 9th gestational week (GW). In 20 patients experiencing an early abortion the preovulatory sHLA-G mean level of 25.9 ± 3.9 SEM ng/ml and the share of 4.2 ± 0.8 SEM % on total sHLA-I were significantly ( p < 0.05) reduced compared to women with intact pregnancy. The same differences ( p < 0.0001) were seen during the monitoring of sHLA-G and sHLA-I levels in intact pregnancy versus early abortion until 9th GW. Twin pregnancy revealed a drastically increase of sHLA-G levels from the 8th GW compared to singleton pregnancies. Further, individual sHLA-DR levels increased during intact pregnancy but decreased in the group of early abortion. With regard to sensitivity and specificity for pregnancy outcome sHLA quantitation reached similar weight as routine HCG determinations at GW 5. Especially women with preovulatory low sHLA-G levels appear to be on risk for early abortion after IVF.

Assessment of the gonadotrophin-gonadal axis in androgen insensitivity syndrome.

To study the value of measuring serum luteinising hormone (LH), follicle stimulating hormone (FSH), testosterone, and dihydrotestosterone (DHT) in androgen insensitivity syndrome (AIS). Retrospective study of patients on a nationwide register of AIS. Sixty one cases of AIS with androgen receptor (AR) dysfunction (abnormalities of the AR gene and/or abnormal AR binding) were divided into three age groups: infants, < 1 year old; children, 1-13 years old; and postpubertal, > 13 years old. Age, dose of human chorionic gonadotrophin (hCG) stimulation, pre-hCG and post-hCG serum testosterone values, serum DHT values, and serum LH and FSH values before and after LH releasing hormone (LHRH) stimulation. In 23 of 30 infants testosterone was within age related reference ranges; six were above this range. The median testosterone rise following variable dosage of hCG was 9.5 times the basal value. The increment was not related to the hCG dose, age, or basal concentration of testosterone. The median basal and stimulated testosterone:DHT ratios were 2.5 and 6.1, respectively. The median increment in DHT was 2.2-fold. Seventeen of 18 FSH and 11 of 19 LH measurements were within age related ranges in infants; in seven patients LH values were above the range. LHRH stimulation performed in 39 patients showed an exaggerated LH in all age groups. The FSH response was not exaggerated in children. Although a positive hCG test excludes biosynthetic defects of testosterone, an inadequate response does not exclude AIS. Basal LH and testosterone may not be raised during early infancy. An LHRH stimulation test might be useful for evaluating cases of suspected AIS presenting in mid-childhood.

Pseudocyesis and its modern perspective.

EDITORIAL COMMENT: We accepted this paper for publication because we have not reported previously on pseudocyesis, which is a rare condition, especially if ‘first trimester cases’ are excluded where there has been confusion with interpretation of intervals of amenorrhoea. These cases can occur at the climacteric when elevated levels of LH can give a false positive HCG test result with older methods of assay and add further to the temporary clinical confusion. The classical clinical picture, unlike the 3 cases reported in this paper, is said to be the nullipara approaching the time of the climacteric who is anxious to conceive. Queen Mary's case must be the most famous on record and also the best documented by means of the serial bulletins issued for her loyal subjects concerning the progress of her royal pregnancy (A). The editor can remember only 1 case of ‘late pregnancy’ pseudocyesis in 40 years of obstetric practice. This woman was finally convinced of her nonpregnant status by failure of a fetal skeleton to show on an abdominal X‐ray. This was many years ago. This test was claimed to be definitive. One wonders how these women coped thereafter. We agree with the authors that follow‐up, not necessarily by a psychiatrist, is important. In the editor's experience pseudocyesis of late pregnancy is less common than advanced true normal pregnancy in a nullipara aged more than 40 years, married for many years, who presents with abdominal pain and finds out to her delighted surprise that she is in labour at term and shortly thereafter produces a surviving normal infant. The reviewers of this paper did not agree with the suggestion that curettage would be an appropriate procedure to convince a woman with pseudocyesis that she was not pregnant. However, the authors, having read this editorial comment, stated that curettage is mentioned in the pseudocyesis literature (4).(A) Dewhurst J. Royal Confinements. Weidenfeld and Nicolson, London. 1980; 28–29.

Accuracy in Diagnosis of Ectopic Pregnancy by Transvaginal Ultrasonography

Forty patients suspected to have ectopic pregnancy by transvaginal ultrasonography had surgery. 77.5% were confirmed to have ectopic pregnancy and 10% had other abnormal pelvic findings. The transvaginal approach appears to enable us to diagnose ectopic pregnancy at an earlier date, with the earliest diagnosis made at 4 weeks 0 days of amenorrhoea. In cases of confirmed ectopic pregnancy, the presence of a complex adnexal mass was the most common feature seen on transvaginal ultrasound and its predictability of ectopic pregnancy is enhanced by a concomitant finding of an empty uterus (95%) or free fluid in the Pouch of Douglas (94%) in the presence of a positive hCG test. The significance of transvaginal ultrasound features, and the advantages of transvaginal over transabdominal ultrasound, are discussed.

Vaginal Sonography and a Positive Serum hCG Test for Early Detection of Ectopic Pregnancy

SummarySummaryA transvaginal scan was performed on 53 women with suspected ectopic pregnancy and a positive serum hCG. In 22 patients, ectopic pregnancy was correctly ruled out, and the diagnosis of ectopic pregnancy was proved at laparotomy in 30 patients. Only one false positive diagnosis was made. The sensitivity of diagnosis of ectopic pregnancy with transvaginal ultrasound was 100 per cent and the specificity was 96 per cent. The positive and negative predictive values of this approach were 97 and 100 per cent respectively. Laparoscopy was avoided in 12 patients (51 per cent) with early intra-uterine pregnancies and corpus luteum cyst complications. The addition of transvaginal ultrasound scan as an aid in the management of ectopic pregnancy gives improved accuracy of pre-operative diagnosis, reduces the number of unnecessary laparoscopies and allows the potential for use of non-surgical methods of treatment.