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Institute for the study and treatment of endometriosis, Chicago, Illinois
ABSTRACT
The cause and effect relationship between endometriosis and infertility, although traditionally accepted, is difficult to prove because of multiple mechanisms through which endometriosis may interfere with fertility. Both hormonal and surgical treatment of endometriosis improve, but do not completely restore fertility in affected women. Endometriosis, especially in its advanced stages, has become a frequent indication for ART, and more specifically, for IVF/ET. The success rates of IVF/ET in endometriosis appear to be comparable to those seen in other diagnostic entities according to most reports. Several studies, however, indicate lower fertilization, lower oocyte/embryo quality, and lower embryo implantation rates in women with endometriosis leading to the overall lower IVF/ET success rates. It is not clear what is the mechanism of such adverse effects, and neither is the reason for the contradictory data. Some studies implicate abnormal autoantibodies, which can be demonstrated in about 60% of women with endometriosis. Abnormal autoantibodies, especially of the antiphospholipid group, bind to the oocyte/embryo and trophoblast, interfering with their development and function, and to platelets, inducing thrombosis in the spiral arteries of the endometrium and in the placenta. They may be responsible for abnormal fertilization, poor embryo development and low implantation and pregnancy rates. They may also cause higher pregnancy wastage. Suppression of abnormal autoantibodies or use of anticoagulants has been associated with improved reproductive performance and improved IVF/ET results. It is likely that the individual variability in autoantibody levels, empirical use during the IVF protocol of drugs that lower their production or prevent their effects, as well as modifications in the IVF laboratory techniques, which prevent oocyte/embryo exposure to such autoantibodies, are the reasons for contradictory reports.
Key words: Endometriosis, infertility, IVF, Autoantibodies
Endometrial ablation; hysteroscopic and
non-hysteroscopic.
Robert S. Neuwirth.
St. Luke's-Roosevelt Hospital Center New York City
ABSTRACT
Menorrhagia is a
widespread condition primarily afflicting women over age 35 causing anemia and
serious life-style problems. In the United States it is estimated that 300,000
hysterectomies are performed annually for the correction of menorrhagia with or
without associated fibroids. The history of endometrial ablation dates back to
the mid-twentieth century. Modern hysteroscopic ablation developed in the early
1980's, following the establishment of reliable diagnostic hysteroscopy using
C02, 5 % dextrose in water, and Hyskon (32% dextran 70). Since these
developments, a variety of modifications have been described, such as the
rollerball electrode, continuos flow resectoscopes, pre-treatment gonadotrophin
agonist ovarian suppression, and others. In spite of all the positive data about
hysteroscopic endometrial ablation, few procedures were done. In the U.S. it was
estimated that 20,000 ablations were being done annually while 200,000
hysterectomies were done for the same indications. The FDA approved a
prospective, randomized trial comparing rollerball hysteroscopic ablation to the
non-hysteroscopic balloon method. The results show reductions in menstrual blood
loss to levels of eumenorrhea or less to be statistically the same in both
groups. On the basis of this study the FDA approved the product for sale in
December 1997. It is clear that a new approach to the management of
perimenopausal menorrhagia is opening up. The patients who want to avoid
hysterectomy to cope with their bleeding will have a new choice, and
gynecologists will be able to offer their patients another option which is
easier to provide than hysteroscopic ablation or hysterectomy, probably not
require general or regional anesthesia, lower the total costs of providing the
treatment, and has less risk of injury.
Key Words: Endometrial ablation, resectoscope, menorrhagia, non-hysteroscopic ablation.
Preliminary results of intracytoplasmic
spermatid injection in patients with spermatogenetic maturation
arrest.
S. Al-Hasani, DMV, Ph.D.* †, I. Palermo, Ph.D. ‡,
W. Küpker, M.D., Ph.D.*, J. Sandmann, M.D. §, R. Johannisson, Ph.D., P. Fornara,
M.D., Ph.D. §, R. Sturm*, M. Bals-Pratsch, M.D. *, O. Bauer, M.D., Ph.D.*, K.
Diedrich, M.D., Ph.D.*
Department of
Gynecology and Obstetric, Department of Urology, and Institute of Pathology,
Medical University Lübeck, Lübeck, Germany; and University of Catania, Istituto
di Medicina Interna e Specialita' Internistiche, Ospedale Garibaldi, Catania,
Italy.
ABSTRACT
Objectives: In this study, an attempt was made to establish
intracytoplasmic injection of spermatids in our laboratory to include patients
with complete Sertoli-Cell-Only-Syndrome and spermatogenetic maturation arrest
in our ICSI program.
Design: Prospective study.
Subjects: Four patients were diagnosed to have complete Sertoli-Cell-Only-Syndrome. Additional biopsies confirmed the diagnosis in two patients, while in the other two a focal functional spermatogenesis at the stage of elongation was found.
Intervention: The tissues were cryopreserved until the time of follicle puncture. Women were stimulated using the long protocol by gonadotrophin injections after down regulation with a GnRH-agonist. The intracytoplasmic injection was performed according to a standard ICSI-procedure using an injection pipette of 8-10 µm diameter. 41 oocytes were harvested. In two patients cryopreserved elongated spermatids were successfully injected while in the other two patients cryopreserved round spermatids were possible to be injected into the oocytes.
Main outcome measures: Fertilization and pregnancy rates.
Results: 10 out of 18 oocytes were fertilized in the first group while 5 out of 16 injected oocytes showed fertilization and cleavage. Two clinical pregnancies were achieved with elongated spermatids, while in case of round spermatids, no pregnancy could be established.
Conclusions: This study confirms that fertilization, cleavage and pregnancy could be successfully achieved in cases with spermatogenetic maturation arrest by injecting cryopreserved elongated as well as round spermatids into oocytes.
Key Words: Spermatogenetic maturation arrest, ROSI, ELSI, Cryo-TESE, ICSI.
Asymptomatic chlamydia trachomatis infection
in a fertile population in Edinburgh, United Kingdom.
Tarek
K. Al-Hussaini, M.D., M.R.C.O.G.
Faculty of Medicine, Assiut University, Assiut, Egypt and Edinburgh
Royal Infirmary, Edinburgh, UK.
ABSTRACT
Objectives: To investigate the prevalence of Chlamydia trachomatis in a pregnant population. To evaluate efficiency of set-up of chlamydia diagnosis in a busy termination of pregnancy (TOP) clinic.
Design: Prospective cross-sectional study of patients undergoing TOP between January and December 1996.
Setting: Royal Infirmary of Edinburgh (RIE) - TOP Clinic.
Subjects: One thousand nine hundred and sixty-seven (1967) pregnant women were screened during this period.
Intervention: Endocervical swab for detection of
Chlamydia trachomatis was taken before surgical TOP ( no. = 959), first
trimester medical TOP ( no. = 850) and second trimester medical TOP
( no. = 158).
Main outcome and results : Prevalence of
chlamydia was (5.4%) among those who had surgical TOP and (4.8%) among those who
had medical TOP. Testing was carried out in ( 1896 / 1976 = 96.4% ) of
patients attending the clinic. Test of cure was performed
in ( 44 / 98 = 44.9%) of these women and revealed 100%
cure.
Conclusions: Screening for chlamydia is important in pregnant women especially those attending TOP clinics. Screening and selective treatment is cost effective in patients attending TOP clinics. There is still a room for improving screening and treatment at Royal Infirmary of Edinburgh.
Key words: C. Trachomatis - Pregnancy- Termination of Pregnancy.
The place of endoscopic ovarian cystotomy
(ovarian drilling) in the management of polycystic ovarian syndrome.
Hassan A. Nasrat, F.R.C.S., F.R.C.O.G.*, Manal M. Badawy, M.B.B.Ch.†,
Hassan Youssef, F.R.C.O.G.†
King Abdulaziz University Hospital, and Erfan and Bagado Hospital, Jeddah, Saudi Arabia.
ABSTRACT
Objective: To examine the outcome of endoscopic ovarian cystotomy (ovarian drilling) in patients with polycystic ovarian disease (PCOD).
Setting: Erfan Bagado General Hospital, Jeddah.
Design: The medical records of all patients who were admitted for endoscopic ovarian drilling over 24 months period were retrospectively reviewed. Patients’ characteristics including type and duration of infertility, results of investigations and any previous treatment received for infertility were recorded. As an endpoint for endoscopic ovarian drilling, achievement of pregnancy during the 6 months following the operation was considered as a satisfactory outcome.
Results: A total of 49 patients underwent endoscopic ovarian drilling, of those 37 were available for follow up. The diagnosis of PCOD was mainly based on the clinical finding of oligomenorrhea with obesity and/or hirsutism in infertile women. Further hormonal tests and/or pelvic ultrasound scan were not always requested. Following endoscopic ovarian drilling clinical pregnancy occurred in 16 patients (43.2%), 4 patients conceived with no further medications, while 8 patients required anti-estrogen therapy and 4 patients required further gonadotrophin administration.
Conclusion: Patients with PCOD are inevitably exposed to some level of risk regardless of the method used for induction of ovulation whether medical or surgical. Ovarian drilling is now a recognized treatment modality for PCOD. However because of its association with periovarian adhesion, it may currently be offered only to patients who have failed to conceive after reasonable attempts of medical induction of ovulation. As a primary treatment option, prospective studies are needed to identify subgroup of women with PCOD in whom the balance of benefit would be more towards surgical rather than medical induction of ovulation.
Key words: Infertility, polycystic ovary, ovarian drilling.
Sperm viability in human semen specimens
cryostored at 5oC using the Bio-Tranz™ container system for semen
transport.
Panayiotis M. Zavos *†‡, Juan R. Correa *§, William
Clark, Panayota N. Zarmakoupis-Zavos *‡
Andrology Institute
of Lexington and Kentucky Center for Reproductive Medicine, Lexington,
Kentucky.
ABSTRACT
Objective: To asses a protocol designed for transport of unprocessed human semen specimens from the production site to distant laboratories.
Design: The viability of semen specimens stored from the time of collection to the time at which the specimens were to be processed and used (24 hr after collection) was evaluated using the Bio-TranzTM technology. Specimens were assessed for percentage and grade of motility, and for the sperm membrane functional integrity as measured by the hypoosmotic swelling (HOS) test. The semen specimen was split into two aliquots (Aliquot 1 and 2) and transferred to 15.0 ml conical centrifuge tubes. Aliquot 1 was used without further processing and Aliquot 2 was mixed 1:1 (v/v) with TYB media. Aliquot 1 was maintained at 21oC. Aliquot 2 slowly cooled to 5oC by placing the tube into the middle compartment of the Bio-TranzTM container.
Setting: Andrology Institute of Lexington, Lexington, Kentucky.
Patients: Semen specimens (n=30) were collected by each participant at intercourse via the use of the MFP TM and delivered to the Andrology Institute of Lexington for processing.
Main Outcome Measure(s): Viable cryostorage of semen specimens during transport at 5oC for 24 hr for andrological evaluation or use in assisted reproductive technologies.
Result(s): Significant differences (P<0.05) in all sperm parameters assessed were noticed between the unprocessed and TYB-prepared specimens after storage for 24 hr. Sperm characteristics were improved when preparing the specimens using TYB (Time 0; P<0.05). Sperm characteristics between the unprocessed (Time 0) and TYB-prepared specimens (24 hr) were not different (P>0.05).
Conclusion(s): Collection and preparation of human semen for transport at 5oC is possible and that the Bio-Tranz TM container maintains adequate sperm viability after 24 hours of cryostorage. The use of the Bio-TranzTM container is convenient for patients that request semen processing services or for other clinical purposes at distant locations.
Key words: semen, spermatozoa, cryostorage, viability, transport
Superovulation and intrauterine insemination
for male factor infertility: a controlled randomized study.
K.A. Jaroudi, F.R.C.S.C*†, H. Hollanders, Ph.D.*, U. Sieck,
F.R.C.O.G*, A. Zahrani, M.B.B.S‡, I. Al-Nour, M.T‡, A. Atared, B.S‡
Department of Obstetrics and Gynecology, King
Faisal Specialist Hospital and Research Center; Riyadh, Saudi Arabia
ABSTRACT
Objective: To determine whether intrauterine insemination (IUI) and controlled ovarian stimulation gives a higher pregnancy rate than natural intercourse and controlled ovarian stimulation.
Design: Prospective randomized controlled trial, and review of the following 2 years experience.
Setting: Tertiary care center.
Patients: Couples with male factor sub-fertility. A total of 36 couples completed 110 randomized cycles. After the randomized trial another 218 couples completed 355 IUI cycles.
Interventions: Intrauterine insemination was performed after controlled ovarian stimulation. In the randomized study the control cycles (56 cycles), consisted of timed intercourse and controlled ovarian stimulation.
Results: There were 8 clinical pregnancies in the 54 IUI cycles, whereas there was no clinical pregnancy in the 56 control cycles. The clinical pregnancy rate in the IUI cycles (14.8% per cycle) was significantly higher than that in control cycles (0%). In the 2 year practice the clinical pregnancy rate was 22.5% (65 out of 355 cycles) that compared favorably with the outcome of the randomized study.
Conclusion: Intrauterine insemination after ovarian stimulation, is of benefit in treatment of infertile couples with abnormal semen and is advocated prior to the employment of other advanced reproductive technologies as intracytoplasmic sperm injection.
Key Words: insemination, male factor, prospective, randomized, controlled
The value of ICSI in cases of repeated
fertilization failure in IVF versus cases with severe male
infertility.
Essam Al-Dein M. Khalifa, M.D.*†, Karim H.
Abdel-Maeboud, M.D. *‡, El-Sir A. Al-Hussein, M.R.C.O.G.*
Infertility/IVF Center- King Fahd Specialist Hospital - Buraidah, Al-Qassim, Kingdom of Saudi Arabia.
ABSTRACT
Objective: To evaluate the outcome of intracytoplasmic sperm
injection (ICSI) in cases with repeated fertilization failure after in-vitro
fertilization (IVF) vs. cases with severe male
infertility.
Design: Prospective clinical study.
Setting: Infertility / IVF center, (Governmental hospital).
Patients: Seventy-one couples underwent 71 cycles of ICSI for severe male factor (Group I, 49 cycles - 369 oocytes) and previous fertilization failure after IVF (Group II, 22 cycles - 204 oocytes).
Main outcome measures: Fertilization and cleavage rates.
Results: Oocyte maturity, Metaphase II (M-II), was greater in Group I, 327/369 (89%) compared to Group II, 156/204 (76%), (P<0.001). In Group I, 3 cycles resulted in no fertilization (NF), 2 of them had immotile sperms, while 3 cycles in Group II resulted in NF, possibly due to cytoplasmic immaturity or an inborn error. In Group II, normal fertilization rate was higher, yet not statistically significant (59% vs. 55%), while, the incidence of triploidy was significantly higher (9% vs. 2%; P<0..01) and the cleavage rate was significantly lower (75% vs. 89%; P<0.01). No significant difference concerning the clinical pregnancy/embryo transfer (ET) (31.6% vs. 24%).
Conclusions: This study suggests that sperm and oocyte quality affect the process of fertilization, hence no significant difference among the 2 groups. But the significant difference concerning the triploidy and the cleavage rates is mostly affected by a possible oocyte defect. Measures for better evaluation of the cytoplasmic maturation or chemical tests evaluating the follicular fluid constituents related to maturity are needed. However, proper ovulation induction and delayed interval (> 4 hours) from oocyte retrieval and the time of ICSI may improve the outcome for treating cases with previous fertilization failure after conventional IVF.
Key words: Cytoplasmic maturity, ICSI, IVF failure, severe male factor.
Fallopian tube sperm perfusion versus
Intrauterine insemination: a preliminary report from a university teaching
hospital.
Sadhana K. Desai, F.R.C.O.G., Gautam N.
Allahbadia, M.D., Prema M. Kania, M.D., P.B. PaiDhungat, F.R.C.O.G., Champa M.
Nariani, M.D., Asha B. Singhal, M.D., Vrunda K. Karanjgaokar, M.B.B.S., Anil A.
Gudi, M.D.
Dept. of Obstetrics and
Gynecology, Division of Reproductive Medicine, Bombay Hospital Institute of
Medical Sciences, Bombay, India
ABSTRACT
Objective: To report our preliminary experience with fallopian tube sperm perfusion (FSP) and intrauterine insemination (IUI).
Design: Prospective study over one year from June 1996 to May 1997.
Setting: The Bombay Hospital Institute of Medical Sciences (a postgraduate teaching Institute affiliated to the University of Bombay), Department of Obstetrics & Gynaecology, Division of Reproductive Medicine (University affiliated tertiary care center).
Patients: 332 infertile patients underwent 389 treatment cycles with controlled ovarian hyperstimulation.
Interventions: All patients were treated by IUI (n=369) and FSP (n=20). The IUI cycles were performed using a twin-sheathed IUI canula (Surgimedik, Andheri,India) and the FSPs were all performed using the Labotect IUI canula. (Labotect CmbH, Goettingen, Germany).
Main outcome measures: Clinical PR and complications after both insemination methods.
Results: The overall clinical PR per treatment cycle was 6.6% (26/389). The overall pregnancy rate per patient was 7.8% (26/332). The multiple PR was 0.5% (2/389). The PR per IUI cycle was 7% (26/369) while there were no pregnancies in the FSP group. There were no ectopic pregnancies in our study. Other complications included one vasovagal episode with FSP. There was no clinical evidence of tubal infection, trauma or perforation in either group.
Conclusion: Fallopian tube sperm perfusion has no advantage over intrauterine insemination with or without controlled ovarian hyperstimulation.
Key Words: Fallopian Tube Sperm Perfusion, Intrauterine Insemination, Unexplained Infertility.
Microlaparoscopy: it's
evolution, present and future.
Oscar D. Almeida,
Jr., MD, FACOG, FACS* †, Botros Rizk, MD, MA, MRCOG, FRCS(C), FACOG,
HCLD*
Department of Obstetrics and Gynecology, University of South Alabama College of Medicine and Providence Park OB-GYN, PC, Mobile, Alabama.
ABSTRACT
The twentieth century has brought many innovations for the evaluation and treatment of gynecologic patients with chronic pelvic pain and infertility. Miniaturized laparoscopes and instrumentation have enabled us to provide surgical evaluation and treatment in a more minimally invasive fashion. The purpose of this paper is to review the evolution of microlaparoscopy since its inception and applicability in gynecology and reproductive medicine today.
Key words: Microlaparoscopy, history,
gynecology, reproductive medicine.
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