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Department of Obstetrics and Gynecology, St James’s University Hospital, Leeds, UK
ABSTRACT
Infertility is explained by uterine factors in only a minority of cases. These factors have traditionally been investigated with hysterosalpingogram. Hysteroscopy is more accurate than hysterosalpingogram and vaginal ultrasound. Hysteroscopy is often better tolerated than hysterosalpingogram. Sonohysterography is more accurate than hysteroscopy as far as investigation of uterine fibroids is concerned. There is some evidence that the routine use of hysteroscopy for the investigation of the infertile patient does alter the management of infertile patients. Hysteroscopic treatment of uterine factors associated with infertility (septum, fibroids and adhesions) is safer than traditional open methods. Term pregnancy rates in excess of 50% are often achieved. The best results are obtained with hysteroscopic division of adhesions. Vaginal route of delivery is usually possible after hysteroscopic treatment.
Key words: infertility, imaging, uterine fibroids, uterine septum, intrauterine adhesions, hysteroscopy, hysteroscopic treatment, surgery.
Klinefelter's syndrome: critical review and
new developments
Fady I. Sharara, M.D
Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA.
ABSTRACT
Objective: Until recently, men with classic 47,XXY Klinefelter*s
syndrome were considered to be mostly azoospermic, and with rare exceptions,
were thought to be sterile. Dramatic recent events describing successful births
to men with classic Klinefelter*s syndrome using ICSI have shattered this prior
concept that these men are sterile.
Design: Critical review of recent manuscripts on the subject.
Results: Two separate groups of investigators have reported successful births using ICSI in men with classic Klinefelter*s syndrome using ejaculated and testicular spermatozoa. Genetic analysis of the offspring showed normal karyotypes in the 5 reported births to date. In another recent study using fluorescent in-situ hybridization (FISH), the percentage of abnormal spermatozoa in one man with a mosaic variant was shown to be much lower than noted in somatic cells.
Conclusions: ICSI has once again revolutionized the treatment of severe male infertility. Despite the successful births to men with classic Klinefelter*s syndrome, it is imperative that extensive genetic counseling be performed prior to treating men with this common syndrome. More data are clearly needed before recommending treatment for such couples. Recent data on the low incidence of abnormal spermatozoa in a man with the mosaic variant is encouraging, and similar investigations should be performed in men with the classic syndrome.
Key words: Klinefelter*s syndrome, ICSI, infertility, FISH
Technique of transmyometrial embryo
transfer
Khaldoun Sharif, M.R.C.O.G., M.F.F.P., F.I.C.S. †,
Osamu Kato, M.D. ‡
Assisted Conception Unit,
Birmingham Women's Hospital, Birmingham, UK and Kato Ladies' Clinic, Tokyo,
Japan.
ABSTRACT
We have originally devised
the Towako transmyometrial embryo transfer method and currently perform it
regularly at our centers; in all embryo transfers in Japan and following
difficult immediate mock transcervical transfer in England. Our published
results (over 1000 cases) compare favorably to the results from transcervical
transfers. Yet, other centers' results (both published and anecdotally reported)
are not as successful. This may be due to significant differences between our
method and theirs. In this report we present a detailed, step-by-step
description of our transmyometrial embryo transfer method as well as discuss the
issue of training. This information will allow other centers to use the method
correctly and validate its results.
Key Words: Embryo transfer, in-vitro fertilisation, techniquel transmyometrial.
Abnormal oocytes: an underestimated
infertility factor revealed by intracytoplasmic sperm injection
Ragaa T. Mansour, M.D.*†, Ahmed Kamal, M.D.*, Mohamed A. Aboulghar,
M.D.*, Nevine A. Tawab, B.Sc.*, Gamal I. Serour, M.D.*, Hana M. Aboulghar,
M.D.*
The Egyptian IVF-ET Center, Maadi, Cairo, Egypt.
ABSTRACT
Objectives: To identify ICSI cycles in which all the oocytes had different morphological abnormalities and relate it to fertilization rate (FR), pregnancy rate (PR), and pregnancy outcome (PO).
Design: Retrospective controlled study.
Patients: Male factor infertility, unexplained infertility and previous fertilization failure in conventional IVF.
Interventions: Intracytoplasmic sperm injection.
Main outcome measures: Fertilization, pregnancy, and miscarriage rates.
Results: A total of 1000 ICSI cycles were revised and 66 cycles (6.6%) were diagnosed to have abnormal morphology for all oocytes. Out of 66 cycles with abnormal oocyte morphology, extracytoplasmic fragments were present in 18 cycles (27%), 11 cycles (17%) with vacuolated cytoplasm, 25 cycles (38%) with dark granular cytoplasm, 9 cycles (14%) with irregular outline of the cytoplasm, and 3 cycles (4%) with structureless solid zona. The fertilization rate, pregnancy rate and abortion rate were 47%, 26%, and 65% in the abnormal oocyte group as compared to 56%, 39% and 22% in the control group, respectively. It was very striking that 11 out of the 17 pregnancies (65%) from the abnormal oocyte group ended in a first trimester abortion.
Conclusions: Cycles in which all the oocytes had abnormal morphology represented 6.6% in 1000 ICSI cycles. Abnormal oocytes represented 5.7% of all oocytes injected. The abnormal oocyte morphology significantly lowered the fertilization rate and embryos developing from them had a very poor chance of ongoing pregnancy.
Key words: Abnormal oocyte morphology, ICSI, oocyte factor infertility, fertilization.
Hysteroscopic evaluation of the uterine cavity
following surgical evacuation
Ahmed L. Aboul Nasr, M.D.,
Saaed M. Thabet, M.D., Hesham G. Al-Inany, M.Sc., Mohamed Aboulghar,
M.D.
Gynecology & Obstetrics Department, Faculty of Medicine, Cairo University.
ABSTRACT
Objective: To investigate hysteroscopically the incidence , extent and grade of intrauterine adhesions (IUA) following surgical evacuation in addition to any other abnormalities in the uterine cavity.
Design: Clinical prospective single-center study.
Setting: Cairo University Hospital.
Patients: 100 patients with history of surgical evacuation divided into two groups, the secondary infertility group (no=57) with a duration of infertility ranging between 1-14 years (mean of 4 years) and the recent aborters group (no= 43) with history of surgical evacuation in the last 6-12 weeks.
Interventions: All patients were subjected to diagnostic hysteroscopy. Hysterosalpingography was done for all infertility cases and 15 recent aborters. Diagnostic laparoscopy was done for all infertility cases and 12 cases of recent aborters. Adhesiolysis was done to disrupt the adhesions.
Main Outcome measures: Incidence, extent and grade of intrauterine adhesions following surgical evacuation.
Results: 64 patients showed intrauterine pathology. Total incidence of IUA was 42%. (no=42). The incidence in the infertility group was 49.1% (no=28cases). It was higher than that in the group of recent aborters (32.6%) (no=14 cases). Intrauterine adhesions in recent aborters were mostly filmy adhesions Grade I ( 71.4%) while in the infertility group cases with IUA were nearly equally distributed among the three grades : Grade I (35.7%), Grade II ( 32.1 %) and Grade III ( 32.1%). The menstrual pattern was found to be correlated with the extent of IUA in most patients. Hysteroscopic findings agreed with hysterosalpingographic findings in about 70% of the cases.
Conclusion: hysteroscopy is an accurate method for the diagnosis of intrauterine adhesions and abnormalities of the uterine cavity such as septae, polyps, submucous myoma. It allows excellent view for the intrauterine adhesions : site, extent and density. The impact of filmy intrauterine adhesions (grade I) on reproductive performance needs further study. Hysteroscopy should be considered in every secondary infertility case with history of surgical evacuation.
Keywords: Hysteroscope, intrauterine adhesions, secondary infertility hysterosalpingography, abortion, surgical evacuation
Exogenous gonadotropin therapy and
intrauterine insemination : the role of etiology and prognostic
factors
Cemal Tamer Erel, M.D.*, Koray Elter, M.D., Levent
Senturk, M.D., Hakan Seyisoglu, M.D., Engin Oral, M.D., Erdogan Ertungealp,
M.D.
Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Cerrahpasa School of Medicine, Istanbul University, Turkey
ABSTRACT
Objectives: To investigate the results of exogenous gonadotropin therapy (hMG) and intrauterine insemination (IUI) in various forms of infertility and to identify some prognostic factors for the success of this therapy.
Design: Retrospective analysis.
Setting: A university hospital.
Subjects: Eighty nine women undergoing a total of 158 cycles were treated by a combined therapy regimen consisting of (hMG) or urinary FSH, and (hCG), and IUI. Infertile couples were divided into three distinct groups with respect to the etiologic factor: group I, male subfertility (n patient = 9, n cycle = 12); group II, unexplained infertility (23/39); and group III, ovulatory disorders (57/107). Women with ovulatory disorders were also divided as group IIIA (15/42), which included patients with World Health Organization (WHO) group I ovulatory dysfunction and group IIIB (42/65), which included patients with WHO group II ovulatory dysfunction.
Main Outcome Measure(s): Total number of ampules of gonadotropins used in the cycle, duration of ovulation induction, serum estradiol (E2) level and number of mature follicles (diameter * 14 mm) on the day of hCG administration and also ovulation, pregnancy and complication rates of cycles in each group were analyzed.
Results: Mean duration of ovulation induction and mean number of ampules per cycle were significantly higher in group III than those in other groups (p * 0.0001). Patients in group III had more mature follicles prior to hCG administration than those in group II (p < 0.001). Mean number of ampules per cycle in group IIIA was also higher than those in group IIIB (p * 0.0001). Ovulation rates per cycle were 83% in group I, 90% in group II, 81% in group IIIA, and 74% in group IIIB. Pregnancy rates per cycle were 0%, 13%, 7%, and 22% in each group, respectively. There were no pregnancies in cycles in which more than 30 ampules of gonadotropins were used and in women whose ages were above 40 or below 20 years. The highest pregnancy rates were found when serum E2 levels were between 500 and 2,000 pg/mL and number of mature follicles was 6 or 7 on the day of hCG administration.
Conclusion: Exogenous gonadotropin therapy and IUI might be administered in unexplained infertility and infertility due to ovulatory disorders before going on with assisted reproductive technologies. However, ovulation induction with gonadotropins may not enhance the pregnancy rate in infertile couples with male subfertility.
Key Words: Unexplained infertility, male subfertility, ovulatory disorders, gonadotropins, COH, IUI.
The outcome of pregnancies conceived
spontaneously in the index cycle of luteal phase long protocol pituitary down
regulation prior to commencement of controlled ovarian stimulation for
IVF-ET.
Patrick E. Egbase, M.R.C.O.G.* I, Muna S.
Al-Sharhan, C.A.B.O.G. I, J. Gedis Grudzinskas, M.D.*
Academic Department of Obstetrics & Gynaecology, St Bartholomew*s, The Royal London School of Medicine & Dentistry, Royal London Hospital, London, and IVF Centre, Maternity Hospital, Kuwait City, Kuwait
Abstract
Objective: to determine the outcome of spontaneous conceptions in women exposed to gonadotrophin releasing hormone agonist (GnRH-a) from the mid-luteal phase awaiting controlled ovarian stimulation (COS) for in vitro fertilization or intracytoplasmic sperm injection.
Design: retrospective case record analysis.
Setting: treatment cycles commenced at the IVF Centre, Maternity Hospital, Kuwait.
Patients: eight women who conceived spontaneously having commenced GnRH-a prior to COS.
Main outcome measures: the course and clinical outcome of these eight pregnancies.
Results: eight women (1.3%) of 621 women who underwent treatment were found to be pregnant, two of whom had ectopic pregnancy, one miscarried and five had uneventful pregnancies leading to the birth of an apparently normal infant at term.
Conclusion: spontaneous pregnancy is possible in women exposed to GnRH-a while awaiting COS. There is no evidence of any deleterious effects on the course or outcome of pregnancy or the neonates in these pregnancies.
Key words: GnRH-a, pregnancy outcome
Transcervical Division of uterine septum: a
prospective study from 1987-1996.
Shirish S. Sheth, Gautam
N. Ailahbadia and Shubhada S. Khandeparkar.
Department of Obstetrics and Gynaecology, Sir H.N. Hospital, Department of Obstetrics and Gynaecology, Bombay Hospital Institute of Medical Sciences, and Department of Obstetrics & Gynaecology, Bandra Bhabha Hospital, Bombay, India.
ABSTRACT
Objective: To assess the value & safety of the different
approaches to transcervical division of uterine septum in contemporary
practice.
Design: Prospective Study.
Setting: University Based Teaching Hospital & the first author's private clinic.
Patients: 36 patients with septate-uterus as proved by HSG and Laparo-Hysteroscopy. 28 women presented with recurrent miscarriage, 7 with preterm deliveries & one with unexplained infertility.
Intervention: Transcervical Division of Uterine Septum was performed using flexible hysteroscopic scissors (n=3), rigid endoscopic scissors (n=24) and a resectoscope (n=9) between January 1987 to December 1996. Patients were followed up until December 1997.
Main outcome measures: Safety and Effectiveness regarding post-operative restoration of normal uterine cavity, uterine perforation & hemorrhage as well as successful pregnancy outcome following the three different approaches with transcervical division of uterine septum.
Results: Transcervical division of uterine septum was performed in 36 cases achieving a perfect restoration of a normal uterine cavity in 33 cases (91.66%). Subtle arcuate configuration, not more than 1 cm in depth , was detected post-operatively in two patients. Perforation occurred in two patients with rigid scissors & bleeding was encountered in two patients but did not require any intervention.
Conclusion: Transcervical division of uterine septum using Rigid Endoscopic Scissors is an efficient and safe technique.
Keywords: Transcervical Division of Uterine Septum, Hysteroscopy, Rigid Endoscopic Scissors
Can the method of sperm preparation for
intrauterine insemination affect subsequent pregnancy
rates? Comparison between the SpermPrep( and the traditional double wash
method.
Panayota N. Zarmakoupis-Zavos,and Panayiotis M.
Zavos.
Kentucky Center for Reproductive Medicine, Andrology Institute of Lexington and University of Kentucky, Department of Reproductive Physiology/Andrology, Lexington, Kentucky, USA
ABSTRACT
Objective: To evaluate and compare the traditional double sperm wash method to the SpermPrepTM filtration technique when processing semen for intrauterine insemination (IUI) and their possible effects on pregnancy rates (PRs).
Design: A prospective study including ninety-one couples participating in this study. The couples underwent IUI under standardized conditions.
Setting: The Andrology Institute of Lexington and the Kentucky Center for Reproductive Medicine
Patients: Two hundred eighty-three couples undergoing infertility treatment were selected for this study. From those, ninety-one couples participated in this study.
Main Outcome Measures: Pregnancy rates per patient and pregnancies per cycle.
Results: The clinical PRs and clinical PRs per cycle were statistically superior when the SpermPrepTM semen preparation method was employed.
Conclusions: The results obtained suggest that IUIs with high quality sperm recovered via the SpermPrepTM filtration method combined with controlled ovarian hyperstimulation (COH) offer a simple alternative and superior mode of treatment for couples with unexplained infertility.
Key Words: Intrauterine insemination, semen preparation, SpermPrepTM, pregnancy rates
A modified low dose gonadotrophin-releasing
hormone agonist protocol for poor responders in IVF.
Raja
Z. Karaki, Hisham M. Hilow, Maher G. Sarraf, Falah A.Khalifa and Mahmoud R
Taher. .
Fertility and Assisted Reproduction Unit / Al - Amal Maternity Hospital and Mathematics and Statistics Department, University of Jordan, Amman, Jordan
ABSTRACT
Objective: To determine the effectiveness of a modified low dose GnRH-a in improving the ovarian responsiveness of patients who responded poorly under the long protocol of GnRH-a.
Design : Prospective evaluation of the proposed protocol for comparing eleven stimulation variables affecting IVF outcome in a paired design where each patient served as her own control.
Patients : Thirty IVF patients with previous poor ovarian response (peak Estradiol = 1000 pg/ml and/or oocytes retrieved =4) under the long protocol of GnRH-a were the experimental units of the proposed dose.
Setting : Fertility and Assisted Reproduction Unit / Al - Amal Maternity Hospital / Amman - Jordan.
Methods : Decapeptyl was administered in a daily s.c. dose of 0.05 mg (which is half the standard dose in the long protocol) from the midluteal cycle phase till the day of hCG in combination with gonadotrophins beginning with the cycle onset.
Results : Ovarian responsiveness was almost doubled under the proposed stimulation cycle when compared with that of the previous cycle. This was reflected as a significant improvement in Estradiol on day 5, peak Estradiol level, number of mature follicles, numbers of retrieved, mature and fertilized oocytes, embryos formed and embryos transferred. On the other hand, no differences between the two cycles were noticed in the number of gonadotrophin ampoules, stimulation days and progesterone level on day of hCG. No retrieval cycle was cancelled in comparison to 7 % cancellation in the long protocol. The pregnancy rate achieved was 31% per ET.
Conclusion : The proposed reduced GnRH-a dose may benefit poor responders in enhancing their ovarian responsiveness as it still prevents premature luteinization.
Key words : Low dose GnRH-– a, ovarian
responsiveness, Paired design, poor responders, Student t-test.
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Cryopreservation reduces
the motility and viability of surgically retrieved spermatozoa but does not
affect the outcome of ICSI.
Ahmed Kamal, Ibrahim Fahmy, Ragaa Mansour, Mohamed Aboulghar,
Gamal Serour, Nevin Tawab and Tarek Anis.
The Egyptian IVF-ET Center and the department of Andrology, Cairo University, Cairo, Egypt
ABSTRACT
Objective: To asses the sperm quality and the results of intracytoplasmic sperm injection (ICSI) using cryopreserved surgically retrieved testicular and epididymal sperm.
Design: prospective study.
Setting: The Egyptian IVF-ET Center.
Patients: Forty-three patients with obstructive azoospermia and sixteen patients with non-obstructive azoospermia were included. Excess spermatozoa from 50 patients undergoing testicular sperm extraction (TESE) or epididymal aspiration (PESA) combined with ICSI were cryopreserved. Nine diagnostic testicular biopsy were also cryopreserved to be used in another ICSI cycle.
Main outcome measures: The recovery rate for motility and vitality of cryopreserved spermatozoa after thawing. The Fertilization and pregnancy rates.
Results: The motility and vitality were significantly reduced after cryo-thawing in all patients (initial motility = 9.7% + 12.1, post thawing = 2.7% + 4.5, P < 0.05 - initial vitality =75.8% + 19.0, post thawing = 35.2% + 15.0, P < 0.05). The mean recovery rate (post-thawing / initial X 100) for motility did show significant difference between patients with obstructive and non-obstructive azoospermia (p< 0.05) while no difference was found in the mean recovery rate for vitality. In 9 cases (15.2%), no motile spermatozoa were found after thawing and a fresh biopsy had to be taken to perform ICSI. There were no statistically significant difference between the fertilization and the pregnancy rates for fresh (56.5 % and 20.8 %), compared to cryo-thawed surgically retrieved spermatozoa (55.9 % and 22.2 %, P > 0.05) respectively.
Conclusion: cryopreservation of testicular and epididymal sperm caused significant reduction in motility and vitality. However, enough spermatozoa could be retrieved and were used for ICSI in 84.7% of patients. The FR and PR after ICSI using cryopreserved or fresh surgically retrieved spermatozoa were not significantly different.
Keywords: Testicular sperm extraction - ICSI - cryopreservation - sperm motility - sperm vitality
Microlaparoscopic ovarian drilling under
local anesthesia.
Oscar D. Almeida, Jr., M.D., F.A.C.O.G.,
F.A.C.S.*†‡, Botros Rizk, M.D., M.A., M.R.C.O.G., F.R.C.S.(C), F.A.C.O.G.,
H.C.L.D. *
Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, Mobile, Alabama, USA and Providence Park OB-GYN, PC, Mobile, Alabama, USA
ABSTRACT
The treatment of polycystic ovarian disease continues to evolve. New minimally invasive surgical techniques using local anesthesia with conscious sedation have enabled us to perform operative microlaparoscopy while the patient is awake. We report the first case of microlaparoscopic ovarian drilling under local anesthesia in the surgical management of polycystic ovarian disease.
Key words: microlaparoscopy/ovarian drilling/local anesthesia/conscious sedation/polycystic ovarian disease