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Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD.
ABSTRACT
Women in the mid to late thirties and early forties presenting with infertility constitute the largest portion of the total infertility population. These women frequently undergo multiple testing, and most will require expensive and invasive therapies including assisted reproductive technologies (ART), with markedly reduced pregnancy rates in those over 40. These women also suffer from a higher incidence of pregnancy loss even after documentation of fetal cardiac activity by ultrasound. Identifying those women who have a very low chance of pregnancy (and a high chance of pregnancy loss) using their own gametes presents a daily challenge to the practicing clinician, especially before embarking on expensive treatment. This manuscript reviews the contemporary investigation of reproductive aging using basal and provocative tests. Women with markedly diminished ovarian reserve should be counseled on their low chances of conception using their own gametes, even with ART.
Key Words: ovarian reserve, FSH, inhibin, fertility, ovarian function, ovary, ovulation induction, in vitro fertilization.
Modern intrauterine contraception:
closer than ever to reversible sterilization without an abdominal scar.
John Guillebaud, M.A., F.R.C.S.E., F.R.C.O.G., M.F.F.P.*
Department of Obstetrics and Gynecology, UCL Medical School and Margaret Pyke Family Planning Center, London, UK
ABSTRACT
We now know three important facts. The first is the finding from
the American collaborative review of sterilization (CREST) Study that female
sterilization is less effective than we used to think, especially in the
long-term because late failures are surprisingly common, due to re-canalization.
The second is that the best modern intrauterine devices (IUDs) are far
more effective than many people think, some do not require replacement
for more than 10 years and if fitted after age 40 all of them can be used
until after the menopause. The third fact is that IUDs do not cause PID
(pelvic inflammatory disease). WHO has established, in studies totaling
over 22000 subjects from every continent, that the only time that the risk
of (PID) is higher than the background risk for that particular population
(which varies very much worldwide) is in the three weeks following insertion.
“Indeed, the low long term relative risk of PID seen in the most careful
studies raises doubt whether beyond the first few weeks after insertion,
PID risk is really any greater among users of currently available IUDs
than among women with the same STD risks who do not use contraception.”
If you put these facts together this article argues against such
widespread use of female sterilization worldwide. It is a useful
choice, yes, but no longer to be seen as “the ultimate solution.”
Why? Because of a “PUSH” away: its lifetime risk of failing the woman
is so much higher than we used to think (even the best available laparoscopic
method, which is the Filshie clip, has recently been estimated to have
a lifetime failure rate of 1 in 200. But even more importantly, because
of a “PULL” - because they are so effective - towards particularly the
copper T380 and, in those countries where they are available, the new frameless
implantable GyneFix or the levonorgestrel IUDs (Mirena) with its additional
gynecological benefits.
If sterilization is nevertheless desired, modern data support
a vasectomy failure rate after 2 negative sperm counts of < 1 in 2000,
which is thus at least 10 times more effective than female sterilization.
Key Words: intrauterine contraception, efficacy of modern copper IUDs, pelvic inflammatory disease, efficacy of female sterilization, vasectomy.
A pregnancy and children follow-up
study of three randomised clinical trials with recombinant follicle-stimulating
hormone (Puregon®) in in-vitro fertilisation.
Henk J. Out, M.D., Ph.D., Stefan G.A.J. Driessen, Ph.D., Bernadette
M.J.L. Mannaerts, M.Sc. Herjan J.T. Coelingh Bennink, M.D., Ph.D.
NV Organon, PO Box 20, 5340 BH Oss, The Netherlands
ABSTRACT
Objective: To compare obstetrical and neonatal outcome of IVF pregnancies following recombinant FSH (Puregon®) or urinary gonadotropin stimulation.
Design: Pooling of data derived from three prospective, randomised, multicentre trials.
Setting: Twenty-five IVF clinics
Population: 159 ongoing pregnancies after recombinant and 83 after urinary gonadotropin stimulation.
Main outcome measures: Gestational age, obstetrical complications, birthweight, congenital malformations.
Results: The average gestational age for singleton pregnancies in the recombinant and urinary gonadotropin groups were 39.6 and 39.5 weeks, respectively. For the multiple pregnancies, these ages were 36.6 and 35.6 weeks. A significantly lower number of small-for-gestational age children was seen in the recombinant FSH multiple pregnancy group (18%) as compared to the urinary gonadotropin group (34%). In the multiple pregnancies, the proportion of neonates with a birth weight < 2500 g was 58% and 63% in the recombinant and urinary gonadotropin groups, respectively. The overall malformation rate was 5.0% in the recombinant FSH group and 3.6% in the urinary gonadotropin group.
Conclusion: The use of recombinant FSH (Puregon®) does not result in increased adverse obstetrical and neonatal outcomes as compared to urinary gonadotropins.
Key words: recombinant FSH, Puregon®, pregnancies, follow-up
Molecular size heterogeneity of human
prolactin in serum and follicular fluid at mid-cycle.
M.A. Kamel, M.D.* ‡ W. Bernart, M.D.†, J. Neulen,
M.D.†, M. Breckwoldt, M.D. †
Division of Clinical Endocrinology, Department of Obstetrics and Gynecology, University of Freiburg, Germany and Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt.
ABSTRACT
Objectives: This study was done to investigate the distribution of prolactin (PRL) isomolecular forms in serum and follicular fluid (FF).
Design and subjects: serum and FF from eight women with suppressed pituitary gonadotropin secretion by gonadotropin releasing hormone agonists (GnRH-A) were treated with human menopausal gonadotropin (HMG) for in-vitro fertilization. Serum and follicular fluid (FF) were collected at the day of ovum pick-up.
Interventions and Methods: Serum and FF were analyzed by column chromatography to study the distribution of PRL isomolecular forms. FF obtained from mature follicles from the same patient was pooled. Serum and FF were concentrated by lyophilization prior to sephacryl S-100 high-resolution column chromatography. Fractions were assayed by PRL immunoassay. The molecular weight of PRL forms was calculated by reference to the elution volumes of ribonuclease A, chymotrypsinogen A, ovalbumin, albumin and blue dextran.
Results: The low-molecular weight of immunoreactive PRL accounts for 81.4% and 92.5% in serum and FF, respectively. The difference was statistically significant (P<0.01). High molecular weight component (big-big and big PRL) accounts for 18.6% and 7.5% in serum and in FF, respectively.
Conclusion: These results demonstrate the presence of different isomolecular forms of PRL in serum and FF in stimulated cycles. The significant differenin the distribution of these forms, between serum and follicular fluid in the same patient, may be explained by selective diffusion of little PRL form from serum to FF or may be due to local synthesis.
Key words: gel chromatography, prolactin heterogeneity, serum, follicular fluid, IVF.
Results of intracytoplasmic sperm injection
using the microprocessor controlled TransferMan
Eppendorf manipulator system.
Safaa Al-Hasani, D.M.V., Ph.D.*, Otmar Bauer, M.D., Ph.D.*, Michael
Ludwig, M.D.*, Rita Sturm*, Oya Karabulut, M.D. †, D. Kahle, Ph.D.§,
Fayza Al-Dimassi, B.Sc. ‡, Klaus Diedrich, M.D., Ph.D.*
Department of Gynecology and Obstetrics, Medical University of Lübeck, Germany
ABSTRACT
Objective: To compare the results of intracytoplasmic sperm injection (ICSI) using a new, microprocessor-controlled manipulator system with a conventional micromanipulator.
Design: Prospective, non-randomized, controlled study.
Setting: Tertiary care fertility department.
Patients: 136 infertile patients with male factor infertility.
Intervention: ICSI was performed using microprocessor-controlled manipulator system.
Results: 1239 oocytes were collected in 136 cycles. 1151 were metaphase II oocytes and 1142 were injected. 1008 (88.2%) were intact after ICSI, 765 showed two pronuclei 16 hours later (75.89%). 128 embryo transfers were performed, giving a clinical pregnancy rate of 34.55% per cycle and 37% per transfer. These data were in the same range as those from 1493 ICSI cycles performed before, using a conventional ICSI system (Narishige). However, the time needed for ICSI of five oocytes was less using the Eppendorf system (5 min) compared to that of the Narishige system (8 min).
Conclusion: Performing ICSI using an Eppendorf manipulator equipment can achieve high fertilization as well as pregnancy rates which are comparable to the results achieved by using a conventional equipment. The Eppendorf manipulator is easy to use, the training procedure is short and the possibility of storing two different pipette positions - e.g. for sperm sampling/injection and parking for sperm transfer from one droplet to another - makes working with this system fast and very efficient.
Keywords: ICSI, TransferMan, laboratory equipment, ART.
Relationship between testicular histopathology
and the outcome of testicular sperm extraction combined with intracytoplasmic
sperm injection in patients with non-obstructive azoospermia.
Ibrahim Fahmy, M.D., Ahmed Kamal, M.D., Ragaa Mansour, M.D.,
Nevine A. Tawab, B.Sc., Mohammed Aboulghar, M.D., Yehia Amin, M.D., Gamal
Serour, M.D.
The Egyptian IVF-ET Center and the department of Andrology, Cairo University - Cairo Egypt
ABSTRACT
Objectives: To report the outcome of testicular sperm extraction (TESE) combined with intracytoplasmic sperm injection (ICSI) after grouping patients with nonobstructive azoospermia according to the type and degree of testicular histopathology.
Design: Retrospective study.
Setting: The Egyptian IVF-ET center.
Patients: 257 consecutive patients with non-obstructive azoospermia who underwent 289 ICSI cycles using surgically retrieved testicular spermatozoa.
Intervention: An extra piece of testicular
tissue, taken during TESE, was prepared for histopathologic examination
and grouped according to well-defined histopathologic patterns.
Main Outcome Measures: The sperm recovery rate (SRR), the clinical
pregnancy rate per completed ICSI cycle (PR/ICSI) and pregnancy rate per
attempted TESE (PR/TESE) were estimated for each histopathologic pattern.
Results: The overall SRR, PR/ICSI, and PR/TESE were 64.7%, 20.3%, and 13.1% respectively. In different histopathologic patterns the SRR were as follows; hypospermatogenesis, 92.3%; incomplete spermatogenic arrest, 90.3%; arrest at early spermatid stage, 57.8%; arrest at primary spermatocyte stage, 26.9%; incomplete Sertoli cell only (SCO), 82.7%; complete SCO, 26.5%; tubular hyalinization, 70.8% respectively. The lower SRR observed in patients with complete spermatogenic arrest and complete SCO were statistically significant compared to patients with incomplete spermatogenic arrest and incomplete SCO respectively (P<0.05). The FR, PR/ICSI, and PR/TESE did not show significant differences among different groups except in cases with complete arrest at primary spermatocyte stage which showed lower PR/TESE compared to patients with partial spermatogenic arrest.
Conclusions: Among patients with non-obstructive azoospermia, the SRR and PR/TESE were less in cases with testicular histopathologic patterns showing more advanced spermatogenic impairment. The FR and PR/ICSI did not show significant differences among various groups.
Keywords: Testicular sperm extraction, ICSI, non-obstructive azoospermia, testis biopsy, testicular histopathology.
The inability to produce semen specimens
at the time of seminal evaluation may reflect difficulties with sexual
drive and deficient seminal parameters.
Panayiotis M. Zavos, Ed.S., Ph.D.*†§, Panayota N. Zarmakoupis-Zavos,
M.D.*†§, Juan R. Correa, Ph.D.*‡§, Pavlos Aslanis, M.D.§,
Spyros Antypas, M.D.||, Constantinos N. Zarmakoupis, M.D.*
Andrology Institute of America and Kentucky Center for Reproductive Medicine, Lexington, Kentucky; Centro de Fertilidad del Caribe, Puerto Rico; and Greek-American Institute of Andrology and Department of Pediatric Surgery, Children’s Hospital “Ayia Sofia”, Athens, Greece.
ABSTRACT
Objective: The objective of this study was to assess the relationship of seminal characteristics and sexual drive in patients that could or could not produce a semen specimen at first attempt via intercourse for andrological evaluation.
Design: Controlled prospective study.
Setting: Clinical and research environment.
Patient(s): Subjects (n=127) were asked to
fill out a questionnaire and were instructed to produce an ejaculate at
intercourse via the use of a condom-shaped semen collection device.
Main Outcome Measure(s): Relationship between semen production
ability and seminal characteristics.
Result(s): Subjects that were different in their ability to produce a semen specimen at intercourse and were divided into two groups (Group 1 and 2) according to their ability to produce a semen specimen as instructed. Semen specimens produced by Group 1 patients (could produce a semen specimen at first attempt) showed superior seminal characteristics than those of specimens obtained from Group 2 patients (could not produce a semen specimen at first attempt). A higher proportion of men in Group 2 were considered subfertile or infertile when compared to Group 1 patients. Furthermore, the sexual frequency in Group 2 patients was only 50% of that in Group 1 patients. Group 1 patients and their spouse’s had been trying to establish a pregnancy for 1.8±0.6 years as compared to 4.1±1.0 years for Group 2 patients.
Conclusion(s): The data obtained from the two patient groups depicts rather clearly that patients are different in their sexual habits (sexual frequency) and that the Group 2 patients may have had difficulties exhibiting normal sexual response such as excitement, erection, orgasm and ejaculation. The results obtained are of clinical significance since patients with such difficulties could be identified during their initial evaluation visits and treated at an early time before other psychological problems and frustrations are established.
Key words: Ejaculatory dysfunction, intercourse, semen evaluation, sexual drive.
El Galaa Maternity Teaching Hospital and Diabetic Endocrine Metabolic Pediatric Unit , Cairo University.
ABSTRACT
Objective: To determine the prevalence of late onset congenital adrenal hyperplasia (LOCAH) in a group of women with chronic anovulation presenting with infertility menstrual irregularities and diagnosed as PCOS.
Design: Prospective study.
Setting: El Galaa Teaching Hospital and Cairo University.
Subjects: One hundred Egyptian women with chronic anovulation presenting with infertility, menstrual irregularities and diagnosed as PCOS. Thirty three normal age-matched women.
Intervention: Hormonal profile including testosterone (T), dehydroepiandrosterone (DHEA), DHEA sulphate (DHEAS), androstenedione (D4A), 17 hydroxyprogesterone 17OHP), 17 hydroxypregnenolone (17OHP5), follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2) progesterone (P) and prolactin (PR) was performed in the follicular phase of the menstrual cycle followed by ACTH stimulation test. Dexamethazone therapy was given to patents diagnosis as LOCAH.
Results: 33% of the women diagnosed as PCOS had evidence of LOCAH , 19% of which were due to 21 hydroxylase deficiency and 14% were due to 3? hydroxysteroid dehydrogenase deficiency. Neither the clinical characteristics nor the basal hormonal levels could distinguish women with LOCAH from those with PCOS. Dynamic tests (ACTH stimulation test) are mandatory to differentiate between these types of patients. Dexamethazone therapy is available and very effective for treatment of infertility and menstrual irregularities caused by LOCAH. It resulted in conception of 73% of infertile women, resumption of regular menses in 87% and improvement of hirsutism in 28.6%.
Conclusion: LOCAH is a common cause of subfertility in Egyptian women. ACTH stimulation test is essential for the diagnosis of LOCAH and to differentiate the disease from PCOS. Dexamethazone therapy is effective in treating infertility and menstrual irregularity caused by LOCAH.
Keywords: Late onset congenital adrenal hyperplasia, PCOS, anovulation
Intracytoplasmic injection of testicular sperm aspirated percutaneously using 22-gauge hypodermic needle with local analgesia in azoospermic men: a simple effective technique.
Patrick Egbase, M.D. M.R.C.O.G.*†, Mona Al Sharhan, M.D. †, Raymond Ing, M.Sc. †, J Gedis Grudzinskas, M.D., F.R.A.C.O.G., F.R.C.O.G.* ‡
Academic Department of Obstetrics & Gynaecology, St Bartholomew’s & The Royal London School of Medicine & Dentistry, Royal London Hospital; & IVF Centre, Maternity Hospital, Kuwait and Faculty of Medicine, Kuwait University, Kuwait
ABSTRACT
Objective: To evaluate the routine usage
of a simplified technique of percutaneous needle (22 gauge) sperm aspiration
under local analgesia.
Design: Open study.
Setting: Tertiary level referral Assisted Reproduction Centre in Kuwait city.
Subjects: Thirty one consecutive males with obstructive (n=9), non-obstructive (n=9) azoospermia and unexpected ejaculatory failure (n=3).
Intervention: Percutaneous needle (22 gauge)
testicular sperm aspiration under local analgesia.
Main outcome measures: Motile sperm for intracytoplasmic sperm
injection; fertilization, cleavage and pregnancy rates.
Results: Sperm was obtained in 28 men, 27 at the first attempt and in 10/4 men who also required aspiration in the contralateral testis; satisfactory rates of fertilization (63.3%) embryonic cleavage (89%) and clinical pregnancy (32%) were observed.
Conclusions: The successful needle aspiration of sperm in 25 of 31 men which could be used for ICSI with good outcome justifies the consideration of this simple technique in men with obstructive and non-obstructive azoospermia, as well as unexpected ejaculatory failure.
Key Words: Testicular sperm aspiration, ICSI
Laparoscopic treatment of ovarian
cysts during pregnancy: initial experience.
Ashraf M. N. Refaie, M.R.C.O.G., Yousef A. E. Ibrahim, M.D.
Department of Obstetrics and Gynaecology. Zagazig University Hospital, Zagazig, Egypt.
ABSTRACT
Objective: To evaluate the role of operative laparoscopy in treatment of ovarian cysts during pregnancy.
Design: A prospective study.
Setting: Department of Obstetrics and GynaecoIogy, Zagazig University Hospital.
Subjects: Five pregnant women with ovarian cysts in their second trimester of pregnancy were included in this study. The cysts varied in size between 6.5 to 11 cm in diameter.
Intervention: The five women had operative laparoscopy between the 13 and 16 weeks gestation. All of them had laparoscopic ovarian cystectomy after aspiration of the fluid content of the cyst. Proper hemostasis was achieved using bipolar and monopolar diathermy. The cyst walls were removed and sent for histopathology Tocolytic therapy started one day before the operation and continued for few days after.
Results: The histopathology showed benign serous cystadenoma in three cases, one mucinous cystadenoma, and one endometriotic cyst. The operating time ranged from 35 to 115 minutes. The patients were followed until delivery both clinically and by ultrasound scan. No evidence of persistent cyst was detected. The pregnancy outcome was satisfactory. Three patients had normal vaginal delivery and the fourth had cesarean section and one on-going pregnancy at 34 weeks gestation.
Conclusion: Laparoscopic ovarian cystectomy during the second trimester of pregnancy was found to be a safe and effective operation.
Key words: Ovarian cystectomy, ovarian cyst in pregnancy, operative laparoscopy.