Management of myoepithelioma of the vulva--case report and review of the literature.

Myoepithelioma of the vulva is a rare condition, with only three cases having been reported so far. As a consequence it is quite difficult to decide on the appropriate management due to the paucity of data. We present our case together with a review of all relevant literature in order to collect and summarise the experience accrued so far, and draw conclusions regarding the management of these myoepitheliomas when they appear on the vulva. It seems that vulval myoepitheliomas can be of low- or high-grade malignancy and that the grade, which determines the prognosis, should be the main factor to consider when planning the management. We also conclude that the clinical behaviour of these tumours of the vulva most probably follow the course of the myoepitheliomas that affect the soft tissues in general.

Leukocytes in semen from men with spinal cord injuries.

OBJECTIVE: To assess the leukocyte populations in semen samples from men with spinal cord injuries (SCIs) and their relation to sperm motility. DESIGN: Cross-sectional study. SETTING: A joint spinal cord injury and fertility clinic at an academic tertiary referral center for fertility treatment and a university-based department of immunology. PATIENT(S): Nine men with chronic SCIs and seven healthy sperm donors as controls. INTERVENTION(S): Semen samples were obtained by electroejaculation from men with SCIs and by masturbation from donors. MAIN OUTCOME MEASURE(S): Leukocyte populations determined by immunohistochemical techniques, bacteriologic assessment of urine, and sperm density and motility. RESULT(S): The most cellular specimens were antegrade specimens obtained from men with SCIs and coexisting urinary tract infections. The highest proportion of leukocytes occurred in retrograde samples from men with SCIs and urinary tract infections. The most predominant leukocytes in all specimens were granulocytes. Infection increased the number of T cells and the degree of cell activation. There was no significant correlation between leukocyte populations and total motile sperm counts. CONCLUSION(S): Increased numbers of leukocytes in semen samples from men with SCIs are the result of urinary tract infections. The reduced sperm motility seen in men with SCIs does not correlate with the numbers of leukocytes; therefore, other factors also contribute to the semen abnormalities in these patients.

The evaluation of the sperm migration test as a predictor for success with intrauterine insemination.

OBJECTIVE: The objective of this study was to prospectively evaluate the sperm migration test (SMT) as a discriminator in couples undergoing intrauterine insemination (IUI). PATIENTS AND METHODS: 261 couples underwent 797 IUI treatment cycles involving gonadotropin stimulation in the three year period. All had a diagnosis of unexplained infertility. All male partners underwent a repeat standard seminal analysis and SMT prior to the female partner undergoing controlled ovarian stimulation. RESULTS: Despite apparently normal seminal analyses before referral, in 22 samples the sperm concentration, motility or morphology were abnormal (WHO criteria). Of these, 20 couples underwent 109 cycles and achieved 2 pregnancies giving a pregnancy rate of 1.8% per cycle and a cumulative pregnancy rate of 10% per couple. From the remaining couples with normal seminal analyses, 71 had an SMT <5 million/mL and 168 had an SMT >5 million/mL. The suboptimal SMT group underwent 276 cycles (3.89 cycles per couple) and achieved 18 pregnancies giving a pregnancy rate of 6.5% per cycle and a cumulative pregnancy rate of 25.4%. The normal SMT group underwent 412 cycles (2.45 cycles per couple) and achieved 60 pregnancies giving a pregnancy rate of 14.6% per cycle and a cumulative pregnancy rate of 35.7%. CONCLUSIONS: We confirm that abnormal seminal analysis leads to poor pregnancy rates with IUI. However, an SMT <5 million/mL despite normal seminal analysis (WHO criteria) also leads to significantly worse pregnancy rates. We would recommend that prior to IUI, couples are screened using the SMT.

Seminal plasma immunoglobulin concentrations in autoimmune male subfertility.

The presence of anti-sperm antibodies (ASAs) in seminal plasma is associated with infertility. They have been shown to reduce sperm motility, interfere with cervical mucus penetration and gamete interaction, and have been shown to reduce spontaneous fertilization and pregnancy rates. Although some causes can be determined, in the majority of cases the initial event causing the immune sensitisation and the reasons for the continuing antibody secretion remains unknown. Quantitative determination of total IgG, IgA and IgM within seminal plasma had not been previously reported in patients with and without specific ASAs. Semen samples from 512 men presenting with infertility were analyzed. One hundred and forty-six men (28.5%) had seminal fluid ASAs as determined by the MAR or TAT tests. The total seminal plasma IgG and IgA concentrations were significantly elevated in the ASA-positive groups compared with ASA-negative groups (IgG: 8.83 mg/100 ml vs. 7.15, P = 0.0008; and IgA: 2.88 mg/100 ml vs. 1.64, P = 0.0001). Only 19 samples showed seminal fluid IgM, and there was no difference between the ASA positive or ASA negative samples. The significance of these findings is discussed.

The effect of progestagens on the carotid artery pulsatility index in postmenopausal women on oestrogen replacement therapy.

Part of the cardioprotective effect of postmenopausal oestrogen replacement therapy has been attributed to arterial vasodilation. This effect is partially reversed in the uterine artery by the addition of a progestagen. This study was designed to compare the effects of the C21 progestagen, dydrogesterone and the C19 testosterone derivative, norethisterone on the carotid artery pulsatility index (PI) (thought to represent distal impedance to flow) using a randomized double blind cross-over trial. The addition of progestagen resulted in a significant increase in the carotid artery PI from a median value of 1.67 during the oestrogen only phase to 1.77 (P = 0.02) during the combined phase. This trend was seen with both dydrogesterone and norethisterone, but there was no significant difference in the size of the effect caused by either progestagen. The addition of cyclical progestagen to ERT partially antagonizes the reduction in the carotid artery PI.

The hypo-osmotic swelling test in recurrent miscarriage.

OBJECTIVE: To determine whether there is any association between sperm membrane integrity as determined by the hypo-osmotic swelling test score and unexplained recurrent miscarriage. DESIGN: Prospective observational study. SETTING: Tertiary referral center for recurrent miscarriage. PATIENT(S): Semen samples from 20 male partners of women who had had three or more first trimester miscarriages of unexplained etiology and semen samples from 20 prospective semen donors of unknown fertility potential. MAIN OUTCOME MEASURE(S): Sperm density, sperm motility, sperm morphology, and hypoosmotic swelling test score. RESULT(S): There was no difference in the median sperm density, the mean sperm motility, or the mean sperm morphology between the two groups. However, the recurrent miscarriage group had a significantly lower hypo-osmotic swelling test score than the control group. CONCLUSION(S): The hypo-osmotic swelling test score is significantly lower in samples from men whose partners have had unexplained recurrent spontaneous abortions. With the exception of cytogenetic abnormalities in peripheral blood karyotype, this is the first study to identify a male factor component in recurrent miscarriage.

Conservative management of azoospermia following steroid abuse.

As well as athletes and competitive body builders, recreational body builders attending gymnasia are known to abuse anabolic steroids, using doses from 10- to 40-fold above physiological levels. Androgenic steroids induce hypogonadotrophic hypogonadism with associated azoospermia, leading to infertility. Little literature exists on the treatment of steroid-induced azoospermia following the cessation of abuse. We present four cases of steroid-induced azoospermia, its conservative management and eventual return of normal semen density.

Seminal plasma lactoferrin concentrations in normal and abnormal semen samples.

Although the iron-chelating protein lactoferrin is secreted by the seminal vesicles, the precise role of lactoferrin in semen is unclear. This study aimed to determine whether there is any association between seminal lactoferrin concentrations and normal and abnormal semen samples with and without leucocytospermia. Lactoferrin concentrations were measured by radial immunodiffusion of semen samples from 368 men attending a regional andrology referral center. Routine seminal analysis, including the presence of leucocytospermia, was also performed. Results showed increased seminal lactoferrin in samples showing oligospermia (13.3 mg/100 ml) and oligoasthenospermia (13.4 mg/100 ml) compared to normospermic samples (11.2 mg/100 ml). There were no significant differences in seminal lactoferrin between normospermic samples and azoospermic samples or asthenospermic samples with normal sperm density. Although there was a trend toward increased lactoferrin concentration with leucocytospermia, this was not significant. Possible causes for raised lactoferrin in association with oligospermia are discussed.

Effects of intrapartum hydrotherapy on labour related parameters.

The use of birthing pools during labour is increasing in the United Kingdom. This is without good scientific evidence of their efficacy or safety. To further investigate the value and safety of intrapartum hydrotherapy, an historical cohort study was performed in a District General Hospital in Liverpool. The study group consisted of 100 women of low obstetric risk who used the birthing pool at some stage during their labours and the control group consisted of 100 women who were matched in terms of age, parity and obstetric history but laboured and delivered in air. The main outcome measures were operative delivery rates, duration of labour, analgesic requirements, perineal trauma and Apgar scores at 1 and 5 minutes. The results showed that nulliparas who used the birthing pool had significantly reduced operative delivery rates, a shorter second stage of labour, reduced analgesic requirements and a lower incidence of perineal trauma. In multiparas there were significant reductions in analgesic requirements.

Effects of sperm activity on zinc and fructose concentrations in seminal plasma.

Attempts to correlate zinc and fructose concentrations in seminal plasma with andrological parameters have produced inconsistent results. To assess further this relationship, a prospective study was performed measuring zinc and fructose concentrations in seminal plasma in 1178 patients referred for fertility treatment. Seminal analysis was performed with biochemical measurements of seminal zinc and fructose. The main outcome measures were the correlation between motile sperm concentration and seminal zinc and fructose concentrations. Zinc concentrations were not influenced by the motile sperm concentration (r = 0.039). Fructose concentrations were found to be negatively correlated with motile sperm concentration (r = 0.062). We conclude that seminal plasma zinc is an unreliable marker of spermatogenic activity. While there does appear to be a negative correlation between seminal plasma fructose concentrations and motile sperm concentration this relationship is far from linear. Due to the biochemical complexity of seminal fluid attempts to perform such simple correlations between seminal plasma components and andrological parameters are likely to produce inconsistent results and their role in the assessment of sperm function must therefore be called into question.

Effect of abnormal hypo-osmotic swelling test on fertilization rate and pregnancy outcome in in vitro fertilization cycles.

OBJECTIVE: To assess the value of the hypo-osmotic swelling test in predicting fertilization, pregnancy, implantation, miscarriage, and live birth rates in IVF-ET cycles. DESIGN: Prospective study. SETTING: Academic tertiary referral center for fertility treatment. PATIENTS: Three hundred twenty-six couples having IVF-ET for tubal damage or male factor infertility with the female partner < 38 years of age. INTERVENTIONS: Each male had a hypo-osmotic swelling test performed between 4 and 8 weeks before IVF-ET. MAIN OUTCOME MEASURES: Fertilization, implantation, miscarriage, and live birth rates. RESULTS: Eighty of 326 men had abnormal hypo-osmotic swelling tests. An abnormal test was not associated with lower fertilization rates (odds ratio [OR] = 1.14; 95% confidence interval [CI] = 0.97 to 1.14) or pregnancy rate (OR = 0.98; CI = 0.50 to 1.96). However, although couples with a normal test had a miscarriage rate of 26.9% (14/52), in the group with an abnormal test the miscarriage rate was 50.0% (7/14) (OR = 0.37; CI = 0.09 to 1.49). This resulted in a reduction in the live birth rate from 14.1% in the group with a normal test to 11.8% in patients with an abnormal test (OR = 1.23; CI = 0.45 to 3.87). CONCLUSIONS: The hypo-osmotic swelling test has little value in predicting fertilization in IVF-ET procedures. However, an abnormal test may help predict adverse outcome if pregnancy is achieved.

Successful pregnancy following oocyte donation in a patient with Diamond-Blackfan syndrome and premature ovarian failure.

Diamond-Blackfan anaemia (DBA) is a rare congenital condition characterized by profound anaemia associated with an absence of red cell precursors on bone marrow examination. This report represents the first case of pregnancy following egg donation in a patient with DBA and premature ovarian failure. The patient was a 24 year old woman who had been diagnosed with DBA when aged 6 months. Shortly after menarche, the patient became amenorrhoeic and was diagnosed as suffering from premature ovarian failure. She was entered onto an assisted conception programme and conceived after one cycle of egg donation. The pregnancy was characterized by a gradual decline in haemoglobin concentration, reaching a low of 8.1 g/dl, necessitating a single blood transfusion at 29 weeks of gestation. The patient suffered preterm rupture of the membranes at 29 weeks gestation and was delivered by emergency Caesarean section at 30 weeks of gestation because of chorioamnionitis and breech presentation. Comparing this case with other reports of pregnancy in patients with DBA, our patient suffered a less dramatic fall in haemoglobin concentration and required only a single blood transfusion. It is suggested that because the pregnancy arose from donated genetic material, this may have conferred some protective effect.