Primary leiomyoma of the ovary in a young woman: literature review and report of a case.

Ovarian leiomyoma is a rare tumor. We present a case of ovarian leiomyoma in a 32-year-old virgin with the complaint of dysmenorrhea for six months. On magnetic resonance imaging, a 6 cm x 4 cm mass in the left ovary exhibiting hypointense signals on both T1-weighted and T2-weighted images was initially considered to be fibroma and/or thecoma. However, after surgery the pathological diagnosis of the removed tumor was leiomyoma of the left ovary. The literature on this rare tumor was also reviewed.

Male infertility after renal transplantation: achievement of pregnancy after intracytoplasmic sperm injection.

Chronic renal failure, dialysis, and immunosuppression after transplantation may cause reproductive failure. Although transplantation may reverse most sperm functions in the male, there is sufficient evidence in the literature that sperm motility may not be restored. Herein we present three cases with male factor infertility who underwent intracytoplasmic sperm injection (ICSI). There is a lack of evidence for use of ICSI for couples in whom the infertile husband had undergone renal transplantation. Case 1, a 25-year-old woman with a 7-year history of infertility had a 33-year-old husband, with asthenoteratospermia status-post renal transplantation 1 year prior. The wife delivered healthy twins at 36 weeks of gestation after three embryos were transferred. Case 2, a 34-year-old woman with infertility of 6 years, had a 34-year-old husband transplanted 2 years prior and hospitalized for chronic rejection during ICSI treatment. He had severe oligoasthenoteratozoospermia. She is currently 20 weeks pregnant with a singleton after transfer of two embryos. Case 3, a 31-year-old woman with a previous spontaneous abortion and 3 years of failure to conceive, had a 41-year-old husband status-post renal transplantation 16 years ago, currently in chronic renal failure treated with continuous ambulatory peritoneal dialysis. His sperm analysis showed oligoasthenoteratozoospermia. However, pregnancy did not occur after transfer of two embryos. Health status after renal transplantation influences sperm function. Because healthy sperm is required for fertilization and embryonic development, ICSI candidates after renal transplantation must be in optimum health.

Gonadotrophin treatment in patients with polycystic ovary syndrome.

Gonadotrophin treatment in clomiphene citrate resistant polycystic ovarian syndrome (PCOS) patients, using either low-dose step-up or low-dose step-down protocols, is highly effective to achieve singleton live births. Concomitant use of gonadotrophin releasing hormone analogues (GnRHa), which will block the endogenous feedback for monofollicular development during the low-dose step-up protocol, should not be employed. It is more difficult to induce ovulation in patients with more 'severe' PCOS, characterized by obesity and insulin resistance. There is need for optimization of starting doses for both the low-dose step-up and step-down protocols. Such optimization will prevent hyperstimulation due to a starting dose far above the FSH threshold, as well as minimize the time-consuming low-dose increments by starting with a higher dose in women with augmented FSH threshold. External validation of reported models for prediction of FSH response is warranted for tailoring and optimizing treatment for everyday clinical practice. Although preliminary, the partial cessation of follicular development, along with regression leading to atresia, lends support to the LH ceiling theory, emphasizing the delicate balance and need for both FSH and LH in normal follicular development. Future well-designed randomized controlled trials will reveal whether IVF with or without in-vitro maturation of the oocytes will improve safety and efficacy compared with classical ovulation induction strategies.

Comparison of microlaparoscopy and conventional laparoscopy for tubal sterilization under local anesthesia with mild sedation.

STUDY OBJECTIVE: To compare tubal sterilization performed by microlaparoscopy and conventional laparoscopy. DESIGN: Prospective, randomized trial (Canadian Task Force classification I). SETTING: Gazi University School of Medicine. PATIENTS: Twenty women undergoing surgical sterilization. INTERVENTION: Ten sterilizations by conventional laparoscopy and 10 by microlaparoscopy. MEASUREMENTS AND MAIN RESULTS: The techniques were comparable in quality of visualization, operating time, amount of drugs used for sedation and local anesthesia, and intraoperative pain scores. However, the postoperative analgesic requirement was significantly less in women treated by by microlaparoscopy. CONCLUSION: Tubal sterilization by microlaparoscopy does not differ greatly from conventional laparoscopic sterilization.

Hydrosalpinx and assisted reproduction: options and rationale for treatment.

Salpingoscopy during laparoscopy yields the best prognosis in patients with hydrosalpinx. It has been demonstrated that in-vitro fertilization (IVF) patients with hydrosalpinx have decreased pregnancy rates as compared with control individuals. If a patient with hydrosalpinx is to be treated with IVF, then the communication between the uterine tube and the uterine cavity should be blocked via salpingectomy or proximal tubal ligation, with or without distal tubal fenestration. This is because there is evidence that hydrosalpinx, especially when it is bilateral and visible by ultrasonography, impacts negatively on pregnancy and implantation rates after IVF cycles.

Non-invasive early prenatal diagnosis using fluorescent in situ hybridization on transcervical cells: comparison of two different methods for retrieval.

OBJECTIVE: We compared the efficiencies of uterine and endocervical lavage to retrieve fetal cells from first trimester pregnancies for further analysis with fluorescent in situ hybridization (FISH). STUDY DESIGN: Transcervical cell (TCC) samples were collected at 7-10 weeks of gestations by uterine lavage (13 women) and by endocervical lavage (12 women) who were scheduled for volunteer termination of pregnancy. A sample of placenta was also obtained for cytogenetic analysis to confirm the sex or genotype in the end of the procedure. FISH was performed using probes for the chromosomes 18, X and Y in a three color hybridization protocol. The statistical analysis included chi(2)-analysis, and t-test. RESULTS: Sufficient cells were obtained in 12 of the 13 (92.3%) in uterine lavage and 10 of the 12 (83.3%) in endocervical lavage group for FISH procedures for fetal sex prediction. The mean success rate of signal detection for FISH procedure was 91.7% (range 83-97%). Fetal sex was correctly predicted in 11 of 12 (91.6%) with uterine lavage and 8 of 10 (80.0%) in endocervical lavage and the difference was statistically insignificant. CONCLUSION: This study demonstrated that there are available cells of fetal origin in the lower part of the uterus and these cells may be collected successfully as early as 7 weeks of the gestation. In addition, our results show that endocervical lavage method is as effective as uterine lavage. FISH has been successfully used to detect status of aneuploidy and sex of the fetus from TCC.

Laparoscopic plication and suspension of the round ligament for chronic pelvic pain and dyspareunia.

STUDY OBJECTIVE: To describe a technique of uterine suspension using round ligaments to relieve pain in selected patients with various degrees of uterine retroversion. DESIGN: Prospective clinical study (Canadian Task Force classification II-2). SETTING: University-based center for reproductive medicine. PATIENTS: Thirty women who underwent laparoscopy for investigation of chronic pelvic pain (CPP) and dyspareunia. INTERVENTION: Round ligaments were plicated using a modification of intracorporeal knot tying during laparoscopy. MEASUREMENTS AND MAIN RESULTS: The extent of plication was planned to elevate the uterus and bring it minimally forward. Mean +/- SD operating time was 14+/-4 minutes. Pain scores before and after surgery were 4.5+/-1.0 and 1.6+/-0.6, respectively (p<0.001). There were no complications during or after surgery. Only three women had minimal dyspareunia postoperatively, although they had anteverted uteri. One patient had severe dyspareunia that developed 7 months after surgery and continued through the second year of follow-up. Nineteen women with anteverted uteri were free of dyspareunia after 2 years. CONCLUSION: Round ligament plication is safe and effective in patients with retroverted uteri and dyspareunia or CPP.

Detection of chromosomal abnormalities by fluorescent in-situ hybridization in immotile viable spermatozoa determined by hypo-osmotic sperm swelling test.

If randomly selected immotile spermatozoa are used for intracytoplasmic sperm injection (ICSI), pregnancy rates are significantly decreased. The hypo-osmotic swelling test (HOST) is the only method available to detect the viable, but immotile spermatozoa for ICSI. However, evidence is still lacking for the chromosomal abnormalities for the normal-looking, but immotile spermatozoa positive for HOST. Sperm samples from 20 infertile men with normal chromosomal constitution were obtained. After Percoll separation, morphologically normal but immotile spermatozoa were transported individually into HOST solution for 1 min using micropipettes. Cells that showed tail curling with swelling in HOST were then transferred back into human tubal fluid solution to allow reversal of swelling. These sperm cells were fixed and processed for the multi-colour fluorescence in-situ hybridization (FISH) for chromosomes X, Y and 18. The same FISH procedure was applied for the motile spermatozoa from the same cohort, which formed the control group. The average aneuploidy rates were 1.70 and 1.54% in 1000 HOST positive immotile and motile spermatozoa respectively detected by FISH for each patient. Our results indicate that morphologically normal, immotile but viable spermatozoa have an aneuploidy rate similar to that of normal motile spermatozoa.

GnRHa for adhesion formation after uterine serosal injury in an euestrogenic milieu.

OBJECTIVE: To assess whether the adhesion-preventing effect of gonadotropin-releasing hormone agonist (GnRHa) is through hypoestrogenism. STUDY DESIGN: Four groups of previously ovariectomized rats received various combinations of depot leuprolide acetate injection (3.75 mg/kg/mo) subcutaneously, conjugated equine estrogens (50 micrograms/kg/d) orally and phosphate-buffered saline injection subcutaneously, yielding group 1, saline only; group 2, saline and conjugated equine estrogens; group 3, depot leuprolide acetate only; and group 4, depot leuprolide acetate and conjugated equine estrogens. Surgical adhesions were induced by monopolar cautery on the right uterine horn through laparotomy and were then scored on day 21 after surgery. RESULTS: Adhesion scores for rats that received conjugated equine estrogens and saline were significantly higher than scores of those given conjugated equine estrogens and depot leuprolide acetate, depot leuprolide acetate only and saline only (P = .019, .026 and .027, respectively). However, there was no significant difference in the adhesion scores for these three groups. CONCLUSION: Hypoestrogenism results in the development of fewer peritoneal adhesions postoperatively. Our findings also indicated that other mechanisms, in addition to those inducing hypoestrogenism, are at work in the adhesion-preventing effects of GnRHa therapy.

Monocyte chemotactic protein-1 expression in human corpus luteum.

Invasion of the corpus luteum by macrophages is a characteristic of luteal regression. Monocyte chemotactic protein-1 (MCP-1), a chemokine that recruits macrophages, is expressed in the rat corpus luteum where it increases in amount during luteolysis. In this study we examined the temporal and spatial expression of MCP-1 and changes in macrophage concentration in the human corpus luteum. Corpora lutea (n = 39) were grouped according to menstrual cycle phase and were examined by immunohistochemistry for MCP-1 and macrophages, and by Northern blot for MCP-1 mRNA. We found increasing amounts of macrophages with progressing luteolysis (P < 0.001). Staining for MCP-1 was stronger in the regressing corpora lutea compared with the staining in corpora lutea of early luteal phase (P < 0.05). MCP-1 was more prominent in blood vessel walls surrounding the corpus luteum than in vessels located far from it. The mean MCP-1 mRNA expression in regressing corpora lutea was higher than that observed in corpora lutea of the early and mid-luteal phase (P = 0.003). In conclusion, we found that MCP-1 expression and the number of macrophages increase with regression of the corpus luteum. MCP-1 is mostly expressed in blood vessel walls surrounding the corpus luteum and may play a role in the recruitment of macrophages to the corpus luteum during its regression.

Endoscopic management of a case of complete septate uterus with unilateral pyometra.

We report a case with an unusual müllerian anomaly: complete uterine septum and pyometra in the right hemicavity and pyocolpos along with a longitudinal vaginal septum. A patient with recurrent low-grade fever and lower abdominal pain was admitted. Pyometra and pyocolpos were detected in the right uterine hemicavity and in the right hemivagina. The septa were resected, the cavities were irrigated, and the patient was treated with antibiotics. The patient conceived 8 months later. Patients with abnormal vaginal findings should be approached with caution; precise knowledge of urogenital anatomy and urogenital anomalies is necessary in the management of these patients.

Endometrial response to unopposed estrogens remains unaltered in patients with chronic renal failure receiving hemodialysis.

Most patients with chronic renal failure who are on maintenance hemodialysis are anovulatory and have menstrual abnormalities. This study was designed to determine the prevalence of organic causes of abnormal uterine bleeding in this group of patients exposed to unopposed estrogens. Eighteen patients with chronic renal failure and abnormal uterine bleeding underwent vacuum curettage. The histopathologic findings were compared with a group of 154 premenopausal women who had abnormal uterine bleeding without detectable organic causes. Excluding patients with secretory and atrophic endometrium, only 2 of 8 patients (25%) with chronic renal failure had endometrial lesions while 44 of 131 patients (33.6%) had either endometrial polyp, simple or atypical endometrial hyperplasia or endometrial carcinoma (p > 0.05). The uremic environment caused by chronic renal failure does not alter the endometrial responsiveness to unopposed estrogens and may lead to the development of endometrial lesions.

Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization-embryo transfer.

OBJECTIVE: To determine the effect of hydrosalpinx on the establishment of pregnancy after IVF-ET. DESIGN: Metaanalysis. SETTING: University medical center. PATIENT(S) AND INTERVENTION(S): All published reports (n=13) and abstracts (n=10) in English that examined the relation between hydrosalpinx and IVF-ET were included in the analysis. The metaanalysis was performed by first calculating the odds ratios for each trial and then combining them to obtain a pooled estimate of the odds ratio and a 95% confidence interval. MAIN OUTCOME MEASURE(S): Clinical pregnancy. RESULT(S): A total of 5,569 cycles was reviewed in the group without hydrosalpinx, and a total of 1,144 was reviewed in the group with hydrosalpinx. The clinical pregnancy rate was approximately 50% lower in patients who had hydrosalpinx. Similarly, the implantation rate was decreased by 50%. These effects were observed also in thawed ET cycles. The abortion rate was more than twofold higher in patients who had hydrosalpinx. CONCLUSION(S): This metaanalysis suggests that hydrosalpinx is associated with a reduced chance of implantation and an increased risk of pregnancy loss.

The effect of monocyte chemotactic protein 1 in intraperitoneal adhesion formation in a mouse model.

OBJECTIVE: Intraperitoneal adhesions are a significant cause of morbidity among women of reproductive age. Monocyte chemotactic protein 1 plays a role in the chemotaxis of mononuclear cells and fibroblasts into the peritoneal injury site. To evaluate its role in intraperitoneal adhesion formation, we used an established postsurgical adhesion model in mice. STUDY DESIGN: Surgical adhesions in mice were induced by scraping and crushing peritoneal sites. We analyzed the injury sites for the temporal expression of monocyte chemotactic protein 1 messenger ribonucleic acid and cellular infiltration at 12 to 24 hours across 10 days and evaluated the effects of monocyte chemotactic protein 1 and anti-monocyte chemotactic protein 1 neutralizing antibody on adhesion formation. On induction of adhesions animals were randomly assigned to 1 of 4 groups: (1) control, (2) nonspecific immunoglobulin G, (3) monocyte chemotactic protein 1, (4) anti-monocyte chemotactic protein 1 antibody. Animals received daily intraperitoneal injections for 6 days. Adhesions were scored on day 14 and immunostained for fibroblasts and macrophages. RESULTS: Adhesions developed consistently by the fifth postoperative day. We detected an increase in monocyte chemotactic protein 1 messenger ribonucleic acid expression at 48 hours; this remained until the fourth postoperative day. By the second day macrophages were present at the injury site. Animals treated with anti-monocyte chemotactic protein 1 antibody had significantly fewer adhesions develop than did the other three groups. CONCLUSION: This study demonstrates that monocyte chemotactic protein 1 may play a role in adhesion formation. Inhibiting the action of this chemokine may help to prevent adhesions.

The role of monocyte chemotactic protein-1 in intraperitoneal adhesion formation.

Abdomino-pelvic adhesions arise from infection, endometriosis, or peritoneal injury during surgery, and represent a significant source of morbidity in women of reproductive age. Monocyte chemotactic protein-1 (MCP-1) plays a role in the chemotaxis of mononuclear cells and fibroblasts in a murine wound repair model. To evaluate the role of MCP-1 in intraperitoneal adhesion formation, we investigated peritoneal fluid MCP-1 levels of women undergoing laparoscopy. Patients without endometriosis were divided into two groups: normal fertile women undergoing bilateral tubal ligation without intraperitoneal adhesions (n=14) and women with pelvic adhesions (n=8). Patients with endometriosis were arranged into two groups: women with (n=17) and without (n=17) adhesions. Peritoneal fluid MCP-1 levels were quantified using an enzyme-linked immunosorbent assay (ELISA). Peritoneal biopsy samples were immunostained for the detection of MCP-1 protein and macrophages, and were also processed for the presence of MCP-1 mRNA expression. Among women without endometriosis, the median peritoneal fluid MCP-1 level was 144 pg/ml (range 54-261) in women without adhesions and was 336 pg/ml (range 130-2494) in women with adhesions (P=0.01). There was a significant correlation between adhesion scores and MCP-1 levels (r=0.50; P=0.018). Among women with endometriosis, peritoneal fluid MCP-1 levels significantly correlated with the stage of the disease. The presence or absence of adhesions did not significantly affect the peritoneal fluid MCP-1 levels in this group of women. In summary, we have found that women with adhesions have elevated peritoneal fluid MCP-1 levels. However, we were not able to show an incremental effect of adhesions on peritoneal fluid MCP-1 levels of patients with endometriosis. Thus, we conclude that factors besides the intraperitoneal adhesions contribute to the elevated peritoneal fluid MCP-1 levels in patients with endometriosis.

Basic fibroblast growth factor: peritoneal and follicular fluid levels and its effect on early embryonic development.

OBJECTIVE: To investigate the effect of basic fibroblast growth factor (FGF) on preimplantation embryos and to evaluate the levels of basic FGF in follicular and peritoneal fluid. DESIGN: Prospective study. SETTING: University-based laboratory. PATIENT(S): Follicular fluids (FFs) were obtained from women undergoing ovulation induction (n = 62) and peritoneal fluids were obtained from women with (n = 49) or without (n = 12) endometriosis. INTERVENTION(S): The effect of basic FGF on mouse embryos was assessed. Basic FGF concentrations were measured in pre-hCG and post-hCG FFs and in peritoneal fluids. MAIN OUTCOME MEASURE(S): Two-cell murine embryos were treated with basic FGF and followed for the rate of blastocyst formation and embryo hatching. Follicular and peritoneal fluid basic FGF levels were measured by ELISA. RESULT(S): Basic FGF (10 ng/mL) decreased the rate of blastocyst formation and embryo hatching. The level of basic FGF did not change in the FF around ovulation, and there was no correlation between FF basic FGF levels and reproductive parameters, with the exception of age. The levels of basic FGF in the peritoneal fluid of women with or without endometriosis were not different. CONCLUSION(S): Basic FGF is present in follicular and peritoneal fluids, but its concentration in these fluids does not change during the menstrual cycle or in the presence of endometriosis. Basic FGF inhibits murine preimplantation embryonic development at concentrations 10-100 times higher than the levels detected in follicular and peritoneal fluids.

Interleukin-8 induces proliferation of endometrial stromal cells: a potential autocrine growth factor.

Proliferation of endometrium is dependent on sex steroid hormones, but specific growth factors are likely to play an important role in regulating this process. A number of cytokines and growth factors are synthesized in the endometrium in response to sex steroid hormones and act to regulate endometrial function. Endometrial cells produce interleukin-8 (IL-8) both in vivo and in vitro. We hypothesized that IL-8, a neutrophil chemoattractant/activating factor and a potent angiogenic agent that has been shown to stimulate growth in other cell types, may directly stimulate proliferation of endometrial cells. We first investigated the effect of IL-8 and mouse antihuman-IL-8 neutralizing antibody on endometrial stromal cell proliferation using both a colorimetric assay and thymidine uptake. We then investigated the modulation of endometrial stromal cell IL-8 production and proliferation by antisense oligonucleotides specific for IL-8. There was a concentration-dependent increase of cell proliferation with IL-8 (2-fold at 1 ng/mL; P < 0.01 between control and concentrations above 0.01 ng/mL) and a concentration-dependent inhibition of cell proliferation with anti-IL-8 antibody (to 30% of the control at 1 microg/mL; P < 0.01 between control and concentrations above 0.1 microg/mL). IL-8 antisense oligonucleotide treatment decreased IL-8 production by endometrial stromal cells in culture as well as cell proliferation when it is compared with scrambled (nonsense) oligonucleotide treatment (P < 0.01). Addition of IL-8 (1 ng/mL) reversed the proliferation inhibitory effect of IL-8 antisense oligonucleotides. We propose that IL-8 may act as an autocrine growth factor in the endometrium, and suggest that it may also play a role in the pathogenesis of endometriosis.

Comparison of intrauterine insemination with timed intercourse in superovulated cycles with gonadotropins: a meta-analysis.

OBJECTIVE: To compare timed intercourse and IUI with the husband's sperm in patients with unexplained infertility who are undergoing superovulation with gonadotropins. DESIGN: Meta-analysis. All published reports of randomized, prospective studies with an English-language abstract extracted from MEDLINE were analyzed. A crossover search was done from the papers obtained. SETTING: Academic center. PATIENT(S): Couples with unexplained infertility. INTERVENTION(S): Meta-analysis of studies evaluating patients superovulated with gonadotropins and randomized for timed intercourse or IUI. MAIN OUTCOME MEASURE(S): Pregnancy rates (PRs) were obtained. The common odds ratio (OR) and 95% confidence intervals (95% CI) were calculated. RESULT(S): There were 49 pregnancies in 431 cycles of timed intercourse (11.37%), whereas there were 110 pregnancies in 549 cycles of IUI (20.04%). The PRs for IUI were significantly increased compared with those for timed intercourse in superovulation cycles (common OR = 1.84; 95% CI = 1.30-2.62). CONCLUSION(S): On the basis of the meta-analysis of 980 cycles in randomized and prospective studies, a patient's chances of becoming pregnant are greater with IUI with her husband's sperm than with timed intercourse in cycles superovulated with gonadotropins.

The peritoneal fluid levels of interleukin-12 in women with endometriosis.

PROBLEM: Interleukin-12 (IL-12) is produced mainly by monocytes/macrophages, and it induces proliferation and cytotoxicity of T-cells and natural killer cells. In women with endometriosis, natural killer cell activity in the peritoneal fluid is significantly decreased. We aimed to measure the peritoneal fluid level of IL-12 in endometriosis. METHOD OF STUDY: We measured IL-12 levels in peritoneal fluid samples from women with or without endometriosis and in supernatants from endometrial stromal, ovarian stromal, and mesothelial cell cultures, using a high-sensitivity enzyme-linked immunosorbent assay. RESULTS: The median concentration of IL-12 in the peritoneal fluid of women with endometriosis was 1.1 pg/ml (range, 0.2-5.5) and was 1.6 pg/ml (range, 0.4-2.8) in women without endometriosis, not a statistically significant difference. IL-12 was not detected in the supernatants of endometrial stromal, ovarian stromal, and mesothelial cell cultures. CONCLUSION: Concentrations of IL-12 in the peritoneal fluid of women with or without endometriosis are low, but they are detectable and are not affected significantly by the presence of endometriosis.