Computerized colposcopy: results of a pilot study and analysis of its clinical relevance.

OBJECTIVE: To evaluate the clinical usefulness of a computer based system that stores and analyzes high-resolution digital colposcopic images. METHODS: Three hundred patients referred to our institutions for evaluation of abnormal cervical cytology underwent colposcopy with development of digital images. The first 70 patients were used to standardize the system. The images obtained from 188 evaluable patients were analyzed and scored by software according to internationally recognized colposcopic criteria. The results were compared with traditional colposcopic diagnoses and with corresponding histology results using kappa statistics for inter-observer agreement and McNemar test for significance. RESULTS: The exact concordance rate between computer-aided impressions and histology (85.1%, kappa = 0.77) was significantly higher (P < .001) than that observed between traditional colposcopic findings and histology (66%, kappa = 0.40). The computer-assisted colposcopy was much more accurate than traditional colposcopy in diagnosing high-grade lesions (91.2 versus 61.8% of exact concordance, P < .001) as well as normal histology (74.1 versus 34.5%, P < .001), but not significantly different when evaluating low-grade lesions (89.6 versus 86.5%). CONCLUSION: The integration of computer imaging and colposcopy can improve the colposcopic diagnostic accuracy. An inexperienced colposcopist may benefit from computerized support to obtain the most appropriate histologic specimen, and eventually access to distant consultation via modem or through on-line services. An additional advantage is the ability to develop a space-saving permanent record of digitized images readily available to review a patient's cervical history or perform effective programs of quality control in colposcopy.

Unexpected pregnancies after tubal recanalization failure with selective catheterization.

OBJECTIVE: To evaluate selective salpingography sensitivity. DESIGN: Retrospective study. SETTING: Obstetrics and Gynecology Department, University of Genoa, Italy. PATIENTS: One hundred seventeen patients previously submitted to selective salpingography because of unilateral or bilateral proximal tubal injection failure. RESULTS: Seven pregnancies, one of which was ectopic, were obtained in 17 patients who had only recanalized tubes available for conception; 15 pregnancies were obtained in 39 patients who had one tube recanalized and one already patent; 3 tubal pregnancies were obtained in 12 patients who had only one tube already patent; 4 pregnancies, one of which was ectopic, were obtained in 19 patients who had neither patent nor recanalized tubes. CONCLUSIONS: Selective salpingography can give false-positive results; therefore, it is possible to obtain a pregnancy even after selective salpingography failure.

Transcervical selective salpingography: a diagnostic and therapeutic approach to cases of proximal tubal injection failure.

OBJECTIVE: Evaluation of selective salpingography for diagnosis and treatment of tubal injection failure during hysterosalpingography (HSG). DESIGN: Prospective study. SETTING: Obstetrics and Gynecology Department, University of Genoa (Italy)--tertiary care. PATIENTS: One hundred eighty infertile women with unilateral or bilateral proximal tubal injection failure during HSG were submitted to the procedure. INTERVENTION: Under fluoroscopy, a 4.5-F nylon catheter (3-F tip) was inserted into the ostium with or without the aid of a J-shaped, coaxial, angiographic guide wire, and 2 to 3 mL of contrast medium were injected. The procedure lasts 20 to 30 sec/tube. MAIN OUTCOME MEASURES: Of 155 tubal ostia, 145 (94.2%) were catheterized. RESULTS: Of the 146 catheterized tubes, 110 (75%) were rendered patent. Of the others, 21 (14.3%) presented hydrosalpinx or distal obstructions, and isthmic obstruction was present in 5 (3.4%). Patency of at least one tube was achieved in 82 (81.2%) of the 101 catheterized women; 8 conceived spontaneously and 11 after gamete intrafallopian transfer to the recanalized tube. CONCLUSIONS: During HSG, selective salpinography can be performed when proximal injection failure is observed to determine its cause or to restore patency.

Comparison of different ovarian stimulation protocols for gamete intrafallopian transfer in patients with minimal and mild endometriosis.

Three different stimulation protocols were tested in patients affected by stage I and II endometriosis with no other causes of infertility, and scheduled for the gamete intrafallopian transfer technique. In two protocols a gonadotropin hormone-releasing hormone analog was used. The analog was started 6 months before stimulation in the former and along with the exogenous gonadotropin in the latter. Patients receiving only gonadotropin served as controls. Sixty patients were selected for this study; 55 reached laparoscopy. Whereas patients receiving either gonadotropin alone or simultaneous analog and gonadotropin had similar pregnancy rates, this was much higher in the patients undergoing a prolonged, medically induced hypoestrogenism. Prolonged analog pretreatment before ovarian stimulation may give better chances of success in endometriosis patients undergoing assisted reproduction techniques.

Endometrial morphology after 12 months of vaginal oestriol therapy in post-menopausal women.

The endometrial effect of long-term vaginal oestriol (E3) therapy for urogenital atrophy was assessed in 23 post-menopausal women. Hysteroscopic and histological examinations were performed in each patient to assess endometrial atrophy before treatment and after 6 and 12 months of therapy (0.5 mg vaginal E3 for 21 days, then 0.5 mg twice weekly). The primary atrophic picture was confirmed at the end of the 6th month in all but one of the patients. In one case, the histology showed an abnormal stromal reaction with no epithelial alterations. Treatment was continued and after the 12th month complete atrophy was confirmed both hysteroscopically and histologically in all patients. Efficacy as regards vaginal and urogenital complaints was good. Our results demonstrate that in women with endometrial atrophy effective and well-tolerated treatment with vaginal E3 can be safely continued for up to 12 months.

Luteal phase defects in assisted reproduction: the role of luteal phase supplementation.

Data from literature show that whereas in non-GnRH-a controlled ovarian hyperstimulation cycles luteal phase supplementation is not crucial, its use in GnRH-a/gonadotropins protocols seems to lead to a definite reduction of the negative effects of such drugs. The most important side effect of the hCG use as luteal support is the increased rate of the ovarian hyperstimulation syndrome (OHSS). Therefore its use should be reserved for very selected patients, for those subjects with preovulatory levels of E2 < 2500 pg/ml. As regard the use of progesterone, most authors agree that it has less efficacy than hCG but this depends on the administration route.

Dibromochloropropane (DBCP) effects on the reproductive function of the adult male rat.

In order to evaluate the effect of dipromochloropropane (DBCP) on reproductive function, groups of male adult Wistar rats were injected subcutaneously with different doses of DBCP. A strictly dose-dependent effect resulting in histological alteration principally toward the seminiferous tubules was observed. Sperm count and sperm motility showed azoospermia or oligoasthenospermia with a significative recovery in the lower dose of DBCP treated rats. Among the enzymatic activities evaluated as biochemical markers of testicular function: LDH was not appreciably affected by the DBCP treatment while GGT and NADPH-cyt P450-reductase significantly enhanced suggesting an induction of the detoxification processes.

Gamete intrafallopian transfer and plasma chorionic gonadotropin dynamics: evidence of a delayed appearance.

The purpose of this study was to compare early human chorionic gonadotropin secretion in two groups of pregnancies. These pregnancies were obtained, in one group, during a natural cycle, while, in the other group, they resulted from gamete intrafallopian transfers performed in hyperstimulated cycles. A logarithmic regression analysis was chosen to allow statistical comparison of serial plasmatic evaluation as hormone determinations were obtained, among patients, at different postovulatory days. The regression lines of the two groups of patients presented similar slopes. The unpaired t test performed on calculated data for 3 different days constantly revealed significantly higher levels (P less than 0.005) of natural vs stimulated cycles; thus a different origin on the x axis (days of the luteal phase) is deduced. These findings support the possibility of a delay in the appearance of human chorionic hormone in the patients undergoing gamete intrafallopian transfer technique.

Variations in some of the body fluid hormone levels currently used for endocrine monitoring during the third trimester of pregnancy.

We have investigated the variability of four hormonal parameters used for the endocrine monitoring of the third trimester of pregnancy (E3, E4, HPL, SP1). We have observed no circadian rhythm of Estriol, Estetrol, HPL, and SP1. The within-a-day and the day-to-day variations are much greater for E4 than for E3 and for HPL than for SP1. The standard deviations were great for the steroids, especially for E4 and much less for the protein hormones, especially SP1. This implies that it is necessary to have serial assays of the steroids to have any confidence in the levels, while good monitoring could be guaranteed with a smaller number of assays for HPL, and SP1.

Comparison of a blocking vs. a flare-up protocol in poor responders with a normal and abnormal clomiphene citrate challenge test.

This study aimed to standardize the clomiphene citrate test (CC-t) in our laboratory while comparing two different protocols of controlled ovarian stimulation in poor responders. One hundred and forty-four patients scheduled for assisted reproductive techniques were submitted to the CC-t within 3 months before starting stimulation; 133 underwent controlled ovarian stimulation with a blocking protocol. Poor responders in the first cycle (n = 30) were subsequently treated with a flare-up protocol. Although it was not statistically significant, more patients reached oocyte retrieval with the flare-up protocol. In the completed cycles, more gonadotropin ampules (55 +/- 15 vs. 34 +/- 13; p < 0.001) and more stimulation days (12.6 +/- 1 vs. 11.6 +/- 1.2; p < 0.005) were needed in the blocking than in the flare-up protocol. No difference was observed in peak 17 beta-estradiol levels, preovulatory follicles, oocytes retrieved or pregnancy rate between the two protocols. According to the threshold values, established on CC-t of patients who obtained a clinical pregnancy (n = 44), the incidence of abnormal results was 10%. All but one patient with abnormal CC-t were poor responders during the first stimulation cycle. The flare-up protocol did not improve the ovarian response in these patients.

Biology of nidation and ectopic implantation.

The incidence of ectopic pregnancy has been steadily growing during the past decade; this fact can only partially be related to known factors (PID, use of IUDs, minipill, inductors of ovulation, sterilization reversal). Ectopic pregnancy is still a frequently misdiagnosed pathology; nevertheless, the recent advances in early diagnosis have allowed a decrease in the mortality rate and an improvement in subsequent fertility. In absence of obvious tubal abnormalities it is difficult to assess the cause of an ectopic implantation. Yet the factors regulating and nidation of the embryo in the human are far from clear. The transport of the embryo in the oviductal fluid depends on ciliary beat (generally regarded as the leading factor) and on muscle contractions mainly in the ampullary-isthmic and in the utero-tubal junction, where a sphincter action is stimulated by estrogens and relaxed by progesterone. Other substances (catecholamines, prostaglandins, oxytocin) are thought to be involved in ovum transport, although their role is unclear. Even less is known about local influence of the embryo on the oviduct. During preimplantation and implantation both the embryo and the mother engage in an elaborate interaction, elsewhere referred to as a 'conversation', involving long-and short-range signals. An essential role is played by the endocrine luminal milieu. A local action of estrogens on a progesterone-primed endometrium may be required for either the release of crucial signals for the blastocyst activation, or to make epithelial cells sensitive to the presence of the embryo, thus inducing the decidualization. In some animals, these estrogens are not ovarian, but synthesized by the blastocyst itself.(ABSTRACT TRUNCATED AT 250 WORDS)

Histological and ultrastructural changes of the endometrium in women using inert and copper-coiled IUDs.

The authors examined biopsy material obtained from women wearing inert and copper-coiled IUDs, under the light and electron microscopes. Examination of this material leads to the conclusion that there are no specific lesion attributable to either type of IUD. It can also be said that lesions characteristic for an inflammatory reaction prevail over all other possible endometrial changes.

Demonstration of human chorionic gonadotropin during the second half of the menstrual cycle in plasma of regularly menstruating women users of copper IUds.

An attempt has been made of demonstrating the beta subunit of HCG in the plasma of 13 regularly menstruating women wearing a copper IUD. Eighteen menstrual cycles were explored with a total of 94 specimens obtained at 3-day intervals starting from the 16th day of the cycle. A cross reaction with LH was excluded by simultaneous assay of this hormone. Progesteron was also assayed so as to exclude anovulatory cycles. Five out of 12 ovulatory cycles yelded positive results with HCG values ranging from 171 to 692 mIU per ml. We therefore agree with the hypothesis according to which copper IUDs do not interfere with fecundation but with subsequent stages, specifically about the time of nidation of the blastocyst in the uterus.

'Blind' transcervical transfer of gametes in the fallopian tube: a preliminary study.

The aim of the study was to assess, in a small number of volunteers, the feasibility of transferring gametes by blind transcervical tubal catheterization. Forty patients underwent ovarian stimulation with a combination of a luteinizing hormone-releasing hormone analogue and exogenous gonadotrophin. Twenty-six patients were submitted to echographical oocyte retrieval and subsequent blind transcervical tubal transfer of the gametes. Successful cannulation of the tube was achieved in 18 subjects, at the first attempt and in four subjects at the second attempt; in the remaining four subjects, three or more attempts were needed. No complications were recorded during the tubal transfer. Seven clinical pregnancies (27% of all transfers) were obtained: three ended in abortion (11%), one was ectopic (4%) and three were ongoing (11%). These preliminary results encourage larger studies using this approach.

The duration of pituitary suppression by means of intranasal gonadotropin hormone-releasing hormone analogue administration does not influence the ovarian response to gonadotropin stimulation and success rate in a gamete intrafallopian transfer (GIFT) program.

The aim of the study was to compare the ability to prevent endogenous luteinizing hormone interferences, ovarian response, and success rate between two groups of patients undergoing GIFT procedures and treated with the same stimulatory protocol but with a different timing in the administration of the gonadotropin hormone-releasing hormone analogue (GnRH-a). The former underwent a concomitant administration of gonadotropin and analogue; the latter started stimulation only after the achievement of complete hypogonadotropinism. The analogue was always given intranasally and stimulation was identical in the two groups. Our results showed that (1) prevention of premature luteinization is obtained with both approaches and (2) no significant difference in terms of length of stimulation, gonadotropin doses, ovarian response, and success rate was recorded between the two groups.