Ovulation induction with tamoxifen and alternate-day gonadotrophin in patients with thin endometrium.

Tamoxifen has been reported to be oestrogenic on the lower genital tract. To evaluate its potential positive effect on the endometrium, and consequently early miscarriage and ongoing pregnancy rate, a prospective study was employed in patients for intrauterine insemination who failed to develop an adequate endometrial thickness in a previous ovulatory cycle. Ovarian stimulation was initiated with tamoxifen 40 mg/day from day 3 of the menstrual cycle for 7 days or clomiphene 100 mg/day for 5 days, in combination with 150 IU of human menopausal gonadotrophin on alternate days starting on day 4. Human chorionic gonadotrophin (HCG) was administered when at least one leading follicle was larger than 20 mm. Intrauterine insemination was accomplished 24-36 h after HCG injection and luteal phase supplement was achieved with micronized progesterone 200 mg transvaginally per day. It was found that tamoxifen-treated patients required more stimulation days and used more gonadotrophin, but recruited less follicles larger than 14 mm than clomiphene-treated patients. However, a significantly increased endometrial thickness (P < 0.001) and pregnancy rate (P = 0.015), decreased early miscarriage rate (P = 0.001) and thus improved ongoing pregnancy (P < 0.001) rate were noted in tamoxifen-treated patients. These results suggest that although tamoxifen may not be a first-line treatment in patients with adequate endometrium, it may be a promising alternative for patients with thin endometrium.

Benefits of intracervical injection of sterile saline solution in laparoscopically assisted vaginal hysterectomy with vaginal colpotomy and bladder mobilization.

OBJECTIVE: To evaluate the influence of intracervical saline injection on inexperienced operators and on laparoscopically assisted vaginal hysterectomy (LAVH). STUDY DESIGN: This retrospective study included 273 women undergoing LAVH. From July 1997 to June 2002, 138 LAVHs were performed with laparoscopically approached colpotomies and bladder mobilization. Among 135 LAVHs with a vaginal approach, colpotomies/bladder mobilization was done directly in 62 and in the other 73 after a circumferential intracervical saline injection. All operations were performed by inexperienced operators under the supervision of senior surgeons. Blood loss, operative time and complications were analyzed. RESULTS: The average follow-up period was 41.2 +/- 17.4 months (range, 12-72). No statistically significant differences were observed in age, hemoglobin levels or length of postoperative hospital stay. The incidence of postoperative infection, hematoma and bowel injury was not significantly different. LAVH with vaginal colpotomies/bladder mobilization and intracervical saline injection was associated with the smallest estimated blood loss (p = 0.002) and operative time (p < 0.001). LAVH with laparoscopic colpotomies and bladder mobilization had the longest operative time (p<0.001) and the highest bladder injury rate (p= 0.004). CONCLUSION: A circumferential injection of normal saline at the cervicovaginal junction is a good option for inexperienced operators.

Human chorionic gonadotropin-induced ovarian hyperstimulation syndrome is associated with up-regulation of vascular endothelial growth factor.

Ovarian hyperstimulation syndrome (OHSS), a life-threatening complication occurring in stimulated ovarian cycles, arises from treatment with gonadotropin for induction of follicular maturation in infertile women. Clinical characteristics of OHSS include ascites and pleural effusion induced by increased vascular permeability, where vascular endothelial growth factor (VEGF) was suspected to be the culprit. To test whether the effects of human CG (hCG) on the pathogenesis of OHSS were mediated through the VEGF produced by luteinized granulosa cells, we measured estradiol, VEGF, IGF-II levels in serum, and follicular fluid and analyzed their mRNA expression in luteinized granulosa cells obtained from 101 women (58 with OHSS and 43 controls) who underwent in vitro fertilization and embryo transfer. This study presents the first evidence that hCG up-regulated VEGF expression of granulosa cells in the OHSS, not the control groups, and that follicular VEGF worked through an autocrine mechanism using its kinase insert domain-containing receptor, not the fms-like tyrosine kinase receptor. We calculated total follicular production of VEGF, by multiplying follicular concentrations by follicular volumes, and verified that an increase in total follicular production of VEGF accounted for elevated serum levels of VEGF, which was associated with the development of OHSS. These findings demonstrate that through up-regulation of VEGF, hCG plays a significant role in the pathogenesis of OHSS.

Challenges in the transvaginal management of abnormal uterine bleeding secondary to cesarean section scar defect.

OBJECTIVE: Research suggests that the resectoscopic management of abnormal uterine bleeding (AUB) following cesarean section (CS) is safe and effective. There is, however, a lack of complementary data from routine clinical practice. We aimed to evaluate the efficacy of resectoscopic remodeling of the CS scar in the management of post CS AUB (pCSAUB). STUDY DESIGN: The case notes of 57 women with pCSAUB who had undergone a resectoscopic remodeling procedure were reviewed retrospectively. Primary outcome measures were the duration of preoperative and postoperative menstruation, and postoperative menstrual change. Secondary outcome measures were the impact of patient-dependent variables on the success of the resectoscopic remodeling procedure. The CS scar was located using transvaginal ultrasonography and hysteroscopy. The remodeling procedure was performed with a hysteroscopic resectoscope, and commenced with resection of the fibromuscular scar. This started at the roof of the scar pouch and progressed towards the external os. It then continued along a line parallel to the axis of the cervical canal. The exposed dilated blood vessels and endometrial-like tissue in the roof of the remaining pouch were electrocauterized with a roller-ball electrode. RESULTS: The mean operating time was 30.2 ± 6.6 min. There was a significant difference in the mean duration of preoperative and postoperative menstruation (12.9 ± 2.9 days and 9.4 ± 4.1 days, respectively; p < 0.001). However, only 59.6% of patients (34/57) reported a postoperative improvement in symptoms. A significant postoperative improvement was observed more frequently in patients with anteflexed uteri than in patients with retroflexed uteri, and this difference was significant (90.6% (29/32) and 20.0% (5/25), respectively; p < 0.001). No correlations were found between treatment outcome and age, body weight, parity, number of cesarean deliveries, duration of preoperative menstruation, or operating time. CONCLUSIONS: Resectoscopic uterine remodeling is an appropriate therapy in patients with pCSAUB and an anteflexed uterus.

Relationship of progesterone/estradiol ratio on day of hCG administration and pregnancy outcomes in high responders undergoing in vitro fertilization.

OBJECTIVE: To evaluate the predictive value of a serum P/E(2) ratio measured on the day of hCG administration regarding pregnancy outcomes in high responders undergoing IVF. DESIGN: Retrospective study. SETTING: Teaching hospital. PATIENT(S): Two hundred twenty-three infertile women classified as high responders in IVF-ET cycles. INTERVENTION(S): Eligible infertile women undergoing IVF were assigned to four groups according to serum P levels on the day of hCG administration: group 1, P2.0 ng/mL. The relationship of E(2) level and P/E(2) ratio on the day of hCG administration and pregnancy outcomes was analyzed. MAIN OUTCOME MEASURE(S): Implantation and pregnancy rate. RESULT(S): Patients in group 4 had highest E(2) level and P/E(2) ratio, as well as lowest implantation and pregnancy rates. Using P for grouping, the sensitivity/positive predictive values (%/%) of P/E(2) ratio in the four groups were 15/66, 30/65, 30/60, and 25/41, respectively. CONCLUSION(S): Using the level of a single sex hormone on hCG day to predict pregnancy outcome in high responders undergoing IVF is confounding, whereas using a P/E(2) ratio on hCG day is theoretically reasonable. However, the low sensitivity and positive predictive value make the use of P/E(2) clinically unfeasible.

An increased serum progesterone-to-estradiol ratio on the day of human chorionic gonadotropin administration does not have a negative impact on clinical pregnancy rate in women with normal ovarian reserve treated with a long gonadotropin releasing hormone agonist protocol.

OBJECTIVE: To evaluate the relationship between serum P:E(2) ratio on the day of hCG administration and the clinical outcomes in infertile women with normal ovarian reserve treated with a long GnRH agonist (GnRH-a) protocol. DESIGN: Retrospective analysis of IVF-embryo transfer data. SETTING: University teaching hospital. PATIENT(S): One hundred thirty-nine infertile women with normal ovarian reserve, who received IVF-embryo transfer with a long GnRH-a protocol. INTERVENTION(S): Cycles were grouped according to whether premature luteinization (PL) appeared on the day of hCG administration. Premature luteinization was defined as a P:E(2) ratio >or=1.2 by using receiver operator characteristic analysis. MAIN OUTCOME MEASURE(S): Treatment cycle hormonal characteristics and clinical outcomes. RESULT(S): The P:E(2) ratio on the day of hCG administration was significantly higher in the PL (n = 41) compared with the non-PL (n = 98) group (2.4 +/- 1.5 and 0.6 +/- 0.3, respectively). The mean number of oocytes retrieved in the PL and non-PL groups were 4.2 +/- 2.8 and 12.7 +/- 6.6, respectively. However, the difference between the clinical pregnancy rates (PR) in the PL and non-PL groups was not statistically significant (29.3% vs. 34.5%). In a logistic regression analysis, the P:E(2) ratio showed no statistically significant correlation with pregnancy outcome. CONCLUSION(S): The increased serum P:E(2) ratio on the day of hCG administration, as an indicator of PL, has a poor predictive value on IVF outcomes in infertile women with normal ovarian reserve treated with a long GnRH-a protocol.

Estradiol-to-testosterone ratio is associated with response to metformin treatment in women with clomiphene citrate-resistant polycystic ovary syndrome (PCOS).

BACKGROUND: To investigate intrinsic alterations in ovarian steroidogenesis in women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS) who ovulated after metformin treatment. METHODS: Fifty-six women of reproductive age (18-40 years) diagnosed with CC-resistant PCOS received metformin for 12 weeks. If ovulation was successfully induced by CC after metformin treatment, the women were classified as responders. Circulating levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), testosterone (T), free testosterone (freeT), fasting insulin and sex hormone-binding globulin (SHBG) were determined at weeks 0, 4 and 12 of metformin treatment. RESULTS: Thirty-seven women with CC-resistant PCOS finished the treatment course. There were no significant differences in circulating levels of FSH, E2, T, freeT and fasting insulin at weeks 0, 4, and 12 between responders and nonresponders. At week 4, responders showed significantly higher LH levels and higher LH/FSH ratios than non-responders (p < 0.005 and p < 0.05, respectively). After the 12-week treatment, responders demonstrated higher serum E2/T ratios and lower freeT levels than non-responders (p < 0.05 and p < 0.05, respectively). CONCLUSIONS: The results suggest that in women with CC-resistant PCOS, elevated E2/T is associated with a better response to metformin.

Laparoscopy versus laparotomy for surgical intervention of ovarian torsion.

AIM: To review the clinical manifestations of ovarian torsion (OT) and to compare the surgical results between laparoscopy and laparotomy. METHODS: From 1997 to 2006, data on 179 patients admitted to a medical center with surgically proven OT were collected. We compared patients' symptom presentations, objective findings and surgical outcomes between patients who underwent laparotomy and those who received laparoscopy, and between patients admitted via the emergency room and those via the outpatient department. RESULTS: The most common symptom and sign was pelvic pain (82.1%), followed by nausea and vomiting (49.7%), elevated white blood count (20.1%), lower urinary tract symptoms (14.5%) and fever (7.8%). An adnexal or pelvic mass could be detected using gynecological ultrasound in almost all of the patients (98.3%). Ovarian torsion was considered among the admission differential diagnoses in 51.4% of patients. One hundred and five patients (58.7%) seen in the emergency room were more likely to present with nausea and vomiting, sudden pain onset and peritoneal signs than those seen in the outpatient department. Patients undergoing laparoscopy had a smaller sized ovarian mass; they were less likely to require oophorectomy; they had a shorter hospital stay; and fewer of them suffered from postoperative fever compared to patients undergoing laparotomy. Discriminant analysis showed that mass size was the single determining factor for choice of operating methods. CONCLUSION: The diagnosis of OT is missed in half of the patients because clinical features are unspecific and objective findings are uncommon. The laparoscopy procedure for ovarian conservation is recommended to treat patients suffering from OT owing to its shorter hospital stay, fewer postoperative complications and ovarian preservation.

Correlation of pelvic organ prolapse quantification system scores with obstetric parameters and lower urinary tract symptoms in primiparae postpartum.

This study investigated the correlation between results of the pelvic organ prolapse quantification (POPQ) system at 3 days and at 2 months postpartum with obstetric parameters and lower urinary tract symptoms (LUTS) in 125 primiparae with vaginal delivery. The clinical characteristics, prevalence of pregnancy-related LUTS, and POPQ scores were evaluated. Regarding the relationship of obstetric parameters with POPQ scoring, the gh was found positively correlated with the body mass index and vaginal laceration at 2 months postpartum. The POPQ evaluation did not find the LUTS to be significantly related to the prolapse score. The mean scores of points C and D were significantly increased, and gh, pb, and tvl were significantly decreased between the initial and 2-month follow-up scores. Our results revealed that a decrease in vaginal size is the principal change during the first 2 months postpartum and that with the exception of gh, neither the obstetric parameters nor the LUTS were associated with the POPQ scoring system.

Repair of recurrent vaginal vault prolapse using sacrospinous ligament fixation with mesh interposition and reinforcement.

OBJECTIVE: Our goal was to study the efficacy of performing the repeated sacrospinous ligament fixation with mesh interposition and reinforcement in women with recurrent vaginal vault prolapse. MATERIALS AND METHODS: Fifteen consecutive patients with symptomatic severe vaginal vault or uterus prolapse after previous sacrospinous ligament fixation were enrolled. The sacrospinous ligament fixation was performed with a mesh interposition between sacrospinous ligament complex and vaginal apex. The mesh was extended to anterior and posterior vaginal wall for the repair of concurrent cystocele and rectocele, if indicated. The surgical results and complications were evaluated. The prolapse evaluation was performed according to International Continence Society (ICS) ordinal stages of pelvic organ prolapse. RESULTS: The mean age was 55 years. The mean follow-up was 2.9 years (range 1.0-5.5 years). Repeated sacrospinous ligament fixation was performed for all patients. Eleven were performed unilaterally to the right and four to the left. The average time for sacrospinous fixation was 20 min. The average blood loss for sacrospinous fixation was 75 ml. No major complication except one accidental rectotomy was observed. It was repaired intraoperatively without sequel. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies, and tension-free vaginal tape procedures. No recurrence of apical prolapse was observed. However, two patients developed stage I prolapse on anterior vaginal wall (cystocele) and required no further repair. Minor postoperative complications were observed. CONCLUSION: Repeated sacrospinous ligament fixation with mesh interposition and reinforcement is a safe and effective procedure for the correction of recurrent vault prolapse. The extended implanted mesh can be used for the repair of concurrent cystorectocele effectively. A long-term follow-up is necessary to detect any late complication.

Ultrasound and urodynamic comparison between caudocranial and craniocaudal tension-free vaginal tape for stress urinary incontinence.

OBJECTIVES: To compare the efficacy and safety of the conventional caudocranial tension-free vaginal tape (TVT) procedure and craniocaudal TVT procedure for the treatment of primary stress urinary incontinence. METHODS: Ninety patients with urodynamic stress incontinence and without prolapse underwent a caudocranial TVT (45 women) or craniocaudal TVT (45 women) procedure. The two patient groups were comparable in terms of age, parity, body weight, previous pelvic surgery, and menopausal status. Both methods were performed under local anesthesia with adequate sedation. Introital ultrasound evaluation on the mid-urethra TVT tapes and urodynamic evaluation was performed before and after surgery. RESULTS: The average follow-up period for caudocranial TVT and craniocaudal TVT was 1.9 years and 1.4 years, respectively. Objective evaluations were performed at similar times at 1 year postoperatively. No significant differences were found in the cure rate at 88.9% (40 of 45 women) after caudocranial TVT and 91.1% (41 of 45 women) after craniocaudal TVT (P = 1.000). The intraoperative complications were minor. No patient had long-term voiding difficulty or required long-term catheterization. Both groups had the vaginal tape implanted at the mid-urethra, with a urethral knee angle observed during maximal straining. A more proximal tape position, less elasticity of the tape, and more obstruction by the sling were found using the craniocaudal approach. Postoperative dysfunctional voiding was minor. CONCLUSIONS: The caudocranial and craniocaudal TVT procedures are highly effective, minimally invasive, and safe procedures in the treatment of urinary stress incontinence. The variations in implanted tape position and postoperative sling obstruction were most likely caused by the mode of insertion.

Successful outcome of intrathoracic injection of autologous amniotic fluid in fetal reduction: report of two cases.

Potassium chloride is reported to kill both monochorionic twins after injection into only one. In this study, two women undergoing in vitro fertilization and embryo transfer were pregnant with triplets containing monochorionic twinning, which were detected by ultrasound with the presence of a "twin-peak" sign. Instead of potassium chloride, intrathoracic injection of amniotic fluid was employed to sacrifice one of the monochorionic fetuses in dichorionic triplets. Our aim was to sacrifice one of the monochorionic twins in order to prevent adverse perinatal outcomes and to avoid the harmful effect of potassium chloride on monochorionic cotwins. One twin pregnancy was terminated with preterm premature rupture of membranes at 25 weeks of gestation. In the second one, two healthy babies were delivered by cesarean section at 36 weeks of gestation. The female baby weighed 2100 gm and the male baby 2600 gm, respectively. Intrathoracic injection of amniotic fluid to create a tamponade is an alternative management for fetal reduction.

Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH.

STUDY OBJECTIVE: To compare results of a vaginal approach to colpotomy (type IA) and laparoscopic-assisted abdominal colpotomy (type ID) in performing a laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective, randomized study (Canadian Task Force classification I). SETTING: Tertiary teaching hospital. PATIENTS: Five hundred forty-one women, 274 in group 1 (type 1D) and 267 in group 2 (type 1A). INTERVENTION: LAVH with follow-up for 3 months to 5 years. MEASUREMENTS AND MAIN RESULTS: There were no statistically significant differences in age, preoperative and postoperative hemoglobin values, or postoperative hospital stay between groups. Operating time and estimated blood loss were significantly reduced in group 2 (p <0.001 and <0.001, respectively). Women in group 1 had nine urinary tract injuries (3.28%), including eight cases of intraoperative bladder injury (2.91%) and one vesicovaginal fistula (0.36%), but no ureteral injury. The bladder injury rate in group 2 was 0.37%, which was significantly lower (p = 0.038). There were no significant differences in ureteral or bowel injuries, pelvic hematomas, or pelvic abscesses. CONCLUSION: LAVH type IA achieved better results than type ID in preventing bladder injury.

Use of the lambda sign in fetal reduction of dizygotic triplets after intracytoplasmic sperm injection.

With the increased use of artificial reproductive technologies, there are ever greater numbers of multifetal pregnancies. The increased incidences of monozygotic twins and triplet gestations can be attributed to several factors. It is important to differentiate the chorionicity in the management of multifetal pregnancies because monochorionic gestations lead to an increased risk of prematurity, twin-to-twin transfusion, morbidity, and mortality. In a dizygotic triplet pregnancy, increased risks of obstetric complications result from the monozygotic twins, such as twin-to-twin transfusion, as well as from the presence of triplets. Fetal reduction can lower these risks. During the first trimester, a "lambda sign" on ultrasound can differentiate between monozygotic twins and a separate fetus. In this paper, we present selective fetal reduction of 1 of the monozygotic twins in order to reduce the risks resulting from either monozygotic twins or from triplets. By sacrificing 1 monozygotic twin, we believe the quality of life of the remaining babies in this case were improved.

Use of intravenous anesthesia for tension-free vaginal tape therapy in elderly women with genuine stress incontinence.

OBJECTIVES: To study the efficacy of the tension-free vaginal tape (TVT) procedure for elderly patients. METHODS: Forty-five women, 65 years old or older (mean 69.1; range 65 to 85), were treated for genuine stress incontinence with the tension-free vaginal tape procedure under intravenous anesthesia with heavy sedation. Urodynamic studies and 1-hour pad test were performed before the procedure and at 1 year postoperatively. Vigorous manual pressure against the abdominal wall and ensuring no lifting of urethra by intraoperative introital ultrasonography were used to position and adjust the vaginal taping. RESULTS: Forty-one (91%) were cured, one improved, and three failed. No major surgical complications occurred. Two bladder perforations were noted. The pad test disclosed a reduction in urine leakage from a mean of 28.9 to 1.6 g/hr (P <0.001). The average blood loss was 72 mL (range 30 to 250), operating time was 21 minutes (range 18 to 35), and postoperative hospital stay was 24.2 hours (range 12 to 72). Spontaneous voiding with an adequate volume of postvoid residual urine was noted for all patients by the fourth day postoperatively. Urodynamic parameters related to the voiding dysfunction showed no significant difference before and after surgery. De novo detrusor instability was observed in 2 patients. CONCLUSIONS: With modifications of the technique and the aid of intraoperative ultrasonography, the TVT procedure can be performed under intravenous anesthesia with heavy sedation. The procedure is safe, effective, and minimally invasive for elderly patients. However, long-term follow-up is needed to determine whether this surgery achieves long-lasting results.

Ultrasound assessment of mid-urethra tape at three-year follow-up after tension-free vaginal tape procedure.

OBJECTIVES: To evaluate the anatomic changes in the polypropylene mesh sling after a tension-free vaginal tape (TVT) procedure using introital ultrasonography in a prospective study. METHODS: Eighty women with genuine stress incontinence but without pelvic relaxation syndrome underwent surgery. Introital ultrasound evaluation of the mid-urethra TVTs was performed after surgery. RESULTS: Of the 70 women available for evaluation at postoperative year 3, 62 (88.5%) were objectively cured and 6 had improvement; in 2 patients, the procedure had failed. The measurement of the tape position from the bladder neck at the first and third year compared with the tape position at 1 month revealed no statistically significant differences. The tapes were located at the mid-urethra in 60 patients (85.7%) and at the proximal urethra in 10. The measurement of the tape from the lower margin of the symphysis pubis using the rectangular coordinate system showed the tape had a downward descent of 1.7 mm at 3 years of follow-up. The rate of descent decreased during the study period. The mean thickness and width of the tape increased with time. A urethral knee angulation during maximal straining was found in 60 patients (92%), with the tape positioned at the mid-urethra for the follow-up period. CONCLUSIONS: The observations of the tape position and characteristics suggest that shrinkage and compromise of the TVT sling does not occur. The TVT sling fixes to its original implanted site along the urethra and appears to slowly descend with the surrounding tissue with time. The urethra dynamic kinking contributes to the postoperative urinary continence when the TVT sling is placed at the mid-urethra.

Tension-free vaginal tape procedure after previous failure in incontinence surgery.

OBJECTIVES: To study the efficacy of the tension-free vaginal tape (TVT) procedure for patients with recurrent genuine stress incontinence. METHODS: Forty-one women, including 11 with urethral sphincter incompetence (mean age 49.6 years, range 37 to 66), were treated for recurrent genuine stress incontinence with TVT procedure under local or regional anesthesia. Urodynamic studies, a 1-hour pad test, introital ultrasonography on the urethra, a cotton swab test, and subjective symptom analysis were documented before the procedure and at 1 year postoperatively. RESULTS: Of the 41 women, 34 (82.9%) were cured, 2 improved, and 5 (12.2%) had treatment failure. Among the women with failure, three had urethral sphincter incompetence with a fixed urethra. No major surgical complications occurred. Four bladder perforations were noted. The 1-hour pad test reduced from a mean of 27.3 to 1.7 g (P <0.001). The operating time was 22 minutes (range 15 to 44), and the postoperative hospital stay was 22.4 hours (range 12 to 72). Spontaneous voiding with adequate postvoid residual urine volume was noted for all patients by the fourth day postoperatively. The preoperative and postoperative cotton swab result was 40.0 degrees (range 10 degrees to 80 degrees ) and 38.7 degrees (range 10 degrees to 76 degrees ), respectively, without statistically significant changes. Of the 36 cured and improved patients, 31 (86.1%) had a cotton swab test result of 30 degrees or more before and after the TVT procedure. Urodynamic parameters related to the voiding dysfunction showed no significant difference before and after the surgery. Urodynamic assessment showed no significant difference in the filling, voiding, and urethral pressure profile (dynamic and static) variables, except for significant increases in the maximal flow rate, bladder volume at the first desire to void, and cystometric capacity, which were measured preoperatively and postoperatively. No de nova detrusor instability or micturition disturbances were found in the cystometric study. CONCLUSIONS: The TVT procedure for the treatment of recurrent genuine stress incontinence is a safe, effective, and minimally invasive option requiring only a short hospital stay. However, the immobile urethra seems to be a risk factor for failure. Long-term follow-up is needed to determine whether this surgery achieves long-lasting results.

The concentration of inhibin B in follicular fluid: relation to oocyte maturation and embryo development.

BACKGROUND: The objective of the present study was to investigate the correlation between inhibin B and estradiol levels in follicular fluid (FF) with the quality of subsequent embryo development from in-vitro fertilized oocytes aspirated from the same follicle. METHODS: A total of 156 infertile women undergoing controlled ovarian stimulation for IVF and embryo transfer was recruited to the present study. Prospectively, 233 FF samples and matched mature oocytes were studied. Concentrations of inhibin B and estradiol were determined by enzyme-linked immunosorbent assay (ELISA) and immunofluorometric assay (IFMA) respectively. RESULTS: Inhibin B levels in FF were significantly correlated with embryo scores on days 2 and 3 (48 and 72 h after oocyte retrieval). In contrast, both inhibin B and estradiol levels in FF were inversely related to age. Furthermore, FF inhibin B levels were inversely associated with serum FSH levels on day 3 of the menstrual cycle, which was believed to reflect the ovarian reserve. CONCLUSION: Inhibin B in FF may serve as an effective marker of follicular development and a useful predictor of quality of embryo. In addition, quality of oocyte is age-related and declines as age increases.

Laser-assisted hatching of embryos in women of advanced age after in vitro fertilization: a preliminary report.

BACKGROUND: For infertile women aged over 37 years, failure of the zona pellucida to rupture is believed to be associated with a decreased implantation rate in in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). It has been suggested that assisted hatching of embryos will increase the pregnancy rate with IVF by means of mechanically facilitating the hatching process. METHODS: One hundred twenty cycles of IVF/ICSI in females aged over 37 years were analyzed. Women included in this study were allocated into 2 groups. In group I, embryos were cultured and transferred without laser-assisted hatching (LAH), whereas embryos of group II were examined and treated with LAH just before being transferred. Laser manipulations were performed using a 1.48-microm (infrared) diode laser (Fertilase). The laser was aimed at the zona to create openings of about 20 microm in diameter. RESULTS: The mean ages of women in groups I and II were 38.8 +/- 1.8 and 39.5 +/- 1.6 years, respectively (p = 0.17). The number of retrieved oocytes, endometrial thickness, and number and quality of transferred embryos did not significantly differ between the 2 groups. Rates of implantation (7.3% and 6.7%, respectively, p = 0.89), pregnancy (16.3% and 17.5%, respectively, p = 0.86), and early pregnancy loss did not differ between the 2 groups. CONCLUSION: Our data failed to demonstrate any benefit of LAH in improving implantation or pregnancy rates in women of advanced age, suggesting that factors other than laser drilling of the zona should be considered.

Clinical evaluation of a new model of self-obtained method for the assessment of genital human papilloma virus infection in an underserved population.

BACKGROUND: We designed a self-sampling method to collect exfoliated genital cells for human papilloma virus (HPV) detection. The aim was to assess whether it was suitable as an assistant tool for the early detection of cervical pre-cancer and cancer in a special category of the women who are not frequently screened for cervical cancer. METHODS: We compared the results of HPV detection that were self-obtained and physician-obtained cervical swabs from the same patient that were analyzed using hybrid capture II assay. The diagnostic rate of cervical pre-cancer and cancer between self-obtained method and physician-obtained method were analyzed. RESULTS: A total of 1194 women were prospectively registered from September 1997 through September 1999. Among them, 144 (12.1%) of self-test samples and 155 (13%) of physician-obtained samples were oncogenetic associated-HPV positive. Statistically, no significant differences existed in the screening rate for cervical cancer using either the self-collected samples or the physician-obtained samples (p > .05). The sensitivity of cervical precancer or cancer detection using self-obtained HPV testing was higher (96.3%) as compared with the Pap smear (79.2%) (p < .02). CONCLUSION: The detection correlation of the HPV test between the self-obtained method and physician-obtained method was 93%. Our results indicated that self-sampling was a reliable method for testing for HPV. The identification of HPV infection through the self-obtained method can be used in early identification of high-risk women with cervical precancer and cancer especially in underserved populations.