Comparison between "short" and "long" protocols in an ICSI programme.

In the present retrospective study we compare the efficacy of gonadotropin-releasing hormone (GnRH) agonist in a long protocol and a GnRH agonist in a short protocol administration for controlled ovarian hyperstimulation (COH) in an ICSI program. A total of 424 consecutive patients with a history of male factor were included in the present study. Three hundred and three patients were included in the long protocol and 121 in the short protocol. Patients treated with the short protocol were stimulated in a shorter time and achieved lower estradiol levels. A significantly higher percentage of oocytes transferred were found in the long protocol. The clinical pregnancy rate per embryo transfer was 39.3% in the long protocol and 19.2% in the short protocol (p=0.001).

Small doses of LH activity are needed early in ovarian stimulation for better quality oocytes in IVF-ET.

OBJECTIVE: To examine whether exogenous LH administration has a beneficial effect on the quality of oocytes, fertilization potential, as well as pregnancy rate in IVF-ET cycles. A randomized trial comparing r-FSH versus r-FSH and LH was employed. STUDY DESIGN: Forty-six infertile couples entering IVF-ET for the first time (either tubal or male factor) were divided after prospective randomization into two groups. In both groups the long protocol with GnRH-analogs was used. In group A, ovarian stimulation started with r-FSH (200 IU/day) for the first four days. In group B, the stimulation protocol started with one amp hMG (75 IU FSH + 75 IU LH activity) daily for four days, with simultaneous administration of r-FSH (150 IU/day). The outcome was compared. RESULTS: Statistical difference was observed in the number of mature oocytes, the number of fertilized oocytes as well as the number of transferable embryos. In all cases, results were statistically significantly better (p < 0.05) in group B. Clinical pregnancy rate, finally, was similar in the two groups. CONCLUSION: The relatively small sample size does not allow a definitive conclusion for the important role of LH during early oocyte maturation. Our results, however, indicate a beneficial effect when small doses of LH are used for ovarian stimulation in IVF-ET cycles. This effect may be more important in cases in which few embryos are available for transfer.

Saline contrast hysterosonography in infertile patients and in women with abnormal uterine bleeding.

OBJECTIVE: We conducted this prospective study to evaluate saline contrast hysterosonography (SCHS) as a diagnostic modality for intrauterine lesions in comparison to hysteroscopy and endometrial biopsy. MATERIALS AND METHODS: We included 135 patients, of whom 70 presented with abnormal uterine bleeding and 65 with subfertility problems. All cases were examined with conventional transvaginal sonography and were further investigated with SCHS using saline as contrast medium, and finally hysteroscopy with endometrial biopsy that was used as the reference test. RESULTS: SCHS revealed the presence of intrauterine pathology in 23 cases and failed in three (4.2%). SCHS had a sensitivity of 94%, a specificity of 71%, a positive predictive value of 76% and a negative predictive value of 95% in the abnormal uterine group. In subfertile patients, SCHS revealed the presence of intrauterine pathology in 34 cases and had a sensitivity of 96%, a specificity of 74%, a positive predictive value of 79% and a negative predictive value of 95%. CONCLUSIONS: We found that SCHS is an extremely accurate modality for the diagnosis of focal endometrial pathology, compared to diagnostic hysteroscopy.

EGF and IGF-I as predictors of ICSI outcome in human preimplantation embryo cultures.

PURPOSE OF INVESTIGATION: Detection of EGF and IGF-I in human embryo cultures and their effect on ICSI outcome. METHODS: Collection of culture medium from embryos of 50 women under ICSI program. EGF and IGF-I were measured via enzyme immunoassay. RESULTS: ICSI outcome was independent of age, infertility years, FSH, LH, prolactine and E2. EGF detection was higher in 48- (32%), than in 72-hour embryos (14%) (p < 0.001). EGF negative embryos are likely to be arrested at the morula stage (p < 0.001) and are associated with poor pregnancy rates (p < 0.05). IGF-I was undetected in 48-hour embryos. CONCLUSIONS: For the first time human embryos were surveyed from fertilization until embryo transfer, regarding EGF and IGF-I production. IGF-I is not a predictor of ICSI outcome. EGF is present in one-third of human embryo cultures at 48 hours, but this ratio wanes at the morula stage. EGF negative embryos are associated with lower pregnancy rates.

Circulating endothelin-3 and prolactin concentrations in healthy lactating women during the early puerperium.

OBJECTIVE: To study the association between the circulating concentrations of endothelin-3 and prolactin in the early puerperium. DESIGN: Prospective clinical study, including twenty-five healthy puerperal women breast-feeding their healthy full-term infants. METHODS: Venous blood was drawn on day 1 and 4 post partum, and plasma endothelin-3 and serum prolactin were determined. RESULTS: Circulating endothelin-3 and prolactin levels on day 4 did not differ significantly from the corresponding levels on day 1. However, a significant negative correlation was found on day 4 between endothelin-3 and prolactin values (r = -0.688, P < 0.001) and an even stronger negative association existed between the net change in endothelin-3 from days 1 to 4 and the corresponding change in prolactin values (r = -0.732, P < 0.001). CONCLUSIONS: On the fourth day post partum, lactating healthy women show negative correlation between circulating endothelin-3 and prolactin levels. Whether this indicates a role for endothelin-3 in the control of prolactin secretion in the post partum period remains to be clarified.

Clinical implications of the ovarian/endometrial renin-angiotensin-aldosterone system.

New organ-specific functions of angiotensin II have recently been described: the importance of its role in the regulation of secretory epithelial function in many tissues including components of the reproductive tract has been documented. The source of angiotensin II in these tissues is the reproductive tract itself, and there is considerable evidence to suggest a distinct renin-angiotensin-aldosterone system in the ovary and uterus. Two main subtypes of angiotensin II receptors are recognized as angiotensin-receptor I and II, according to their sensitivity to the angiotensin II antagonists. However, the presence of angiotensin II receptors in the male and female reproductive tract suggests a multiplicity of roles that are unrelated to their primary functions or to each other. The renin-angiotensin-aldosterone system is a major determinant of sodium balance in pregnancy. More recently RT-PCR methods have revealed angiotensinogen transcription in the smooth muscle of spiral anteries of the decidua; a specific allele of this gene may be associated with hypertension in pregnancy as well as in pre-eclampsia. We investigated the evolution of plasma renin activity and aldosterone levels during normal and hypertensive pregnancy. Both were found to increase progressively during all three trimesters of normotensive pregnancy. Plasma renin activity in hypertensive women remained unchanged during all three trimesters of pregnancy. Plasma aldosterone levels in hypertensive women increased progressively during all three trimesters of pregnancy. However, plasma aldosterone levels remained significantly lower than the ones of normotensive pregnant women. These increased aldosterone levels were noticed despite unchanged renin levels. Further clinical studies investigating the renin-angiotensin-aldosterone system in the pathogenesis of pregnancy hypertension are needed. A renin-independent role of aldosterone in this pathological entity is suggested.

Endometriosis and reproductive disorders.

The classic concept of endometriosis as a cause of infertility is challenged. Traditionally, both surgical and medical therapy have focused on alleviation of symptoms, prevention of disease progression, and promotion of fertility. In spite of significant developments in medical and surgical approaches, the optimal therapy for treating endometriosis-associated infertility has yet to be established. The relationship between prevalence of fecundity and stage of the disease was studied according to the type of management. Of 151 women who were consecutively proved by laparoscopy to have endometriosis stage I and II, operative laparoscopy was performed in 49, medical treatment in 59, and expectant management in 43 cases. During a 24-month period, the cumulative pregnancy rates were 36.7%, 30.5%, and 20.9%, respectively. Survival analysis over the 20 weeks of pregnancy showed that the probability of carrying the pregnancy beyond this week was 30.6%, 25.4%, and 16.2%, respectively. Of 64 patients with advanced disease, 34 (53%) became pregnant during the 2-year follow-up period. A significantly increased pregnancy rate was found for the first year as compared to the second (76% vs. 24%). The existence of adhesions affected adversely the outcome of the treatment when early achievement of pregnancy is considered. Diagnosis and treatment of endometriosis was beneficial for the infertile women. Laparoscopic surgery seems to be the best treatment in these cases, as it increases the fecundity and involves minimal risk.

Biological factors in culture media affecting in vitro fertilization, preimplantation embryo development, and implantation.

Optimal culture conditions are of paramount importance for in vitro fertilization of gametes, preimplantation embryo development, and implantation for all species. Water is the basis of all culture media, and ultrapure water should be employed. The main energy sources of a medium are lactate, pyruvate, and glucose. The concentrations of the first two vary in different media, whereas the latter is necessary mainly for the later stages (morula to blastocyst) of development. A fixed nitrogen source is essential for implantation embryo development whether this is provided by amino acids, albumin, or serum. Suboptimal culture conditions can block development. Pronuclear zygotes of most species (but not human) arrest at some point between the two-cell and the 16-cell stage. Modifying culture conditions can lead the embryos to develop through this block. Hypoxanthine also causes a two-cell block to mouse pronuclear zygotes, and this again depends largely on culture conditions. Simple culture media are bicarbonate-buffered systems with pyruvate, lactate, and glucose. Complex media, such as Ham's F-10, contain in addition amino acids and other elements found in serum. Human tubal fluid simulates the fallopian tube microenvironment. EDTA, gonadotropins, growth factors, and other substances can be included in the media to stimulate development. Coculture of embryos with oviductal cells has shown promising results.

Adhesions: laparoscopic surgery versus laparotomy.

This study was undertaken to assess the effectiveness in pregnancy rates of microsurgery and operative laparoscopy in adhesiolysis. Adhesions were found to be the sole infertility factor in 15% of our patients. One hundred and ninety infertile patients with periadnexal adhesions as the only cause of their infertility were treated by microsurgery (86) or operative laparoscopy (104) and were followed up for 24 months. Our results indicate that advanced laparoscopic surgery in general is as effective as microsurgery in healthy infertile patients with adhesions but offers some advantages in comparison to laparotomy. Factors that adversely affect the postoperative success rates are the age of the women, the duration of infertility, and the severity of the adhesions.

Group B streptococcus colonization of Greek pregnant women and neonates: prevalence, risk factors and serotypes.

OBJECTIVE: To evaluate the prevalence and risk factors of group B streptococcus (GBS) colonization among pregnant women and their neonates in Greece, and to examine the serotype distribution of the GBS strains isolated and their susceptibility to antibiotics. METHODS: A vaginal and a rectal swab were obtained from 1014 pregnant or parturient women followed at public and private hospitals in Athens and in a city of northern Greece. Cultures were also taken 24 h after birth from 428 neonates born to these women. RESULTS: The overall maternal and neonatal colonization rates were 6.6% and 2.4%, respectively. The vertical transmission rate was 22.5%. By logistic regression analysis, multiparity (>/=III) was associated with a lower colonization rate (odds ratio 4.4, 95% confidence interval 1.08-18.63). In contrast with other studies, middle-class women followed privately were more frequently colonized (10%) than those followed at the public hospital (3.9%) (odds ratio 3.1, 95% confidence interval 1.83-5.42). A higher number of prenatal visits was also associated with a higher colonization rate (change in true odds ratio when visits increased by one, 1.3; 95% confidence interval 1.14-1.60). No association was found between colonization and maternal age, previous obstetric history, marital status, nationality, prematurity, Caesarean section, or infant birth weight. The most common serotypes were II (26.9%), III (22.4%), Ia (19%), Ib (12%), and V (9%). A considerable proportion of the isolated strains was resistant to erythromycin (4.5%), clindamycin (6%), or both (6%). CONCLUSION: The rate and risk factors of maternal and neonatal GBS colonization may vary in different communities. These rates, as well as the incidence of neonatal disease, need to be thoroughly evaluated in each country to allow the most appropriate preventive strategy to be selected.

Reconstruction of urethrovaginal fistula and vaginal atresia in an adolescent girl after an abdominoperineal-vaginal pull-through procedure.

OBJECTIVE: To report a rare case of urethrovaginal communication and vaginal atresia. DESIGN: To reconstruct the communication and the vaginal route. SETTING: Division of Pediatric and Adolescent Gynecology and Corrective Gynecological Surgery, University of Athens, and "Alexandra" Hospital. PATIENT(S): A 16-year-old girl with cyclic hematuria, periodic pelvic pain, and primary amenorrhea. INTERVENTION(S): Diagnostic studies, followed by an abdominoperineal-vaginal pull-through procedure. MAIN OUTCOME MEASURE(S): Reconstruction of the urethrovaginal fistula and vaginal route. RESULT(S): Normal menstruation through the vaginal route. CONCLUSION(S): A careful examination of every infant's external genitalia should be performed immediately after delivery. A urethrovaginal fistula should be corrected in time to facilitate menstrual flow and improve future reproductive potential.

Oocyte morphology correlates with embryo quality and pregnancy rate after intracytoplasmic sperm injection.

OBJECTIVE: To evaluate the relation of oocyte morphology with embryo quality and pregnancy rates (PRs) after intracytoplasmic sperm injection (ICSI). DESIGN: Retrospective study of patients undergoing ICSI. SETTING: University Hospital IVF Center. PATIENT(S): Sixty-eight patients who underwent ICSI and had transfer of good-quality embryos (grade 3), 60 patients with transfer of both good- and poor-quality embryos (grade 3 and grade 2), and 18 patients with transfer of poor-quality embryos (grade 2). INTERVENTION(S): Comparison of the outcome of ICSI in the three groups of patients and the relation of oocyte morphology to embryo quality. MAIN OUTCOME MEASURE(S): Oocyte morphology and embryo quality (grade). Fertilization, cleavage, and pregnancy rates. Serum E2 on the day of hCG administration. RESULT(S): Oocytes with poor morphology (dark cytoplasm; many vacuoles or fragments in cytoplasm) led to poor-quality embryos and consequently to lower PRs (5.5% versus 29.4%). Serum E2 on the day of hCG administration was significantly higher in the group with good-quality embryos compared with that with poor-quality embryos (2,047 +/- 135.7 versus 1,651 +/- 164.8 pg/mL, respectively). CONCLUSION(S): Serum E2 on the day of hCG administration is a marker of embryo quality. Oocyte morphology correlates well with embryo quality and PRs after ICSI.

Birth of two infants who were seronegative for human immunodeficiency virus type 1 (HIV-1) after intracytoplasmic injection of sperm from HIV-1-seropositive men.

OBJECTIVE: To report two cases of live births after intracytoplasmic sperm injection (ICSI) in two women who were seronegative for human immunodeficiency virus type 1 (HIV-1) after the use of processed semen from their seropositive husbands. DESIGN: Case reports. SETTING: University hospital IVF center. PATIENT(S): Two HIV-1 seropositive men and their HIV-1 seronegative female partners; all gave their informed consent in writing before undergoing the ICSI procedures. INTERVENTION(S): The men provided semen samples that were processed with the use of Percoll and swim-up techniques. Ovarian stimulation in the women was performed with the long protocol using GnRH analogs and recombinant FSH. ICSI was performed. MAIN OUTCOME MEASURE(S): Oocytes were fertilized by ICSI, and the resulting embryos were transferred to the patients. The mothers and babies were tested for HIV-1 antibodies. RESULT(S): In the first case, seven mature oocytes were collected and fertilized with ICSI, and three embryos were transferred; the woman became pregnant and gave birth to a healthy boy. Six months after the birth, testing for HIV-1 antibodies in the woman and the baby gave negative results. In the second case, 10 mature oocytes were collected and fertilized with ICSI, and four embryos were transferred; the second woman became pregnant and also gave birth to a healthy boy. Testing for HIV-1 antibodies at the baby's delivery also gave negative results. CONCLUSION(S): In women who are infertile because of fallopian tube obstruction or in men who have poor quality semen for artificial insemination, ICSI can be performed using processed semen. This method, which involves the use of only one spermatozoon per oocyte, provides HIV-1 seropositive men with the opportunity to have children with a minimal risk-if any-of infecting their female partners.

Why is endometrial cancer less common in Greece than in other European Union countries?

Among European countries, Greece has the lowest incidence of and mortality from endometrial cancer. We have undertaken a case-control study aiming to identify possible reasons for this. Cases were 84 women with histologically confirmed incident endometrial cancer, whereas controls were another 84 women with intact uterus admitted for small gynaecological operations, mainly pelvic prolapse. Women provided information concerning socio-economic, reproductive and medical variables. Most findings were in line with those previously reported from other investigations; no association was as striking as to suggest an effect modification that could underlay the favourable position of Greece with respect to endometrial cancer. Novel findings were the statistically significant inverse associations of endometrial cancer with coffee drinking and suggestive inverse associations with height-induced abortions. Low average height of Greek women, high frequency of induced abortions and low frequency of replacement oestrogens use may contribute to the lower endometrial cancer incidence in Greece.

Expression of p53, bcl-2 and heat shock protein (hsp72) in malignant and benign ovarian tumours.

The occurrence of p53, bcl-2 and heat shock protein (HSP) expression in ovarian tumours was examined and the correlation was investigated between the expression of these proteins and other disease parameters, including FIGO stage, histological subtype, tumour differentiation and steroid hormone receptor status. We analysed p53, bcl-2 and HSP expression in 100 smears of patients with epithelial ovarian carcinomas, 16 smears of patients with borderline malignancy and 20 smears of patients with benign ovarian neoplasms by using immunocytochemical techniques. There were 29 patients with stage I disease, 24 with stage II disease, 40 with stage III disease and seven with stage IV disease according to the FIGO classification. The sensitivities and specificities of bcl-2, p53 and HSP for malignancy were 53% and 40%, 43% and 80%, and 37% and 90%, respectively. HSP was statistically significantly associated with malignant rather than benign tumours. Significant association was also observed between bcl-2 and p53, and p53 and HSP. The association of HSP with malignant tumours is confined to the premenopausal group of patients and in this group by itself there is also a significant association between p53 and malignancy. HSP and p53 were associated with undifferentiated carcinomas, bcl-2 and p53 expression is reduced as disease stage progresses in serous carcinomas and bcl-2 expression is increased as disease progresses in endometrioid carcinomas. There was no significant association between bcl-2 and ER/PR status. In conclusion, HSP has a high specificity for malignant ovarian tumours, bcl-2 and p53 have only moderate to low sensitivity and specificity. Changes in the frequency of bcl-2 and p53 overexpression between FIGO I and FIGO III stage disease of different ovarian carcinomas indicate a different role of these substances in cellular survival mechanisms in different carcinomas. bcl-2 probably is associated with cell proliferation but not with differentiation.

Clinical course and treatment results of breast cancer patients with ten or more positive axillary nodes.

Two-hundred and fifty-nine women with operable breast cancer, having more than 10 involved nodes without a distant metastasis, were treated with radical, modified radical or partial mastectomy with complete axillary dissection. Survival at 5 years was 63% and at 7 years 54%. Fifty-six per cent and 52% were disease free 5 and 7 years after initial therapy. Postmenopausal women had an overall survival rate of 64% and disease free survival rate of 61% while premenopausal women had an overall survival of 58% and disease free survival of 52%. Survival and disease free survival rate for those with 10-20 positive nodes were 65% and 69% respectively, while for those with more than 20 positive nodes the rates were 49% and 52% respectively; a statistically better survival in the 2nd group. Although the observational time of patients having adjuvant CEF is short, a better survival rate and disease free survival rate is possible in women treated with CEF.

Cathepsin D immunoreactivity in ovarian cancer: correlation with prognostic factors.

In view of the somewhat inconclusive nature of the reports of the role of Cathepsin D (Cath D) in ovarian carcinoma and its relationship with various other parameters of malignancy the present study was performed to aid in the further clarification of this role. One hundred freshly resected primary ovarian carcinomas of various histological types were studied for ER, PR and Cath D status and the results examined with respect to menopausal status, histology, size and lymph node invasion. In our series Cath D positivity was more frequent in serous than in other types of ovarian cancer but this Cath D positivity was not related to the frequency of lymph node invasion regardless of the size of the tumor. Nor was any association observed between Cath D positivity and ER or PR status of the tumors or the menopausal state of the patients. The reported prognostic value of Cath D, ER and PR is discussed as well as the distinction between tumor invasion by lymphatic channels and direct interstitial infiltration. It was concluded that Cath D may not play a role in the former mode but, as might be expected from its proteolytic properties, in local spread by means of tissue destruction.

Septic lithiasis of the pelvis.

Laparoscopic cholecystectomy has become a standard technique for the treatment of symptomatic cholelithiasis. Despite a significant reduction in the complication rate with increasing experience, bile duct injury and gallstone spillage still occur more frequently with this approach than with the open procedure. Unretrieved gallstones, in particular, have been associated with late infection and the formation of abscesses in virtually every area of the abdominal cavity. We present a rare case of an isolated pelvic abscess that developed in a postmenopausal woman 5 months after laparoscopic cholecystectomy for recurrent cholecystitis. The preoperative differential diagnosis of this case is also discussed.

Uptake and washout of 99mTcV-dimercaptosuccinic acid and 99mTc-sestamibi in the assessment of histological type and grade in breast cancer.

This study was performed to investigate the relationship between histological type and grade, with the uptake and washout of 99mTc-hexakis-2-methoxyisobutylisonitrile (99mTc-sestamibi, 99mTc-MIBI) and 99mTcV-dimercaptosuccinic acid (99mTcV-DMSA) in breast cancer. Forty-five patients with histologically proven breast cancer had previously been referred for 99mTcV-DMSA and/or 99mTc-MIBI scintimammography. Twenty-five of them underwent both 99mTcV-DMSA and 99mTc-MIBI scintigraphy in a double phase study. Lateral prone and anterior supine images were acquired at 15 and 60 min after administration of 740-925 MBq of each radiotracer. Uptake ratios and retention index were calculated and correlated with histology and grade of malignancy. Histology showed eight different histotypes: 77.7% were infiltrating ductal or lobular carcinomas. Mammography was definitely positive in 32/45, indeterminate in 10 and negative in three cases (sensitivity 71%). 99mTcV-DMSA was true positive in 37/40 (sensitivity 92.5%) and 99mTc-MIBI in 28/30 (sensitivity 93.3%) breast cancers. Uptake ratios were significantly higher in ductal than in lobular carcinomas on 99mTcV-DMSA and 99mTc-MIBI scintigrams at early and delayed phases. Grade II carcinomas had significantly lower values of retention index (rapid washout) than grade III carcinomas. This finding was statistically significant only on 99mTc-MIBI scans and was observed in ductal and lobular carcinomas. The retention index did not show any significant difference between ductal and lobular carcinomas. Uptake ratios were also not statistically different between grade II and III cancers. It is concluded that 99mTc-MIBI and 99mTcV-DMSA uptake in breast cancer is probably related to histological type and may distinguish ductal from lobular carcinomas. To a certain degree, the washout rate may reflect the histological grade, but since grade is not the only factor influencing this phenomenon it should be explored further in conjunction with other parameters by multivariate analysis in order to clarify eventual indirect correlations.

Tissue evaluation of immune markers in endometrial and cervical carcinomas.

Major histocompatibility complex (HLA system) class II molecules including HLA-DR antigens, associate with peptides, which are derived from antigens, for presentation to T4 lymphocytes. Functional and adhesion assays have shown that CD4 molecule interacts with HLA class II molecules, leading to enhanced responses of T4 cells. In the present study, we examined the tissue expression of HLA-DR antigens and the quantitative variance of T4 lymphocytes in a series of 50 "endometrioid" adenocarcinomas of the endometrium and 35 cervical squamous-cell carcinomas. A three-step avidin-biotin immunoperoxidase staining method was applied. As primary antibodies, we used the TAL.1BS monoclonal antihuman HLA-DR alpha (alpha) chain antibody and the OPD4 mouse antihuman antibody; the latter mainly identifies benign T4 lymphocytes. Twenty-four percent (24%) of women with endometrial cancer were high immune responders, while the relative percentage in women with cervical cancer was 40%; the respective tumours were of early clinical and surgical stages. HLA-DR determinants were predominantly expressed in membranes of stromal cells, mainly histiocytes, usually around HLA-DR+ lymphoid cells, as well as on endothelial cells. Greater numbers of OPD4+ aggregated lymphocytes were observed when the tumour stroma was rich in HLA-DR+ cells. Epithelial elements, either cancerous or benign, were seldom HLA-DR+. In those samples, positive immunolabelling was often confined in the intercellular space and did not seem to activate an effective host immune response against neoplastic cells. High expression of HLA-DR molecules in professional antigen presenting stromal cells may be used as a lymphocyte activation marker in endometrial and cervical carcinomas. This activation appears to be an early event in the evolution of invasive endometrial and cervical carcinomas.