A new culdocentesis system.

A new culdocentesis system is presented, based on vacuum fixation of the posterior vaginal wall together with Douglas peritoneum in a small vacuum cup, enabling a controllable central perpendicular puncture with a special catheter-needle unit. The advantages of the new system are the creation of a relatively safe and painless access to the pouch of Douglas, less risk of contamination, the possibility of repetitive examinations, and satisfactory effectiveness in collecting peritoneal fluid. The results of 164 culdocenteses in ambulant infertility patients are reported. Application of the technique is proposed for the investigation of sperm migration in vivo, steroid analysis of peritoneal fluid, and intraperitoneal insemination.

The staging of peritoneal endometriosis by the type of active lesion in addition to the revised American Fertility Society classification.

OBJECTIVE: To evaluate changes in peritoneal endometriosis by the type of lesion in comparison with the scoring system of the revised American Fertility Society (AFS) classification. DESIGN: Prospective evaluation at laparoscopy before and 6 months after discontinuance of a 3-month medical therapy with either dydrogesterone or danazol. SETTING: A general hospital. PATIENTS: Forty cycling women with endometriosis and infertility. Fourteen patients could be fully evaluated by their revised AFS score and type of peritoneal lesion. INTERVENTIONS: Laparoscopy before and 6 months after discontinuance of medical therapy. MAIN OUTCOME MEASURE: Revised AFS score and type of peritoneal lesions. RESULTS: The revised AFS score decreased or remained unchanged in 13 of 14 patients, whereas red papular or vesicular lesions were present at both laparoscopies in 5, absent in 4, disappeared in 3, and appeared de novo in 2. A changing pattern also was seen in other types of small peritoneal lesions. CONCLUSION: In contrast with the revised AFS score, the study of the type of peritoneal lesions shows a changing pattern of activity. The significance in pathophysiological and clinical studies should be investigated further.

Cyclic changes in the concentration of glucose and fructose in human cervical mucus.

OBJECTIVE: To determine a possible cyclic change in the concentration of glucose and fructose in the aqueous phase of human cervical mucus (CM). DESIGN: Concentrations of glucose and fructose were longitudinally determined in the aqueous phase of CM of normal cycling women using enzymatic techniques, modified for small quantities. SETTING: Patients visiting a fertility clinic were selected. PATIENTS: Nine healthy women with regular menstrual cycles of 28 +/- 3 days that appeared to be ovulatory, demonstrated by sonographic follicle immaging and serum progesterone (P) measurements. INTERVENTIONS: Cervical mucus samples were longitudinally collected preovulatory, postovulatory, and premenstrual in ovulatory cycles, monitored by ultrasound and blood estradiol and P measurements. MAIN OUTCOME MEASURES: The study was designed to measure glucose and fructose longitudinally on three different points during one cycle. RESULTS: The preovulatory glucose concentrations in CM were lower than postovulatory and premenstrual. The preovulatory fructose concentrations were lower than premenstrual. The glucose concentration correlated with the blood P level. CONCLUSION: There is a consistent change in the glucose concentration measured in human CM in three phases of the menstrual cycle. The preovulatory and premenstrual fructose concentrations differ significantly. Knowledge of the carbohydrate metabolism in human cervical mucus may contribute in illuminating the possible role of the carbohydrate metabolism in sperm migration at midcycle and implantation in the luteal phase.

The origin of orchiopexy-induced testicular lesions in the pig.

Cooling experiments of abdominal testes in adult, naturally cryptorchid pigs indicate that spermatogenic arrest in abdominal testes is not due to an inborn defect, but is caused solely by maintenance of the testis at abdominal temperature. It is postulated that failure of spermatogenic cells to differentiate after orchiopexy results from surgical trauma. Evaluation of the orchiopexy procedure revealed that simple manipulation of a normally descended testis may give rise to damage to the spermatogenic epithelium. Furthermore, it appeared that, in normally descended testes of naturally unilaterally cryptorchid pigs subjected to orchiopexy, the spermatogenic epithelium was poorly developed as compared with that of scrotal testes of unilaterally cryptorchid pigs that had not undergone a surgical procedure.

Cost-effectiveness of in vitro fertilization and embryo transfer.

OBJECTIVE: Economic analyses in reproductive medicine often fail to take into account the chances of treatment-independent conception. We compared the cost-effectiveness of several realistic strategies involving IVF using no treatment as the reference strategy. DESIGN: A decision tree was constructed for a subfertile couple in which the clinician had to decide whether to offer treatment with IVF. No treatment at all was used as the reference strategy. SETTING: An analytic decision-making framework. PATIENT(S): Hypothetical subfertile couples. INTERVENTION(S): Two potential treatment approaches: three IVF cycles performed as soon as possible, or no treatment performed initially and then three or four IVF cycles performed if a pregnancy resulting in a live birth does not occur naturally after 212 years. MAIN OUTCOME MEASURE(S): The cost of establishing one pregnancy that results in a live birth. RESULT(S): The cost-effectiveness of IVF depended not only on the costs and expected success rates of IVF itself but also on the couple-specific chances of treatment-independent conception. Consequently, the cost-effectiveness of IVF is strongly dependent on the age of the female partner. This finding corresponds with everyday clinical experience. CONCLUSION(S): Economic analyses in reproductive medicine should take into account the option of providing no treatment.

The performance of CA-125 measurement in the detection of endometriosis: a meta-analysis.

OBJECTIVE: To assess the diagnostic performance of serum CA-125 measurement in the detection of endometriosis. DESIGN: Meta-analysis. SETTING AND PATIENT(S): Twenty-three studies comparing serum CA-125 levels and laparoscopically confirmed endometriosis. INTERVENTION(S): Serum CA-125 measurement and laparoscopy. MAIN OUTCOME MEASURE(S): Sensitivity and specificity of serum CA-125 measurement in the diagnosis of endometriosis with laparoscopy as the reference standard. RESULT(S): The estimated summary receiver operating characteristic curves showed that the performance of serum CA-125 measurement in the diagnosis of endometriosis grade I/IV is limited, whereas its performance in the diagnosis of endometriosis grade III/IV is better. CONCLUSION(S): Despite its limited diagnostic performance, we believe that the routine use of serum CA-125 measurement in patients with infertility might be justified. In contrast to laparoscopy, serum CA-125 measurement is an inexpensive test that is not a burden for the patient. It could identify a subgroup of patients who are more likely to benefit from early laparoscopy. Studies reporting on the mutual dependence between serum CA-125 measurement and data from the history and physical examination are needed.

Regression of endometrial thickness in combination with reduced withdrawal bleeding as a progestational effect of tibolone in postmenopausal women on oestrogen replacement therapy.

For 176 postmenopausal women on HRT with progestogen addition 'on demand' medroxyprogesterone acetate (MPA), noresthisterone and tibolone were used to protect the endometrium in 214 cases. Tibolone is a gonadomimetic steroid with combined progestogenic and estrogenic effects. In this study tibolone has been used as a progestogen. The results of these three progestogens were compared. The endometrial thickness before and after the use of progestogen was determined by vaginosonography. In 175 out of 214 cases progestogen addition during oestrogen therapy caused endometrial regression. Withdrawal bleeding was observed 166 times. If the endometrial thickness on the onset of progestogen addition was 5 mm or more, in nearly all cases withdrawal bleeding occurred when MPA or norethisterone was used. If tibolone was used, no withdrawal bleeding occurred in over half the cases studied. We report the first observation of induced endometrial regression without withdrawal bleeding.

Progesterone receptors in human oestrogen target tissues.

The levels of specific oestrogen and progesterone receptors have been measured in myometrial, endometrial and vaginal tissues obtained from 18 women between the ages of 28-73 yr. High speed cytosols of the three tissues were incubated at four different concentrations of specific ligands: E2 for the oestrogen receptor (ERc) and Org-2058 for the progesterone receptor (PgRc). Separation of bound and free hormones was done by dextran-coated charcoal; data were analysed according to Scatchard. In the myometrium and endometrium both PgRc and ERc were found. In the vaginal tissues obtained from the same patients only ERc was present. There was no evidence of specific progesterone receptors in the vagina. Both clinical and histological findings indicate that the vagina is an oestrogen-sensitive organ. Therefore, it is surprising that progesterone receptors, which are considered to be a specific response of oestrogen target tissue, are absent in the human vagina. This finding suggests that the induction of the progesterone receptors is not a specific response to oestrogen stimulation in the human vagina.

The effect of hysterectomy and endometrial ablation on follicle stimulating hormone (FSH) levels up to 1 year after surgery.

OBJECTIVES: In this study the hypothesis was tested, that in premenopausal patients FSH-levels would rise after 'simple hysterectomy'. As endometrial ablation is not supposed to compromise ovarian bloodflow, there would be no such change in ablated patients. METHODS: Between January 1995 and April 1996, consecutive premenopausal patients with dysfunctional uterine bleeding who were scheduled for hysterectomy or endometrial ablation were asked to participate in the study. Bloodsamples were drawn before surgery, six weeks, six months and one year after surgery. FSH and oestradiol (E2) were assayed. In all patients data about length and weight were collected to calculate Body Mass Index (BMI). Every visit patients filled in a questionnaire, containing questions about typical climacteric complaints, combined in a five-point scale. RESULTS: Except for a significant difference in preoperative FSH-level between both groups, there were no significant differences regarding age, Body Mass Index (BMI), oestradiol (E2) or the percentage of women with vasomotor complaints. Compared to the preoperative starting level, six weeks, six months and one year after surgery a significant rise in serum FSH in the hysterectomy group, as well as in the ablation group was found. However there was no significant difference in FSH increase between both groups. One third of the patients in both groups had typical climacteric complaints as flushing and nocturnal sweating. CONCLUSIONS: Assaying serum FSH-levels before and after uterine surgery and comparing hysterectomized patients and patients after endometrial ablation, we found a significant rise in FSH-level up to one year after surgery in both groups postoperatively, indicating impaired ovarian function. There was no difference in FSH-levels between both groups. Therefore major uterine surgery (hysterectomy, ablation) may prelude an earlier onset of menopause.

A 15-year-old girl with an expansively growing tumour.

Often decisions have to be made in acute situations, when there is no time for discussion. The decision may have extreme consequences for the patient. The case is reported of a girl aged 15 years with an expansively growing tumour of the uterus. An intra-abdominal haemorrhage was caused by a ruptured vascular connection. The aggressive behaviour of the tumour aroused suspicion of malignancy. At emergency laparotomy the tumour was enucleated from the uterus. Uterus and adnexa were preserved. The next problem in decision-making was the doubt concerning the pathological diagnosis: benign cellular leiomyoma or low-grade leiomyosarcoma. Now, 5 years after the laparotomy, there are no signs of recurrence. The problems concerning the diagnoses of 'leiomyoma' and 'leiomyosarcoma' are briefly reviewed.

[Indications for an increased risk of neural tube defects in pregnancies following ovulation induction and (or) in-vitro fertilization]. / Aanwijzingen voor een verhoogde kans op defecten van de neurale buis bij zwangerschappen ontstaan na ovulatie-inductie en (of) in vitro-fertilisatie.

Several authors have reported a possible association between IVF or induction of ovulation on the one hand and the occurrence of neural tube defects on the other hand. Here a review is given of recent literature on this subject, including data available from The Netherlands. Collaborative epidemiologic studies are needed to evaluate the potential risks. In individual pregnancies prenatal examination is advised. In spontaneous abortions fetal pathological evaluation is desirable.

Prognostic capacity of transvaginal hydrolaparoscopy to predict spontaneous pregnancy.

BACKGROUND: In 1998, transvaginal hydrolaparoscopy (THL) was introduced as a new outpatient procedure for exploration of tubo-ovarian structures and tubal patency in subfertile patients. At present, there are no large studies that relate the findings at THL to fertility outcome. METHODS: Consecutive patients undergoing THL for subfertility between 2000 and 2004 were included in this prospective cohort study. Follow-up ended when ongoing pregnancy or tubal surgery occurred or at the day of last contact. Kaplan-Meier curves for the occurrence of intrauterine pregnancy (IUP) (spontaneous or after intrauterine insemination) were constructed for a normal THL, a THL with a one-sided tubal pathology and a THL with a two-sided tubal pathology. Fecundity rate ratios (FRRs) were calculated to express the association between THL findings and the occurrence of IUP. Patients rated their pain experiences and acceptability on a visual analogue scale (VAS). RESULTS: We included 272 women. In 96% (261) of the patients, access to the pouch of Douglas was achieved. Complications occurred in 2% of the procedures. In 203 (78%) patients, both tubo-ovarian structures could be visualized and tubal patency was shown. One-sided tubal occlusion was found in 10%, whereas two-sided tubal occlusion was seen in 4% of the patients. Adhesions and/or endometriosis were observed in 8% of the patients. The FRRs for one-sided tubal pathology, two-sided tubal pathology and adhesions/endometriosis were 0.59, 0 and 0.80, respectively. The VAS scores showed pain to be limited and the procedure to be acceptable. CONCLUSION: THL is a feasible technique. Its capacity to predict spontaneous ongoing pregnancy is comparable to that of laparoscopy.

The prevention of orchiopexy-induced testicular lesions in the pig.

From previous experiments it was concluded that failure of spermatogenic cells to differentiate after orchiopexy seems to be due to surgical trauma. Furthermore it appeared that in normally descended testes of naturally unilaterally cryptorchid pigs subjected to orchiopexy, the spermatogenic epithelium was poorly developed as compared with that of scrotal testes of unilaterally cryptorchid pigs that had not undergone the surgical procedure. Even simple inguinal surgery in unilaterally naturally cryptorchid piglets may already give rise to severe histological lesions in the spermatogenic epithelium of the normally descended contralateral testes at adulthood. On the other hand extirpation of the retained testis by laparotomy does not affect the spermatogenic epithelium in the contralateral scrotal testis. From these experiments it may be concluded that with regard to the prevention of sterility in unilaterally cryptorchid pigs it may be preferable to extirpate the retained testis rather than to perform an orchiopexy.