Management of a rhegmatogenous retinal detachment in a low-resource setting: treatment options when there is no vitreoretinal surgeon.

We discuss the case of a 49-year-old soldier with a macula-on rhegmatogenous retinal detachment in Sierra Leone. The case highlights the challenge of accessing visually preserving ophthalmic specialist care in sub-Saharan Africa (SSA) for vitreoretinal (VR) disease. It highlights a shortage of VR surgeons in SSA, limited examination facilities, the larger issue of accessing specialist care urgently and the costs associated with accessing surgery out-of-country. It also identifies a shortage in epidemiological data on the issue which limits the assessment of the scale of the problem.

Steroidogenesis in human follicles approaching ovulation as judged from assays of follicular fluid.

Human chorionic gonadotrophin (HCG) was given to patients at mid-cycle before the endogenous LH surge. Graafian follicles were aspirated 32-33 h later, before ovulation was expected, and the levels of several steroids in follicular fluid and in matching serum samples were measured by radioimmunoassay. Two types of Graafian follicle were identified at laparoscopy , based on the nature of the oocyte, granulosa cells and follicular fluid withdrawn from the follicles. Some were large, preovulatory and presumably becoming luteinized while others were generally smaller, non-ovulatory and still growing. The concentrations of dehydroepiandrosterone (DHEA) and 17alpha-hydroxypregnenolone (delta5 intermediates), androstenedione and testosterone were higher in non-ovulatory follicles, whereas large follicles usually contained high levels of progesterone, 17alpha-hydroxyprogesterone, pregnenolone and oestradiol-17beta. A cluster analysis of these data grouped follicles into two distinct clusters, which accorded with their identification as ovulatory or non-ovulatory at laparoscopy. Levels of progesterone, 17alpha-hydroxyprogesterone and oestradiol-17beta in follicular fluid were high in preovulatory follicles in comparison with plasma. Results in two patients indicated that plasma levels of these steroids were determined by the preovulatory follicle. Levels of plasma delta5 steroids were closer to follicular fluid concentrations, whereas DHEA was higher in plasma. The role of the theca and granulosa is discussed in relation to the synthesis of progesterone and oestradiol-17beta in follicles as ovulation approaches.

Steroidogenesis in preovulatory follicles of patients given human menopausal and chorionic gonadotrophins as judged by the radioimmunoassay of steroids in follicular fluid.

The administration of human menopausal gonadotrophin (HMG) followed by human chorionic gonadotrophin (HCG) stimulated the development of various numbers of follicles in patients treated for infertility. Graafian follicles from these patients were aspirated 32-33 h after the injection of HCG and the levels of steroids in the follicular fluid and matching serum samples were measured by radioimmunoassay. The follicles could not be grouped into two distinct clusters as found in patients given HCG during the menstrual cycle but a broad classification of follicles into four groups was indicated from the dendrogram. Two of the groups were similar to the ovulatory and non-ovulatory groups found previously, whereas the other two groups of follicles were more intermediate in nature. The use of a discriminant analysis showed that these two groups had clearly been stimulated by the HMG and HCG, although they were not yet fully ovulatory. Our data indicate that the number of developing follicles is considerably increased by treatment with HMG and HCG but there is asynchrony in follicular development because the pattern of steroid synthesis differs in many follicles. The effects of this asynchronous development on oocyte maturation and disorders of the luteal phase are discussed.

Steroidogenesis by cultured granulosa cells aspirated from human follicles using pregnenolone and androgens as precursors.

Human granulosa cells from Graafian follicles aspirated 3-4 h before the expected time of ovulation were incubated with various steroid substrates, including pregnenolone, androstenedione, testosterone and dehydroepiandrosterone (DHA). Steroid production after 3 and 10 h of incubation was determined by radioimmunoassay. Progesterone and 17alpha-hydroxyprogesterone were the major products of granulosa cells in control short-term cultures with endogenous substrates. The addition of pregnenolone increased the synthesis of progesterone and 17alpha-hydroxyprogesterone compared with the controls, although the response varied considerably between paired short-term cultures. Little or no oestradiol-17beta was produced from endogenous precursors or short-term cultures to which pregnenolone had been added; one follicle, however, produced similar amounts of oestradiol-17beta in the control cultures and after incubation with pregnenolone. When granulosa cells were cultured with various amounts of androstenedione, DHA or testosterone, large amounts of oestradiol-17beta were produced, especially in short-term cultures in which larger amounts of substrate were added. Progesterone production continued and progesterone was synthesized more rapidly or in greater amounts in some short-term test cultures than in the controls. The results indicate that human granulosa cells are one source of oestradiol-17beta during the preovulatory phase. The data support the two-cell theory for oestradiol synthesis, for granulosa cells do not appear to undertake steroid conversion via the 5-unsaturated pathway, but aromatize androgens known to be produced by thecal cells. It is also suggested that either androgens or oestradiol-17beta stimulate progesterone production by granulosa cells, at least in vitro.

Pregnancy following in vitro fertilization using cryopreserved semen from a man with testicular teratoma.

Semen for cryopreservation was collected in a man with a testicular teratoma after unilateral orchidectomy but before chemotherapy which rendered him azoospermic. After two years artificial insemination using this semen in his wife failed repeatedly. The semen quality on thawing was extremely poor in terms of sperm motility. A pre-freeze motility of 90 per cent was reduced to 2 per cent, and the movement was graded as sluggish. Using the techniques of semen and oocyte preparation and in vitro fertilization, a number of cleaving embryos was produced. A pregnancy was established after four of these embryos were replaced in the wife. The pregnancy aborted spontaneously, but a subsequent course of treatment resulted in an on-going twin pregnancy. The potential of in vitro fertilization for overcoming the poor quality of semen after storage by cryopreservation from men with testicular neoplasms is discussed.

Treatment of idiopathic infertility, cervical mucus hostility, and male infertility: artificial insemination with husband's semen or in vitro fertilization?

Couples with male infertility (n = 86), idiopathic infertility (n = 68), and cervical mucus hostility (n = 48) of a long duration were treated either by in vitro fertilization (IVF) or artificial insemination with husband's semen (AIH). The incidence of pregnancy per cycle in couples in whom the male partner was infertile was significantly (P less than 0.01) higher after IVF, compared with AIH (21% versus 5%, respectively). The differences were most apparent in couples with asthenospermia (47% versus 0%, respectively); no significant difference was found when the infertility was caused by oligospermia only (11% versus 9%, respectively). More patients with idiopathic infertility became pregnant after one cycle with IVF, compared with AIH (20% versus 8%, respectively); but, because of intragroup disparity in size, this difference was not significant. A highly significant difference (P less than 0.01) was found after one attempt with IVF, compared with AIH, in patients with cervical mucus hostility (38% versus 3%, respectively).

In vitro fertilization using cryopreserved donor semen in cases where both partners are infertile.

The incidence of pregnancy after in vitro fertilization (IVF) was studied in a group of 38 couples (55 cycles) where both partners were infertile. Cryopreserved donor semen (IVF-D) was used in all cycles. Results were compared with those in a control group of couples where the husband's semen was considered normal and only the wife was infertile. No significant differences were found between the IVF-D and control groups in the incidence of fertilization (80% versus 72%), pregnancy per cycle (33% versus 29%), and abortion (18% versus 20%), despite the considerably lower percentage of motile spermatozoa in the IVF-D group. Forty percent of patients, each treated unsuccessfully with at least 12 artificial inseminations with donor semen, became pregnant after one or two IVF-D cycles. It is concluded that IVF with frozen donor semen is a beneficial treatment for couples where both partners are infertile.

In vitro fertilization: a treatment for male infertility.

Three-quarters of 41 women whose husbands were the cause of infertility in the couple had one or more embryos replaced after in vitro fertilization. One-third became pregnant despite their long history of infertility; the incidence of pregnancy was 45% after one or more replacements of embryos. In a group of 61 couples where both partners were infertile, 26% became pregnant. These data indicate that the lower chance of fertilization with poor semen is balanced by a higher chance of pregnancy in women with a normally functioning reproductive system. Oligospermia, asthenospermia, teratospermia, and autoimmunity are among the many forms of male infertility which can now be successfully treated by in vitro fertilization. Overall, 57% of the oocytes were fertilized, and almost 50% of men with very low numbers of active spermatozoa (less than or equal to 0.5 X 10(6)/ml motile spermatozoa) were successful in establishing pregnancy. Two semen parameters impaired fertilization most: seminal inflammatory cells and low progressive activity. The collection of split ejaculates and the careful preparation of spermatozoa, by sedimentation and layering methods, proved to be beneficial, improving sperm motility and raising the chance of fertilization.

Rsearch and other horizons in laparoscopy.

PIP: Accomplishments by laparoscopy and prediction of possible future development are reviewed. Some gynecological disorders can now be diagnosed at an early stage. Indications for laparotomy can be determined and postoperative assessments made. Improved safety factors have been introduced and methods of dealing with complications are described. In a case of uterine perforation at the time of aspiration abortion, fetal parts have been removed from the pelvis by laparoscopic technique. In 10 instances, appendectomy through a very small incision has been done under laparoscopic control. Intratubal devices have been placed for contraceptive purposes. This is a readily reversible procedure. In research studies, follicular growth and ovulation have been studied with human menopausal gonadotropin, human chorionic gonadotropin, and clomiphene administration. The levels of various steroids and prostaglandins in follicular fluid have been determined. More ovaries will be conserved. Diseased oviducts can be more accurately diagnosed and treated. Endometriomata will be better treated. With the new bioplar method and recently developed endothermic instruments, sterilization by coagulation will be safer. By using endothermal methods tubal and ovarian blood supply will be less injured. Teaching and textbooks will need to be revised. Other new fields of discovery and treatement promising valuable clinical application are anticipated.^ieng

Gynecological laparoscopy.

PIP: Laparoscopy is reviewed in this keynote lecture of the 1st annual meeting of the American Association of Gynecological Laparoscopists in Las Vegas, Nevada, November 1972. The pneumoperitoneum may produce pressure on the inferior vena cava and stomach and cause splinting of the diaphragm leading to impaired ventilation, reduction in venous return to the heart, and possible regurgitation of stomach contents. Absorption of carbon dioxide may cause a rise of partial pressure of carbon dioxide with associated cardiac arrhythmias. All of these problems are controlled or prevented by a general anesthetic with intubation by a cuff tube, good muscle relaxation, and controlled ventilation by a respirator. Laparoscopy may be used to determine intact ectopic pregnancy and study female sterility, early endometriosis, acute salpingitis, chronic pelvic inflammatory disease, small uterine or other masses, and primary and secondary amenorrhea. Surgical uses include puncture and/or aspiration of ovarian cysts or tubo-ovarian cysts, removal of foreign bodies, resection of adhesions, tubal sterilization, and ventrosuspension of uterus. Contraindications include difficulty in establishing an adequate pneumoperitoneum; acute peritonitis, ileus, or intestinal obstruction; and inadvisability of penumoperitoneum or Trendelenburg position. Laparoscopy can diagnose the extent and nature of pelvic and abdominal cancer and evaluate treatment. Reported complications with laparoscopy include puncture of vessels, perforation of intra-abdominal viscus, parietal or omental emphysema, cardiorespiratory embarrassment, and effects of high-pressure gas injections. A woman infertile due to absent or useless oviducts but with a healthy uterus and at least 1 healthy functioning ovary could seemingly be assisted through recovery of oocytes via laparoscopy, fertilization and cleavage of the ovum in vitro, and finally embryo transfer into her uterus. The first 2 steps have already been accomplished for women.^ieng

Letter: Tubal transplants.

PIP: An article discussing the possibility of tubal grafts states it may be a temporary solution sufficient to allow a pregnancy, but also states it may offer a permanent cure to severe tubal damage. Not only are these statements contradictory, but women with old pelvic inflammatory disease have not achieved successful uterine pregnancy, and have a high risk of ectopic pregnancy. In vitro fertilization and embryo transfer, on the other hand, can be repeated until pregnancy occurs. Both methods should be researched further since some patients are more suited to tubal transplant or to embryo transfer.^ieng