Methods employed to overcome difficult embryo transfer during assisted reproduction treatment.

PURPOSE: Multiple steps, at both scientific and clinical level, are involved in assisted reproduction technology (ART). Optimization of each of these steps contributes to maximize the success of ART. Embryo transfer is one of the vital steps in ART. An easy embryo transfer increases the success of ART. Adequate training is required to undertake embryo transfer, but anatomical difficulties in completing this procedure alter the success of treatment. Difficult embryo transfer is challenging for clinicians but has an overwhelming negative impact on patients. Difficult embryo transfer may cause cervical or endometrial trauma with uterine contractions which can lead to unsuccessful implantation and poor outcome after ART. METHODS: Literature review of published material looking at all interventions that were employed to overcome difficult embryo transfers during ART. RESULTS: We identified 5 methods (17 studies) were employed to overcome difficult embryo transfer which are: Hysteroscopic methods in 4 studies (2 case reports, 2 case series). Malecot catheters after hysteroscopic evaluation were used in 2 studies (1 case report, 1 case series). Dilators including hygroscopic dilators were used in 2 studies (1 case report, 1 case series) and mechanical dilators were used in 3 studies (2 case series, 1 RCT-patients 367). Intrafollopian transfer was reported in 1 case report. Transmyometrial embryo transfers were reported in 5 studies (2 case reports, 2 case series, 1 RCT). CONCLUSION: There were only two randomized controlled studies (RCTs) identified in the review. All other were either case series or case reports. We found that there was no uniform classification or grading of difficulty of embryo transfer in the literature. A grading system has been suggested in this review. We recommend that there should be a consensus guideline formulated for interventions to overcome difficult embryo transfer. A large multicenter randomized controlled study is required to compare different methods for women with difficult embryo transfer.

Adnexal torsion, a medical complication of in vitro fertilization.

With the expanding use of assisted reproductive technologies, general obstetricians and gynaecologists must maintain a high index of suspicion for complications of in vitro fertilization. We present the case of a pregnant woman with unilateral adnexal torsion following in vitro fertilization and its diagnostic implications in an emergency setting.

Expression of androgen receptors in upper human fetal reproductive tract.

BACKGROUND: Androgens play a key role in human fetal development. All androgens act through a single intracellular androgen receptor (AR), which is encoded by a single copy gene on the X chromosome. ARs are expressed as early as 9 weeks in the epithelium and mesenchyme of the urogenital sinus, paramesonephric (Müllerian) and mesonephric (Wolffian) ducts. METHODS: Using immunohistochemistry, we investigated the distribution of ARs in the gonads and lower genital tracts of 54 human fetuses at 8-11 weeks of gestation. Gender was determined by PCR. RESULTS: The AR was expressed in a similar pattern in both male and female fetuses. There appears to be no difference in expression in the mesonephros or the mesonephric ducts when male and female pelvises were compared. Expression in the female paramesonephric duct was within the epithelium, whereas, in the male pelvises, expression was in the mesenchyme of the paramesonephric duct. When AR expression was compared in the ovary and testes, both gonads seem to express AR at 9 weeks, but this expression was extended into the 10th week of gestation in the male. CONCLUSION: The specific pattern of AR expression implies a key role in gonadal development. However, the pattern of staining was similar in the gonads at 8 and 9 weeks in both sexes, although staining persisted longer in the testis until the 10th week. AR expression, therefore, is not a key determinant of human gonadal differentiation.

Current practice in the management of vasectomy reversal and unobstructive azoospermia in Merseyside & North Wales: a questionnaire-based survey.

OBJECTIVE: To investigate the current incidence of vasectomy reversal procedures, the techniques used and which practitioners use them. PATIENTS AND METHODS: Using a questionnaire, 130 general surgeons and urologists practising in Merseyside and North Wales were surveyed. RESULTS: The response rate was 74%, with 24 urological surgeons and 14 general surgeons undertaking vasectomy reversal. Annually, urological surgeons carried out significantly more procedures than did general surgeons, at 8.5 and 5.3 (P = 0.029), respectively. They were also more likely to use double-layer closure and microsurgical techniques, whilst significantly less likely to use stents. Urologists reported significantly greater patency rates, at 76% and 52% (P = 0.017), respectively, with no significant differences in subsequent pregnancy rates (30% vs 25%). Only one practitioner checked tubal patency in the female partner before vasectomy reversal. CONCLUSIONS: The use of vasectomy reversal is a cost-effective treatment for men wanting paternity after vasectomy. The technique used by the clinician and proper audit of the results require close attention; it would also appear to be obvious that all the partners of men seeking a vasectomy reversal should have their fertility status established before reversal, something that is clearly not done at present.

Antioxidant levels in the cord blood of term fetus.

The aim of this study was to compare the differences in the total antioxidant levels in the cord blood after a normal vaginal delivery and after an elective caesarean section. This was a prospective study approved by the Wirral Hospital ethical research committee. The study was carried out in a district general hospital. We investigated 96 healthy pregnant women who had normal antenatal period with singleton pregnancies between 37 and 42 completed weeks of gestation. Sixty-five women had a spontaneous normal vaginal delivery and 31 underwent elective caesarean section. Umbilical cord blood was obtained immediately after delivery. Antioxidants such as glutathione peroxidase (GPX) and superoxide dismutase (SOD) were measured and compared between the normal vaginal delivery and elective ceasarean sections. The mean values for GPx in umbilical cord arterial blood (95; 86-103, n=74) was found to be significantly higher (P=0.0133) than that found in umbilical cord venous blood (84; 80-88, n=95). The arterial SOD values were found to be significantly higher (P=0.0337) in infants who had been delivered by caesarean section (1188; 1065-1311, n=22) than by vaginal delivery (1021;958-1083, n=39). The differences in the levels of GPX between the arterial and venous systems is not well documented but may be due to differences in the level of selenium, hydroperoxides or glutathione. In addition, why infants delivered by ceasarian section have a higher level of arterial SOD than those delivered by vaginal delivery remains unclear, but it may be a reflection of a relatively low level in infants subjected to the stress of labour.