National survey of the current management of endometriomas in women undergoing assisted reproductive treatment.

STUDY QUESTION: What is the current management of women with ovarian endometriomas undergoing assisted reproductive treatment (ART) in the UK? SUMMARY ANSWER: It appears that the majority of gynaecologists in the UK offer surgery (mostly cystectomy) for endometriomas prior to ART, regardless of the presence of symptoms. WHAT IS KNOWN ALREADY: The ideal management of endometriomas in women undergoing ART remains controversial and presents a dilemma to reproductive specialists. STUDY DESIGN, SIZE AND DURATION: This was a national cross-sectional survey. A total of 388 gynaecologists completed the questionnaire. PARTICIPANTS, SETTINGS AND METHODS: All clinicians fully registered with the Royal College of Obstetricians and Gynaecologists were contacted. An 11-item survey was administered electronically using Survey Monkey software. Quantitative data were analysed using descriptive and comparative statistics. MAIN RESULTS AND THE ROLE OF CHANCE: The majority of responders were consultants (65%), 25% practiced ART and 65% performed laparoscopic surgery. Overall, 95% of responders would offer surgery for endometriomas in women undergoing ART, either on the basis of the size (>3-5 cm) of the endometrioma (52%), the presence of symptoms (16%), the presence of multiple/bilateral endometriomas (2%), regardless of the size and symptoms (19%) or only to women undergoing IVF (6%). The remaining 5% of responders would not offer surgery before ART. Excision was the most common surgical modality (68%), followed by ablation (25%). Laparoscopic surgeons were almost twice as likely to 'offer surgery to all patients with endometriomas prior to ART' compared with clinicians performing laparotomy (22 versus 12%, P < 0.001). LIMITATIONS, REASONS FOR CAUTION: Our overall response rate, with answers to the questionnaire, was low (15%). However, the response rate amongst reproductive specialists was estimated at 60%. It is possible that there might have been an element of bias towards over-representation of responders who are more concerned about 'normalization' of the pelvic anatomy. Furthermore, our survey relied on self-reporting of practice and it is possible that being presented with a list of 'ideal' options may have resulted in respondent bias. WIDER IMPLICATIONS OF THE FINDINGS: Despite the available evidence that surgery for endometriomas does not improve the outcome of ART and may damage ovarian reserve, it seems that the majority of gynaecologists in the UK offer ovarian cystectomy to their patients.

Antioxidant enzyme expression, lipid peroxidation, and protein oxidation in human myometrium with parturition.

Oxygen levels fluctuate considerably during human labor leading to hypoxia and reoxygenation of the uteroplacental unit and in some cases may compromise the progression of labor. Our aim was to assess the possible contribution of oxidative stress to the onset of labor. Thiobarbituric acid was used as a marker of lipid peroxidation along with Western blotting using anti-dinitrophenylhydrazine (DNPH) to assess protein carbonylation in myometrial samples obtained before and after the onset of term and preterm labor. Levels of key antioxidative enzymes were also compared. Higher levels of lipid peroxidation were observed in myometrial samples obtained during term or preterm labor. Reduced levels of glutathione peroxidase (GSHPx) were also encountered in these 2 groups. Conversely, protein carbonyl content was higher in laboring term and preterm myometrial samples. Levels of catalase (CAT) and superoxide dismutase (SOD) were unaltered across all 4 groups. Lipids in the laboring myometrium are susceptible to oxidative injury possibly due to diminished protection as a result of lower GSHPx activity. The reason for enhanced protein carbonylation suggests differential mechanisms governing protein turnover in the pregnant compared with the parturient uterus. Localized, oxidant damage of human myometrium may be a causal factor in difficult deliveries.

Membrane integrity and development of immature murine cumulus-oocyte complexes following slow cooling to -60 degrees C: the effect of immediate rewarming, plunging into LN2 and two-controlled-rate-stage cooling.

Cryopreservation of murine germinal vesicle (GV) stage cumulus-oocyte complexes (COCs) has been shown to result in poor development and cumulus cell damage. In an attempt to determine the stage of the cryopreservation protocol at which damage occurs, three cooling profiles were compared: slow-cooling (0.3 degrees C/min) to -60 degrees C (protocol A); slow-cooling to -60 degrees C and plunging to -196 degrees C (protocol B); or slow-cooling to -60 degrees C followed by further cooling at 10 degrees C/min to -150 degrees C, then plunging to -196 degrees C (protocol C). GV-stage COCs were collected from hormone-primed mice by repeated puncturing of ovarian follicles. COCs were exposed to 1.5 M Me(2)SO prior to cooling to -60 or -196 degrees C. Membrane integrity was assessed immediately after thawing using carboxy fluorescein and propidium iodide. A greater proportion of cumulus cells were damaged following protocol B than protocol A. Damage was less extensive following protocol C than following protocol B. For assessment of development, COCs were matured and fertilised in vitro. Morphological normality was significantly reduced following cooling to -60 or -196 degrees C compared with non-cryopreserved controls. Fertilisation of oocytes assessed as normal post-treatment was not significantly different between any of the groups. Development to blastocyst was least from oocytes exposed to protocol B, being significantly worse than for oocytes exposed to protocol A, but not significantly different to protocol C. A protocol comprising two stages of controlled-rate cooling decreased damage to the membranes of cumulus cells but did not significantly improve embryo development.

Evaluation of the role of laser treatment for the treatment of pain in endometriosis.

There have been few appropriately conducted trials to evaluate the effectiveness of laser destruction of endometriosis in relieving pain symptoms, yet the techniques are increasingly being used. Laser destruction has been shown to be more effective than the placebo effect of laparoscopy alone in one trial, at least at 6-month follow-up. Longer-term studies suggest increasing recurrence of symptoms with time [23% at 12 months in one study, and 44% by a mean of 19.7 months (5-60) follow-up]. These recurrence rates are similar to those seen following 6 months medical treatment. It is unknown whether laparoscopic uterosacral nerve ablation (LUNA) in addition to destruction of lesions will produce better results, and appropriate trials are needed in several areas to determine the role of laser therapy.

Developmental potential of murine germinal vesicle stage cumulus-oocyte complexes following exposure to dimethylsulphoxide or cryopreservation: loss of membrane integrity of cumulus cells after thawing.

BACKGROUND: Cumulus cells of the cumulus-oocyte complex (COC) are important in oocyte maturation. Thus, in preserving immature oocytes it is prudent to also preserve their associated cumulus cells. The survival and function of oocytes and their associated cumulus cells was assessed following cryopreservation or exposure to cryoprotectant without freezing. METHODS: Immature COCs were collected from mice primed with pregnant mare's serum. COCs were either slow-cooled or exposed to 1.5 mol/l dimethylsulphoxide without freezing. Treated and fresh COCs were stained for membrane integrity or, after in-vitro maturation and IVF, were assessed for developmental capability. Development of cumulus-denuded fresh oocytes, as well as denuded and frozen-thawed oocytes co-cultured with fresh cumulus cells, was assessed. RESULTS: Slow-cooled oocytes had significantly reduced coverage by intact cumulus cells compared with fresh COCs. Cumulus cell association and developmental capability were not substantially affected by exposure to cryoprotectant without freezing. Denuded fresh oocytes and cryopreserved COCs had decreased developmental potential that was not overcome by co-culture with fresh cumulus cells. CONCLUSIONS: Loss of association between oocyte and cumulus cells was induced by cryopreservation, but not by treatment with cryoprotectant alone. The data indicate that direct physical contact between cumulus cells and the oocyte, throughout maturation, improves subsequent embryo development.

Perifollicular vascularity as a potential variable affecting outcome in stimulated intrauterine insemination treatment cycles: a study using transvaginal power Doppler.

BACKGROUND: The aim of the present study was to assess any potential relationship between perifollicular vascularity and outcome in an in-vivo environment following human chorionic gonadotrophin (HCG) administration. METHODS: A total of 182 unselected consecutive patients undergoing stimulated intrauterine insemination (IUI) cycles was recruited where the perifollicular vascularity of follicles > or =16 mm was studied using a subjective grading system and transvaginal power Doppler ultrasonography, 36 h after HCG administration. RESULTS: A total of 601 follicles was studied. The incidence of follicles showing high-grade perifollicular vascularity (3 and 4) was higher than those with low-grade vascularity (1 and 2) (80 versus 20%). Treatment cycles were divided according to uniformity of vascularity grades of follicles > or =16 mm on the day of IUI [55% all high (3/4) grade; 33% mixed (1/2 and 3/4) and 12% all low (1/2) grade]. The mean age and duration of subfertility were significantly higher (P < 0.05), whereas the number of follicles > or =16 mm pre/post HCG, serum oestradiol and incidence of ultrashort gonadotrophin-releasing hormone (GnRH) agonist use were all significantly lower (P < 0.05) in treatment cycles with uniformly low follicular vascularity grades compared with mixed or uniformly high-grade cycles. However, on subjecting the data to multiple logistic regression analysis, the only independent variables that affected pregnancy rates appeared to be serum oestradiol (OR 1.28, 1.01--1.62) and high-grade follicular vascularity (OR 2.41, 1.08--5.40). CONCLUSION: These data would suggest that perifollicular vascularity has an important role to play in the outcome of IUI cycles, and that power Doppler has the potential to refine the management of assisted reproduction treatment cycles.

An unusually aggressive case of endometriosis showing p53 expression.

A 43 year old woman who underwent a hysterectomy and bilateral salpingo-oophorectomy for secondary dysmenorrhoea was found to have bilateral ovarian endometriosis. During the following four years she developed a series of tumour-like vaginal masses, which were locally excised, a pelvic mass causing acute large bowel obstruction, which necessitated an emergency Hartmann's procedure, and a further pelvic mass causing hydronephrosis with a non-functioning kidney. Pathological examination of all the resected specimens showed endometriosis with abundant stromal and glandular elements. Immunoreactivity for p53 protein was detected within endometriotic foci from the initial oophorectomy as well as the latest resection specimens. Immunostaining for p53 may help identify potentially aggressive cases of endometriosis for proactive treatment.

Membrane permeability of human oocytes in the presence of the cryoprotectant propane-1,2-diol.

OBJECTIVE: To determine the permeability of unfertilized human oocytes to water and the cryoprotectant propane-1,2-diol over a range of temperatures and to use these data to predict osmotic responses under given conditions. DESIGN: Laboratory-based study. SETTING: Teaching hospital. PATIENT(S): Infertility patients donating unfertilized oocytes in excess of those required for treatment. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Water and cryoprotectant permeability were determined from measurements of oocyte volume excursions on exposure to 1.5 M propane-1,2-diol at 30 degrees C, 24 degrees C, and 10 degrees C. RESULT(S): Permeability of human oocytes to water and cryoprotectant increased as temperature increased. The predicted response of oocytes, based on these data, closely matched the measured response of an oocyte on exposure to a widely used method for addition of cryoprotectant before freezing. CONCLUSION(S): Commonly used cryopreservation protocols involving slow cooling in the presence of propane-1,2-diol cause potentially damaging excursions in cell volume on exposure to cryoprotectant. Modifications that can be expected to reduce cell volume excursions, based on oocyte permeability data, are suggested.

Phagocytosis of Loma salmonae (Microsporidia) spores in Atlantic salmon (Salmo salar), a resistant host, and chinook salmon (Oncorhynchus tshawytscha), a susceptible host.

The in vitro phagocytosis of Loma salmonae spores by macrophages of Atlantic salmon and two strains of chinook salmon were investigated. Opsonisation of L. salmonae with plasma factors increased uptake by head kidney macrophages. Macrophages of Atlantic salmon, which are resistant to the parasite, had a significantly higher phagocytic index (PI) than those of chinook salmon, a susceptible species. This may indicate a possible mechanism contributing to resistance in Atlantic salmon or that L. salmonae is able to evade or suppress initial binding by macrophages of chinook. Non-specific binding or lectinophagocytosis was also suggested by significantly higher PI of spores from EDTA treated plasma when compared with no plasma or heat treated plasma. In comparison, uptake of Baker's yeast Saccharomyces cerevisiae by phagocytes was not significantly different between fish species and strains for all treatments.

Trial of scar or elective repeat caesarean section at maternal request?

In a study between 1 January 1996 and 31 December 1998 at Watford General Hospital, we identified all women who booked having had a previous caesarean section. Data on age, social class and previous obstetric history was extracted from the notes, as was mode of delivery. Of the 718 patients identified, 497 were considered suitable for trial of scar. Of these 221 (44.5%) requested repeat caesarean section. Age, social class and indication for previous caesarean section could not predict those who accepted trial of scar. Of the 60 women who had had a previous successful trial of scar 59 (98.3%) underwent trial of scar and of the 48 who had had a vaginal delivery prior to caesarean section 37 (77.1%) underwent trial of scar (P < 0.01). Maternal request for caesarean section, without obstetric contraindication to trial of scar, accounted for 24.9% of all the elective caesarean sections undertaken in our unit.

The management of endometriosis: a survey of patients' aspirations.

The aim of this study was to determine the aspirations of women with endometriosis in terms of the management of their disease. We interviewed 32 women with confirmed endometriosis and asked them to discuss the potential benefits of the establishment of a specialist endometriosis clinic. Eighty-eight per cent of the participants agreed that a separate specialist clinic would be beneficial. The reasons they cited can be grouped under four main themes: information provision, quality and type of care, peer support and endometriosis awareness. On the basis of these responses we propose that a strategy utilised in the management of other chronic diseases, drop-in group medical appointments, may provide a way forward. In addition, on the basis of the range of symptoms reported by our participants, we would argue that a multidisciplinary approach is necessary if endometriosis management is to be effective.

The potential effect of controlled ovarian hyperstimulation on follicular vascular perfusion: a study applying power Doppler ultrasonography within a treatment programme using donor sperm.

This was a prospective observational study to evaluate the effect of controlled ovarian hyperstimulation on follicular vascularity. A subjective grading system was applied to assess vascularity using transvaginal power Doppler ultrasonography on the day of insemination (32-36 hours post-HCG administration) in donor treatment cycles undergoing either controlled ovarian hyperstimulation (COH group) with gonadotrophin and intrauterine insemination or intracervical insemination with/without clomiphene stimulation (non-COH group). The incidence of follicles (81% vs. 53%; P < 0.05) as well as cycles (63% vs. 49%; P < 0.05) with uniformly high grade vascularity was significantly higher in treatments that had controlled ovarian hyperstimulation compared with unstimulated or clomiphene induced donor cycles. Pregnancy rates were higher and early pregnancy loss rates lower, in cycles with uniformly high grade follicular vascularity in both treatment groups compared with other vascularity grades. Using multiple logistic regression analysis, the only independent variable that was significantly related to pregnancy rates in this treatment programme was follicular vascularity. Controlled ovarian hyperstimulation appears to have an effect on follicular vascularity and this may contribute to improved outcome in donor insemination treatment programmes.

Innate susceptibility differences in chinook salmon Oncorhynchus tshawytscha to Loma salmonae (Microsporidia).

Loma salmonae (Putz, Hoffman and Dunbar, 1965) Morrison & Sprague, 1981 (Microsporidia) is an important gill pathogen of Pacific salmon Oncorhynchus spp. in the Pacific Northwest. Three strains of chinook salmon O. tshawytscha were infected in 2 trials with L. salmonae by feeding of macerated infected gill tissue or per os as a gill tissue slurry. Intensity of infection was significantly higher in the Northern stream (NS) strain as compared to the Southern coastal (SC) and a hybrid (H) strain derived from these 2 strains. Both wet mount and histological enumeration of intensity of infection demonstrated strain differences. Survival in the NS strain was significantly lower than the other strains. The NS strain may represent a naive strain and be less able to mount an effective immune response against the parasite.

Experimental and natural host specificity of Loma salmonae (Microsporidia).

The microsporidian Loma salmonae (Putz, Hoffman & Dunbar, 1965) Morrison & Sprague, 1981 has caused significant gill disease in Pacific salmon Oncorhynchus spp. Host specificity of the parasite was examined experimentally by per os challenge of selected salmonids and non-salmonids with infective chinook salmon O. tshawytscha gill material. Pink Oncorhynchus gorbuscha and chum salmon O. keta, brown Salmo trutta and brook trout Salvelinus fontinalis, and chinook salmon (controls) were positive, whereas Atlantic salmon Salmo salar and Arctic char Salvelinus alpinus were negative. In addition, no non-salmonids were susceptible to experimental exposure. Wild Pacific salmon species in British Columbia, Canada, were examined for L. salmonae during their freshwater life history stages (smolts, prespawning, spawning). All stages were infected, although infections in smolts were only detectable using a L. salmonae-specific PCR test. Many previous Loma spp. described from Oncorhychus spp. are likely L. salmonae based on host, parasite morphology, and site of infection.

Viability of Loma salmonae (Microsporidia) under laboratory conditions.

The viability of the fish-infecting microsporidian Loma salmonae Morrison and Sprague, 1981 was determined under laboratory conditions by polar filament extrusion and infectivity to chinook salmon (Oncorhynchus tshawytscha). Extrusion rates of isolated spores decreased from 51.0% to 0.0% by 100 days after storage in fresh or sea water at 4 degrees C. Spores stored up to 95 days in either solution infected 80.0-100.0% of exposed chinook, although no spores infected fish at 100 days in one trial. Viability in Earl's balanced salt solution was tested up to 50 days, with 23.7% of spores extruding filaments and 80.0% of exposed chinook becoming infected. Spores frozen to -20 degrees C or -70 degrees C were unable to infect fish.

A method for differentiating nonunique estimates of membrane transport properties: mature mouse oocytes exposed to glycerol.

Measurement of the osmotic response of a cell in the presence of cryoprotectant facilitates the determination of permeability coefficients which, in turn, can be used to design cryopreservation protocols which minimize osmotic stress. One problem encountered in determining permeability coefficients, using the Kedem-Katchalsky (K-K) model of membrane permeability, is that several combinations of the three passive coupled transport coefficients, namely, hydraulic permeability (L(p), microm min(-1) atm(-1)), solute permeability (P(gly), microm s(-1)), and the reflection coefficient (sigma), can give a similar fit to the measured data. A method for determining the "correct" set of coefficients is suggested. The osmotic response of 10 metaphase II mouse oocytes was measured on perfusion with 1.5 mol L(-1) glycerol at 24 degrees C. For 8 of 10 oocytes perfused, two combinations of L(p), P(gly), and sigma gave a predicted response which closely matched the measured osmotic response, depending upon the initial estimates supplied to the software for these parameters. For the remaining two oocytes, similar values for the permeability coefficients were generated regardless of the initial estimates. To determine the correct set of parameters, the K-K equations were used to predict experimental conditions for which volumetric histories would be distinctly different for the two sets of "best-fit parameters," and then additional experimental data were compared to these predictions. Thus a further three oocytes were perfused with 0.2 or 0.5 mol L(-1) glycerol in the absence of nonpermeating solute. In the presence of both 0.2 and 0.5 mol L(-1) glycerol, L(p) = 2.11 +/- 0.69, P(gly) = 0.0016 +/- 0.0015, and sigma = 0.44 +/- 0.11 yielded a very poor fit to the measured response while L(p) = 0.98 +/- 0.70, P(gly) = 0. 0031 +/- 0.0021, and sigma = 0.91 +/- 0.15 yielded a close fit to the measured response. Thus the latter combination of coefficients was taken to be correct.

Temperature dependence of Kedem-Katchalsky membrane transport coefficients for mature mouse oocytes in the presence of ethylene glycol.

Ethylene glycol (EG) is the emerging cryoprotectant of choice for preservation of mammalian embryos but has not been widely used for oocyte preservation. Techniques for oocyte cryopreservation need to be improved before they can be incorporated into routine clinical practice. Hence the permeability characteristics of oocytes in the presence of EG have been determined in order to facilitate the design of cryopreservation protocols using this cryoprotectant. Individual mouse oocytes were held using negative pressure applied to the zona pellucida by means of a micropipet. Each oocyte was perfused with 1 ml 1.5 mol L(-1) EG at 30, 19, or 10 degrees C, a total of 10 oocytes being perfused at each temperature. The osmotic response of each oocyte before, during and after perfusion was recorded on videotape. Measurements of mean cell diameter across three axes were used to calculate oocyte volume, assuming them to be spherical, and, using mathematical modeling, values for hydraulic conductivity (L(p)) were found to be 0.91 +/- 0.05, 0.51 +/- 0.02, and 0.18 +/- 0.01 microm min(-1) atm(-1); cryoprotectant permeability (P(EG)) was 0.24 +/- 0.01, 0.09 +/- 0.005, and 0.03 +/- 0.004 microm s(-1); and reflection coefficient (sigma) was 0.98 +/- 0.005, 0.96 +/- 0.01, and 0.97 +/- 0.01 at 30, 19, and 10 degrees C, respectively. The activation energy (E(a)) of L(p) was 14. 0 kCal mol(-1) and of P(EG) was 16.4 kCal mol(-1).

Permeability characteristics of human oocytes in the presence of the cryoprotectant dimethylsulphoxide.

Equilibration of oocytes with cryoprotectants is a prerequisite of low temperature storage. However, cryoprotectant exposure may induce damage via osmotic stress. Knowledge of cell membrane permeability characteristics and their temperature dependence would facilitate the design of cryopreservation protocols in which osmotic stress is minimized and the incidence of intracellular freezing is reduced. To obtain such data, the volume change of donated human oocytes following exposure to cryoprotectant was measured at a variety of temperatures. After removal of cumulus cells, each oocyte was placed in a 5 microl droplet of phosphate-buffered medium. The oocyte was held in position by suction generated using a fine pipette and perfused with 1 ml 1.5 mol/l dimethylsulphoxide (DMSO) at 30, 24 or 10 degrees C. The volume of the oocyte before, during and after perfusion was recorded by videomicroscopy. Oocyte volume was calculated from radius measurements and the Kedem-Katchalsky (K-K) passive coupled transport coefficients, namely L(p) (hydraulic permeability), P(DMSO) (permeability to DMSO) and sigma (reflection coefficient) were derived. The resulting coefficients were L(p) = 1. 65 +/- 0.15, 0.70 +/- 0.06 and 0.28 +/- 0.04 microm/min.atm; P(DMSO) = 0.79 +/- 0.10, 0.25 +/- 0.04 and 0.06 +/- 0.01 microm/s and sigma = 0.97 +/- 0.01, 0.94 +/- 0.03 and 0.96 +/- 0.01 at 30, 24 and 10 degrees C respectively. The activation energy for L(p) was 14.70 and for P(DMSO) was 20.82 kcal/mol. The permeability parameters of human oocytes are higher than those of murine oocytes, suggesting that they require a shorter period of exposure to DMSO with concomitantly reduced toxic effects.