Prognostic value of serum progesterone and LH values on the day of hCG administration in IUI GnRH antagonist cycles.

OBJECTIVE: to evaluate the effect of LH surge and progesterone rise in IUI cycles under gonadotropin stimulation with GnRH antagonist coadministration on pregnancy rates (PR). STUDY DESIGN: The population under study consisted of 152 women prospectively studied and subjected to IUI. RESULTS: The higher the progesterone cutoff value, the lower the PR were 26.5% and 10.9% when the cutoff was 1 ng/mL, 26.0% and 8.6% when the cutoff was 1.2 ng/mL, 25.6% and 7.1% when the cutoff was 1.4 ng/mL and 25.3% and 0% when the cutoff was 1.6 ng/mL. CONCLUSION: In IUI cycles under GnRH antagonist coadministration, serum progesterone levels over 1.0 ng/mL are associated with lower PR, the higher the progesterone levels, the lower the PR.

Cytological vitreous findings in a patient with infantile neurological cutaneous and articular (CINCA) syndrome.

The CINCA syndrome is an inflammatory disease characterised by persistent rash and chronic aseptic meningitis, with extensive infiltration of polymorphonuclear and macrophage cells at the sites of inflammation. The CINCA syndrome belongs to the group of systemic autoinflammatory diseases characterised by episodic or fluctuating degrees of inflammation, without evidence of high-titre autoantibodies or antigen-specific T cells. The disease is caused by mutations in the CIAS1 gene that encodes a protein cryopyrin, NALP3 or PYPAF1. Mutations in cryopyrin have a profound pro-inflammatory effect. Cryopyrin is a caspase 1 activator, which in turn causes the activation of interleukin (IL)1ß. The activating mutations of cryopyrin induce an excessive activation of IL1ß, which causes an influx of macrophages and polymorphonuclear cells to the site of inflammation, in our patient, in his eye.

Surgical embolus removal in retinal artery occlusion.

AIMS: To evaluate the anatomical outcomes, safety and functional effectiveness of surgical embolus removal in retinal artery occlusion (RAO). METHODS: Prospective study of seven patients with RAO of <36 h duration. All eyes underwent pars plana vitrectomy and a longitudinal incision of the anterior wall of the occluded arteriole in an attempt to remove the embolus. Outcome measures included visual acuity and arteriolar reperfusion, as evaluated with fluorescein angiography. RESULTS: Surgical removal of the embolus was achieved in six of the seven (87.5%) patients, visual acuity improved from a median of 20/400 (range: hand movements 20/25) to 20/40 (range: hand movements 20/25), and reperfusion of the occluded vessel was angiographically confirmed in four of the six patients in whom the embolus was successfully removed. CONCLUSION: Surgical removal of retinal arterial emboli seems to be an effective and safe treatment for RAO, but a randomised and controlled clinical trial will be necessary to establish an evidence base for the role, if any, of this intervention.

Comparison of different techniques for purification of triamcinolone acetonide suspension for intravitreal use.

BACKGROUND: Intravitreal triamcinolone has increasingly been used for the treatment of oedematous and neovascular diseases and purification of triamcinolone suspension may be important in order to avoid the potential toxic effects of the vehicle. The aim was to evaluate different techniques used to reduce the solvent agent benzyl alcohol (9.9 mg/ml) from a commercially prepared triamcinolone acetonide suspension. METHODS: Different techniques were used to reduce the solvent agent benzyl alcohol: filter techniques using 0.22 mum or 5 mum pore size, and non-filter techniques using sedimentation or centrifugation. Quantification of triamcinolone acetonide and benzyl alcohol was performed by high pressure liquid chromatography (HPLC). RESULTS: Benzyl alcohol concentration was decreased significantly in all the techniques used compared with the original commercial suspension (p<0.05), with no significant differences among them. The reduction was approximately one tenth of its original concentration. However, triamcinolone acetonide concentration differed significantly depending on the method used. Centrifugation method showed no differences versus the original commercial solution; sedimentation technique reduced the expected dose only 25%; the filter technique using a 5 mum pore size membrane reduced the expected dose to one fourth, while the filter technique using a 0.22 mum pore size membrane reduced the expected dose to 45%. CONCLUSIONS: All the different techniques employed effectively reduced the concentration of benzyl alcohol. However, the final concentration of triamcinolone was much lower than expected using the filter techniques. The pore size membrane inversely influenced the final concentration, with part of the triamcinolone crystals probably being entrapped in the filter. Centrifugation is recommended as the best way of administering the drug.

Ovarian stimulation in intrauterine insemination with donor sperm: a randomized study comparing clomiphene citrate in fixed protocol versus highly purified urinary FSH.

BACKGROUND: The study was conducted to compare the results of intrauterine donor insemination (DI) under ovarian stimulation with either clomiphene citrate (CC), in a fixed protocol, or FSH, with ovarian monitoring. METHODS: Forty-nine patients were randomized using a computer-generated list to receive highly purified urinary FSH (starting dose of 150 IU) and were subjected to periodic vaginal ultrasound and estradiol determinations. HCG was given when > or =2 follicles (> or =17 mm) were identified and estradiol reached >400 pg/ml. Intrauterine insemination (IUI) was performed 36 h later. The other 51 received CC on a fixed protocol (100 mg/day from the day 5-10 of the ovarian cycle) with HCG being administered on the day 12, and IUI performed 36 h later. Up to six IUI cycles were performed on all patients if pregnancy was not reached before. Women failing to conceive in the CC group underwent IUI with FSH. The main outcome measures were intrauterine gestational sac observed by transvaginal ultrasound, per cycle and per woman pregnancy rate (PR) and multiple PR. RESULTS: The per cycle PR was significantly higher in the FSH group, 14.4% (30/209) versus 6.1% (16/261), as well as the per woman PR, 61.2% (30/49) versus 31.4% (16/51). 12.5% (2/16) of pregnancies obtained in the CC group were multiple, compared with 20% (6/30) in the FSH group. There were no triplets or higher order pregnancies in CC versus two in FSH (6.7% of pregnancies). Patients failing to conceive with CC, who later underwent intrauterine DI with FSH, had similar results to the primary FSH group: 54.3% PR per patient (19/35) and 16.0% per cycle (19/118), with a multiple PR of 31.6% (6/19). The PR for women starting with CC cycles and, if pregnancy was not obtained, continuing with six FSH cycles, was 69.2%. CONCLUSIONS: The PR obtained with CC stimulation was approximately half that obtained with FSH. There was a trend to lower multiple PR with CC. It is recommended that each case should be considered on an individual basis and the treatment options discussed with patients. In our opinion, CC could be a reasonable approach for young women with good prognosis, whereas in the remaining cases FSH would be the preferable method.

Ultrasound-guided embryo transfer improves pregnancy rates and increases the frequency of easy transfers.

BACKGROUND: Recent reports have suggested that ultrasound (US) guidance during embryo transfer might improve pregnancy rates. METHODS: A prospective randomized (computer-generated random table) trial was performed to compare embryo transfer under abdominal US guidance (n = 255 women) with clinical touch embryo transfer (n = 260). RESULTS: The clinical pregnancy rate was 26.3% (67/255) in the US-guided transfer group compared with 18.1% (47/260) in the clinical touch transfer group (P < 0.05). The implantation rate was 11.1% (100/903) in the US group compared with 7.5% (66/884) in the clinical touch group (P < 0.05). US-guided transfer was associated with a decrease in the difficulty of the transfers: 97% of transfers were easy in the US-guided group compared with 81% in the clinical touch group (P < 0.05). CONCLUSIONS: US-guided embryo transfer increased pregnancy and implantation rates in IVF cycles, as well as the frequency of easy transfers. It is suggested that the decrease in cervical and uterine trauma can play a role in the increase in pregnancy rates associated with US-guided transfer. It is recommended that embryo transfer should be performed under US guidance.

Vitreoretinal surgery and endoresection in high posterior choroidal melanomas.

PURPOSE: Eyes with posterior choroidal melanomas more than 9 mm in thickness frequently are enucleated because of the potential complications of radiotherapy. The aim of this study was to evaluate the safety and efficacy of internal resection of these tumors. METHODS: Twenty-five consecutive patients with high posterior choroidal melanomas with a diameter less than 15 mm and a thickness greater than 9 mm were treated. If the retina was not invaded by the tumor, a vitrectomy was performed, followed by posterior hyaloid dissection, 120 degrees anterior retinotomy, endophotocoagulation 2 mm past the tumor margin, melanoma removal with the vitrectomy probe, retinal reattachment with liquid perfluorocarbon and air, and silicone oil exchange. If the tumor invaded the retina, the laser was applied through the retina, and the retina and tumor were removed together. RESULTS: The mean patient age was 46.6 years. The tumor thicknesses ranged from 9.1 to 12.8 mm, and the tumor diameter ranged from 8.9 to 14.8 mm. The mean preoperative visual acuity was 20/60. In 11 patients, the tumor had invaded the retina. We removed the entire tumor from all 25 eyes. The main postoperative complications were cataract (40%), retinal detachment (16%), macular traction (16%), and epiretinal macular proliferation (8%). The mean postoperative visual acuity was 20/100. No tumors recurred, and there was no evidence of metastasis. The follow-up ranged from 12 to 72 months. CONCLUSIONS: These data suggest that internal resection of high posterior melanomas may conserve ocular and functional vision and does not seem to increase the risk of metastatic disease. Longer follow-up is necessary to establish the safety of the procedure.

The role of vitreoretinal surgery in the management of myopic macular hole without retinal detachment.

PURPOSE: To evaluate the anatomic and functional outcome of vitreoretinal surgery in eyes with pathologic myopia and macular hole and to determine if surgery improves visual acuity. METHODS: Twenty-four consecutive highly myopic eyes with full-thickness macular hole without posterior retinal detachment were treated by vitrectomy. Posterior hyaloid dissection, removal of epiretinal and internal limiting membranes (ILM) if thickened, instillation of platelet concentrate, and flushing with 25% sulfur hexafluoride were performed. RESULTS: Patients' refractive error ranged between -8.0 and -17.5 diopters, and axial length ranged from 27.1 to 31.4 mm. Two epimacular membranes and 10 macular ILM were removed. Ten patients also underwent phacoemulsification and intraocular lens implantation at the same procedure. Mean preoperative best-corrected visual acuity was 20/200. Successful anatomic macular hole closure occurred 6 months postoperatively in 100% of eyes after one (21 eyes, 87.5%) or two surgeries (3 eyes, 12.5%). Visual acuity improved three or more lines in 83.3% of patients. Mean postoperative visual acuity was 20/70. No retinal detachment was observed during the follow-up period, which ranged from 12 to 45 months. CONCLUSION: Our results suggest that vitreoretinal surgery may effectively manage myopic macular holes, thus improving anatomic and visual outcomes. By closing the hole, vitreoretinal surgery may decrease the risk of posterior retinal detachment in highly myopic eyes.

Recombinant human FSH versus highly purified urinary FSH: a randomized study in intrauterine insemination with husbands' spermatozoa.

A randomized trial was carried out comparing recombinant FSH (rFSH) and highly purified urinary FSH (uFSH) in intrauterine insemination (IUI) with husbands' spermatozoa. A total of 45 women received rFSH (139 cycles), while 46 women received uFSH (155 cycles). The starting dose was 150 IU/day s.c., beginning on the second day, and on days 6-7 the dose was adjusted according to ovarian response, assessed by vaginal ultrasound and plasma oestradiol concentration. The pregnancy rate according to the intention to treat was 57.8% in rFSH versus 52.2% in uFSH, the corrected pregnancy rates 56.8% and 52.2%, and the cumulative pregnancy rates 69.6% and 61.0%, but the differences were not statistically significant. The per cycle pregnancy rate was 18.12% in rFSH and 15.48% in u-FSH, also not statistically significant. In the rFSH group, the consumption of FSH ampoules per cycle was significantly lower (19.20 +/- 7.02 versus 23. 80 +/- 10.78; P < 0.0001). The ratio of oestradiol/FSH ampoules was significantly higher in rFSH (56.45 +/- 31.26 versus 46.41 +/- 29. 25; P < 0.001). These data indicate that, in IUI cycles, rFSH has a higher potency than uFSH.

Therapeutic options for capillary papillary hemangiomas.

PURPOSE: To describe the results and therapeutic complications of treatment of papillary capillary hemangiomas over the last 13 years. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Five cases of unilateral capillary papillary hemangiomas were reviewed. Three patients had von Hippel-Lindau disease, and two had no associated familial or systemic disease. METHODS: Two patients were treated with argon green laser, one patient received argon green and diode photocoagulation, and two patients underwent argon green photocoagulation and diode transpupillary thermotherapy (TTT); two eyes also underwent vitreoretinal surgery. Follow-up ranged from 1 to 13 years. MAIN OUTCOME MEASURES: The presence of exudative retinal detachment associated with the activity of the hemangioma and the visual acuity were the two main parameters. RESULTS: Prompt argon green laser treatment was the most effective therapy; -II was ineffective. Vitreoretinal surgery, transscleral drainage, and argon endolaser photocoagulation in one case resolved bullous retinal detachment secondary to tumor exudation. Pretreatment visual acuity (VA) levels ranged from 20/25 to counting fingers; posttreatment VA levels ranged from 20/25 to light perception. CONCLUSIONS: If left untreated, papillary hemangiomas may evolve to exudative retinal detachment and marked VA decreases. Although we have not established an ideal therapy, we recommend appropriate treatment on diagnosis. Close follow-up and multiple treatments with argon laser are likely the best therapeutic course.

LASIK for the correction of residual refractive errors from previous surgical procedures.

BACKGROUND AND OBJECTIVE: To evaluate laser assisted in situ keratomileusis (LASIK) efficacy in correcting residual refractive errors after corneal or intraocular surgery (penetrating keratoplasty, radial keratotomy, photorefractive keratectomy, phacoemulsification with intraocular lens (IOL) implantation, penetrating ocular trauma and phakic IOL implantation). MATERIAL AND METHODS: We performed LASIK in 87 eyes of 62 patients previously operated by means of other surgical techniques to completely correct the residual refractive error. We report the mean refractive error (in terms of spherical equivalent refraction), uncorrected visual acuity (UCVA) and spectacle corrected visual acuity (SCVA) before and after the surgical procedure. We also analyze safety and stability, in these results with a minimum of 12 months follow-up. RESULTS: Mean preoperative spherical equivalent was -5.25 +/- 2.1 diopters (D). Postoperatively, mean spherical equivalent was -0.70 +/- 0.65 D, 76% of eyes were between plano and -1.00 D and 99% were between plano and -2.25 D. At 12 months follow-up the change in the refractive result was equal or less than 0.5 D in 94% of eyes. Preoperatively SCVA was 1.0 or better in 24.13% of cases, and 0.5 or better in 89.65%. Postoperative SCVA was 1.0 or better in 26.43% and 0.5 or better in 95%. Preoperative UCVA was 0.1 in 2 eyes, 0.05 in 4 eyes and count fingers in the rest of the cases. Postoperative UCVA was 1.0 or better in 1.1% and 0.5 or better in 70.1%. We had an extremely low complication rate in this particular group of patients. CONCLUSIONS: LASIK can be successfully used to correct residual refractive errors after other surgical procedures.

Total immunoreactive alpha-inhibin in human seminal plasma, sperm quality, and in vitro fertilization rates.

OBJECTIVE: To assess the relationship between the concentrations of total immunoreactive alpha-inhibin in human seminal plasma, sperm quality, and in vitro fertilization (IVF) rates. SETTING: Medical school hospital. DESIGN: Prospective study. PATIENTS: 72 consecutive couples undergoing IVF with husband's sperm in which at least 4 oocytes were obtained. MAIN OUTCOME MEASURES: Alpha-inhibin determination by means of enzyme-linked immunosorbent assay, sperm analysis for density and motility, IVF rates. RESULTS: Total immunoreactive alpha-inhibin levels were not correlated with IVF rates. Nor were there any differences in fertilization rates in the different groups. Lower inhibin levels were found in oligozoospermic cases. Lower sperm counts were found in cases with inhibin values below the median value, and also with respect to various other cutoffs. No correlation was found between inhibin levels and any of the sperm variables measured. CONCLUSION: Total immunoreactive alpha-inhibin is not a prognostic factor in IVF cycles. However, an association was found between inhibin and sperm concentration, suggesting that alpha-inhibin in the human seminal fluid could be a marker for some aspects of spermatogenesis.

Treatment of the male with follicle-stimulating hormone in intrauterine insemination with husband's spermatozoa: a randomized study.

We have examined the potential of follicle-stimulating hormone (FSH) therapy for the male to improve pregnancy rates in intrauterine insemination (IUI) with husband's spermatozoa. A prospective randomized trial was performed in 148 couples undergoing IUI because of male subfertility. In the treatment group, 150 IU FSH were administered to the husbands, either i.m. or s.c., three times a week, starting 3 months before the beginning of IUI cycles and maintained until the fifth IUI cycle. In the control group no treatment was given. FSH therapy did not change semen parameters. The pregnancy rate per cycle was 13.47% in the FSH group versus 10.07% in the non-FSH group; the pregnancy rate per woman was 44.38% in the FSH group versus 37.18% in the non-FSH group. Although the pregnancy rate increase was > 30% per cycle and > 20% per woman, statistical significance was not achieved. The cumulative pregnancy rate was 59.20% in the FSH group versus 42.91% in the non-FSH group. The pregnancy rate outside the IUI cycle was 14.70% (10/68) in the FSH group versus 2.5% (2/80) in the non-FSH group, the difference being statistically significant. In conclusion, a non-significant trend towards higher pregnancy rates in IUI was observed in the FSH group.

The role of vitreoretinal surgery in the treatment of posttraumatic macular hole.

PURPOSE: To determine if vitreoretinal surgery is successful in closing traumatic macular holes and subsequently improving visual acuity. Blunt trauma may result in a macular hole when it causes traumatic separation of the vitreous from the retina, contusion necrosis, or subfoveal hemorrhage. Like idiopathic macular holes, traumatic macular holes are surrounded by a ring of subretinal fluid and result in severely diminished visual acuity. METHODS: Fourteen eyes with full-thickness posttraumatic macular holes were treated. The patients ages ranged from 15 years to 36 years (mean, 22 years). Preoperative best corrected visual acuity ranged from 20/200 to 20/50 (mean, 20/80). A pars plana vitrectomy and posterior hyaloid dissection were performed, followed by complete fluid-gas exchange and instillation of 0.1 mL of platelet concentrate just over the macular hole. A final flushing with 25% sulfur hexafluoride was done. The postoperative follow-up period ranged from 6 months to 28 months (average, 13 months). RESULTS: Successful anatomic macular hole closure was achieved 6 months after surgery in 13 years (92.86%). Visual acuity improved four or more lines on the Snellen chart within 6 weeks after surgery in every eye with a closed hole; a final visual acuity of 20/20 was achieved in two eyes (15.3%). The mean postoperative visual acuity was 20/30. No intraoperative or postoperative complications were noted, and the lens remained clear in all eyes during the follow up period. CONCLUSION: Our results suggest that intraoperative application of platelet concentrate in combination with vitrectomy may be useful in managing posttraumatic full-thickness macular holes, thus improving anatomic and visual outcomes. The greater recovery of visual acuity obtained in this study compared with that obtained in other series of idiopathic macular holes could be related to the young age of the patients with traumatic macular holes and the early diagnosis and treatment.

Pharmacokinetics and retinal toxicity of intravitreal liposome-encapsulated 5-fluorouridine.

BACKGROUND: Fluoropyrimidines may be effective in preventing proliferative vitreoretinopathy after repair of complicated retinal detachments. Liposome encapsulation of these antiproliferative drugs may extend the intravitreal half-life and increase their efficacy. METHODS: The current study evaluated the pharmacokinetic behavior of intravitreally injected 5-fluorouridine (5-FUR), free and encapsulated in liposomes, either conventionally or coated with collagen into 25 New Zealand rabbits. Additionally, we investigated the retinal toxicity of intravitreal injections of 100, 250 and 500 microg as well as 1 mg 5-FUR as free drug or encapsulated in liposomes in the rabbit eye. RESULTS: The half-life of free 5-FUR after liposome injection into the vitreous cavity was 18.17+/-2.43 h, considerably longer than the half-life of free 5-FUR (0.82 h). Electrophysiologic tests did not show any changes in latency and a-wave amplitude and minimal changes in the b-wave amplitude. Histopathologic studies revealed integrity of the inner limiting membrane, and mild vacuolization in the outer retina. CONCLUSION: Encapsulation of 5-FUR within liposomes markedly increases its intravitreal half-life. Our study suggests that liposome-encapsulated 5-FUR is not toxic to the retina even at doses of 1 mg.

Spontaneous pregnancy in couples waiting for artificial insemination donor because of severe male infertility.

OBJECTIVE: To assess the spontaneous fertility in couples with severe seminal conditions while waiting for artificial insemination donor. STUDY DESIGN: Prospective follow-up during a period of 24 months. SETTING: University Medical School. PARTICIPANTS: There were 285 couples in which the male had a very severe seminal pathology: 166 azoospermia, 86 oligozoospermia and 33 severe asthenozoospermia. OUTCOME MEASURES: Pregnancy rates after being included on waiting list. RESULTS: The spontaneous pregnancy rate was 3.2% (9/285), per month spontaneous pregnancy rate being 0.13%. Spontaneous pregnancy rate was 0% in azoospermia (0/166). versus 7.6% (9/119) in non-azoospermia cases. Spontaneous pregnancy rate was 8.5% (4/47) in the group with less than 0.1 million motile sperm/cc, 6.5% (3/46) in the group between 0.1 and 1 million/cc and 7.7% (2/26) in the group with 1-2 million/cc. CONCLUSION: In a 2-year follow-up, pregnancy rate among non-azoospermic couples before undergoing artificial insemination was 7.6%. Extramatrimonial pregnancy (based on anamnesis and sperm analysis) seemed to be uncommon. Even in cases with less than 0.1 million of motile sperm/cc there was not a negligible spontaneous pregnancy rate.

Intrauterine insemination with frozen sperm increases pregnancy rates in donor insemination cycles under gonadotropin stimulation.

OBJECTIVE: To compare the efficacy of IUI donor and pericervical insemination donor in frozen sperm insemination cycles under gonadotropin stimulation. DESIGN: Couples where infertility was caused by male conditions were randomized into two groups: IUI and pericervical insemination. Semen samples, gonadotropin stimulation, and ovarian monitoring were the same in both groups. One IUI was performed per cycle as against two pericervical inseminations. SETTING: The donor insemination program at the Human Reproduction Unit at the Hospital of Cruces, Pais Vasco University. PATIENTS: Eighty-eight women (47 IUI and 41 pericervical insemination) with at least one patent fallopian tube and < 40 years of age. MAIN OUTCOME MEASURE: Intrauterine gestational sac observed by transvaginal ultrasound. RESULTS: Per woman pregnancy rate (PR) was higher in IUI than in pericervical insemination (65.96% versus 41.46%, odds ratio [OR] = 2.73, confidence interval [CI] = 1.06 to 7.2). Pregnancy rates were always higher in IUI irrespective of woman and husband's status, but statistical significance was not reached in any subgroups analyzed independently. Per cycle PR was also significantly higher in IUI than in pericervical insemination: 24.03% (31/129) versus 11.89% (17/143) (OR = 2.34, CI = 1.17 to 4.71). Moreover, cumulative PR was higher in IUI (86% versus 49.5%) (OR = 6, CI = 1.98 to 18.80). CONCLUSION: Per woman and per cycle PRs were significantly higher in IUI.

Ophthalmologic findings in a patient with cerebellar ataxia, hypogonadotropic hypogonadism, and chorioretinal dystrophy.

PURPOSE: To determine the ophthalmologic findings in a 39-year-old woman with the Boucher-Neuhäuser syndrome, which is a disorder of autosomal recessive inheritance characterized by the triad of spinocerebellar ataxia, chorioretinal dystrophy, and hypogonadotropic hypogonadism. METHODS: The patient underwent clinical and electrophysiologic examinations and fluorescein angiography. RESULTS: The main clinical findings were extensive areas of retinal pigment epithelial and choriocapillaris atrophy affecting the posterior pole and midperiphery of both eyes. Results of electroretinographic examination showed subnormal photopic and scotopic responses. CONCLUSIONS: The Boucher-Neuhäuser syndrome should be included in the differential diagnosis of patients with chorioretinal degeneration, particularly if there are neurologic or endocrinologic manifestations.