The development of a continuous quality control programme for strict sperm morphology among sub-Saharan African laboratories.

Inter-technician and between-laboratory differences, especially during the evaluation of sperm morphology, have been a major cause of concern. The study aimed to develop an intensive training programme with intervals of continuous quality control assessments for sperm morphology. Twenty andrology laboratories from sub-Saharan Africa were invited to participate in a World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction semenology workshop. Following intensive training in strict sperm morphololgy evaluation, a continuous quality control programme was introduced on a quarterly basis. At baseline, the mean (+/- SD) percentage difference reported between the participants and the reference laboratory reading was 33.50 +/- 11%. After training, the mean percentage difference had decreased to 14.32 +/- 5% at 3 months and to 5.00 +/- 5% at 6 months. Pairwise comparison of the differences at each evaluation time revealed the following: Baseline differences (pre-training) differed significantly from the differences at 3 months (P = 0.0002) as well as at 6 months after training (P = 0.007). The differences at 6 months did not differ significantly from those at 3 months (P = 0.27). Training of andrology technicians as well as continuous proficiency testing can be conducted on a national and international level with the support of a referring laboratory. Global quality control measurements in andrology laboratories should become mandatory, since these results indicate that continuous quality control for laboratory technicians can be highly successful.

Three consecutive recurrent ectopic pregnancies.

A case of three consecutive repeated ectopic pregnancies is presented in a 36-year-old woman who was being managed for infertility. The first two ectopic pregnancies occurred in the right fallopian tube, and both were treated conservatively. All three ectopic pregnancies were confirmed histopathologically. The aetiology, symptoms and management of the case are discussed, and the literature is reviewed.

PIP: Staff of the infertility clinic at King Khalid University Hospital in Riyadh, Saudi Arabia, cared for a Yemeni woman who had a poor obstetric history. She had had pelvic inflammatory disease. Her 1st pregnancy concluded in a full term vaginal delivery, but gastro-enteritis caused the infant's death at 4 months. She delivered her 2nd child at 32 weeks gestation and the infant died 3 days later. Her 3rd and 4th pregnancies occurred in the right tube. A laparotomy, conservative evacuation of the conceptus from the right tube, and peritoneal lavage were used to treat the ectopic pregnancies. She experienced spontaneous abortion of the 5th pregnancy at 10 weeks. The woman presented at the hospital's gynecology clinic at 40 days amenorrhea with low abdominal pain and a small amount of vaginal bleeding. She had not passed any clots or tissue. The general examination was normal. The pregnancy test was positive. Since she had past ectopic pregnancies, the physicians conducted an ultrasound, which revealed no intrauterine pregnancy and a heterogenous 4.5 cm x 5.5 cm mass near the left tube. Laparoscopy confirmed a normal size uterus, a mass on the left tube, and bleeding into the peritoneum. Laparotomy was performed to remove the unruptured left ampullary ectopic pregnancy in such a way as to preserve the patency of the tube and therefore fertility. The surgeons also conducted peritoneal lavage with dextran saline to remove the blood in the peritoneum. The surgeons lysed the adhesions they found between the omentum, abdominal wall, and the uterus. Both ovaries were in good condition. The right tube was in good condition. She did fine postoperatively and was released 7 days after operation. The physicians could not determine the patency of the left tube, because she was lost to follow up. This case shows that conservative management of the tubes to retain tubal patency was successful, since she was able to conceive, but recurrent ectopic pregnancies may damage the tubes.

Fetal biophysical profile monitoring and perinatal outcome.

A prospective study of 109 high risk pregnancies on whom 279 fetal biophysical (FBP) examinations were performed showed positive and negative predictive values of 100% and 71.4%, respectively in the last FBP examination prior to delivery. The study confirmed other reports in the literature of a high correlation between normal examination and satisfactory perinatal outcome. The absence of perinatal mortality within one week of a normal FBP examination, which was also in agreement with other reported studies, reaffirms the reassuring nature of a normal examination. The high positive predictive value in our study may be due to several factors, including the use of a protocol which ensured standardization of the patient's condition prior to examination as well as repeat evaluations after non-reassuring tests. FBP evaluation is considered a simple, reliable and useful examination for the management of high risk pregnancies. Its main value would appear to be a reduction in the number of high risk pregnancy patients who would otherwise have been admitted on the basis of the clinical findings.

Ventriculoperitoneal shunt and pregnancy.

A pregnancy in a patient with ventriculoperitoneal (VP) shunt was recently managed at the authors's institution. Review of the literature showed only six previous case reports. The management of this uncommon neurosurgical condition in pregnancy is presented along with a review of the literature. We conclude that pregnancy in a patient with a VP shunt for maternal hydrocephalus, generally has a normal outcome and that the function of the shunt is unaffected by pregnancy.

Maternal and cord plasma levels of high-density lipoprotein cholesterol and triglycerides in Nigeria.

Plasma total cholesterol, triglycerides and high-density lipoprotein cholesterol levels were determined in 70 pregnant women immediately after delivery and in the cord blood of their babies; 62 non-pregnant women served as controls. The mean lipid levels were significantly higher in the pregnant women than in the non-pregnant women. The lipid levels in the cord blood were much lower than those in the maternal blood but were not different from values which have been reported from the developed countries; they were independent of socio-economic class. The total and high density lipoprotein cholesterol levels were related to socio-economic status both in the pregnant and non-pregnant women, but the ratio of high density lipoprotein cholesterol to total cholesterol and triglyceride levels were not. The cord blood lipid levels were also independent of socio-economic class.

Serum free fatty acids, insulin and blood glucose in pregnancy.

Blood glucose, serum insulin and free fatty acid levels were determined in 60 pregnant and 44 non-pregnant women. The mean blood glucose level was significatnly lower in pregnant women than in non-pregnant women but there were no significant changes during pregnancy. The mean serum insulin and free fatty acid levels were not significantly different from the levels for the non-pregnant women, there was also no significant change in their mean levels throughout pregnancy.

Clinical trial of Ferastral in iron-deficient, non-pregnant patients in Ibadan, Nigeria.

Fifteen patients with proven iron-deficiency anaemia treated with intramuscular injections of Ferastral, iron-poly (sorbitol-gluconic acid) complex, have been studied. Fourteen showed a satisfactory rise in haematocrit. No local or systemic complications were observed. One patient with iron-deficiency anaemia due to a bleeding malignant lesion did not achieve a satisfactory haematocrit level although the bone marrow showed iron repletion following the injection. It is concluded that Ferastral is an effective drug in the treatment of iron-deficiency anaemia.

Acquired gynaetresia in Ibadan.

Acquired atresia of the vagina is much less common than the congenital type, but more frequent in the tropics than in the developed countries (Lawson and Stewart, 1967). This is because most of the causes which include chemical vaginitis (Frith, 1960), female circumcision (Mustafa, 1966) and birth injuries (Lawson and Stewart, 1967) are largely confined to the tropics, due to poverty, ignorance and lack of good medical facilities. In the developed parts of the world, acquired gynatresia is rare, and perhaps follow mainly colporrhaphies and intra-vaginal irradiation from treatment of pelvic malignancies, (Patterson and Rhodes 1958, Whitely, 1964). In Ibadan, Nigeria, however, by far the commonest cause of vaginal atresia is chemical vaginitis from vaginal insertion of local caustic pessaries, for the treatment of certain gynaecological problems. This paper is, therefore, designed to highlight the clinical presentation of acquired gynaetresia as seen in Ibadan with particular emphasis on its incidence, causation, symptomatology and operative management.

Plasma estrogens in euthyroid and thyrotoxic women.

Plasma levels of estrogen were measured daily by radioimmunoassay for 28 consecutive days in 12 healthy euthyroid women and 15 thyrotoxic women (10 with hypomenorrhea and 5 with amenorrhea) before commencement of therapy (except in one case) in an effort to increase understanding of the relationship between the thyroid gland and ovarian function. The results show that the patterns of plasma estrogen in thyrotoxic women with hypomenorrhea were similar to those in euthyroid women, although the levels in the thyrotoxic women were significantly elevated (P less than 0.001). Thyrotoxic women with amenorrhea also had a markedly elevated plasma estrogen level with a persistence of a sharp peak of estrogen but without the secondary estrogen rise associated with corpus luteum function. This suggests a failure of the positive feedback effect of estrogen on the hypothalamopituitary axis with resultant failure of ovulation.

Role of sex-hormone-binding globulin in hormonal changes and amenorrhoea in thyrotoxic women.

Plasma levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), oestrogen, testosterone and sex-hormone-binding globulin (SHBG) were determined in 15 thyrotoxic women in the reproductive age before and after treatment with carbimazole. The levels of these hormones and SHBG were compared with those of 12 euthyroid healthy female volunteers of comparable age and parity. Plasma gonadotrophins (LH and FSH), oestrogen, testosterone and SHBG were all markedly elevated in thyrotoxic subjects but became normal when the euthyroid state and normal menstruation were restored after treatment. From the results a hypothesis is suggested that related the hormonal disturbance primarily to a thyroid hormone-induced rise in SHBG levels.

Plasma concentration of gonadotrophins, oestrogens and progesterone in thyrotoxic women.

Plasma levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), oestrogen and progesterone were measured daily in 15 thyrotoxic women in the reproductive age for 28 to 30 consecutive days before commencement of therapy and for a similar period following restoration of the euthyroid state. Five of these patients had secondary amenorrhoea whilst the other 10 had hypomenorrhoea. Twelve healthy volunteer eythyroid women of similar age and parity, with no history of menstrual abnormality, served as controls. The levels of both gonadotrophins (LH and FSH) and oestrogen were found to be significantly raised in all thyrotoxic patients in comparison with levels in the euthyroid female controls (P less than 0.001). "Mid cycle" LH and FSH peaks were present in thyrotoxic patients who were still menstruating whilst they were absent in those who developed amenorrhoea. Plasma oestrogen concentration rose to a peak on the day before the surge of LH (and FSH) in all euthyroid frmale controls as well as in thyrotoxic patients who were still menstruating. In contrast, oestrogen peaks occurred without ensuing LH (and FSH) peaks in thyrotoxic patients who had developed amenorrhoea, suggesting a failure of the positive feed-back mechanism. The levels and patterns of plasma progesterone in thyrotoxic subjects who were still menstruating were similar to those of euthyroid controls. However, no significant circulating plasma progesterone was detected in thyrotoxic subjects who were amenorrhoeic. The levels and patterns of all of these hormones (gonadotrophins, oestrogen and progesterone) became normal after restoration of euthyroid state and normal menstruation.

Plasma concentration of gonadotrophins, oestrogen and progesterone in hypothyroid women.

In an effort to determine the influence of hypothyroidism on the hypothalamopituitary-ovarian axis plasma levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), oestrogen and progesterone were measured daily for 10 to 14 consecutive days in five women with hypothyroidism. In all subjects investigated the levels of all the hormones measured were low in comparison with the values in euthyroid women. FSH/LH ratios were, however, higher in hypothyroid women than in both phases of the menstrual cycle in euthyroid controls. It is postulated that changes in the FSH/LH ratio may be related to the low levels of oestrogen and probably to failure of ovulation in hypothyroid women.

Serum lipids in pregnancy and socio-economic status.

Serum total and free cholesterol, phospholipids and erythrocyte free cholesterol levels were determined at four-weekly intervals from the first trimester until term in pregnant Nigerian women from three different socio-economic levels. The results showed a similar pattern of serum lipids in all three groups with a similar percentage increase at the peak levels. Serum phospholipids and total cholesterol levels were not significantly increased after the second trimester in contrast to report of a progressive hyperlipaemia in pregnant women of Western countries. Erythrocyte free cholesterol levels showed a mirror image of those of serum free cholesterol.