Role of rescue IVF-ET treatment in the management of high response in stimulated IUI cycles.

Rescue in-vitro fertilisation and embryo transfer (IVF-ET) has been used in high response gonadotrophin intrauterine insemination (IUI) cycles to minimise the risks of ovarian hyperstimulation and multiple gestation. Such unplanned IVF treatment increases the cost of treatment. But can this added cost and the risks associated with IVF be justified? We present our experience with this treatment using clinical pregnancy and live birth rates as the primary outcomes. Between 1998 to 2001, 40 women undergoing IUI cycles who over responded (>3 follicles measuring >15 mm in diameter on the planned day of hCG administration) to gonadotrophin were offered the choice of conversion to IVF-ET or cancel the cycle. 17/40 declined rescue IVF/ET and had their cycles cancelled. 23/40 converted to IVF/ET and underwent transvaginal oocyte retrieval. 21/23 had embryo transferred. The clinical pregnancy and live birth rates were 52% and 48%, respectively. Rescue IVF-ET offers excellent clinical pregnancy and live birth rates in high responders. However, affordability can be an obstacle in the utilization of this treatment option.

Are the anticipated benefits of myomectomy achieved in women of reproductive age? A 5-year review of the results at a UK tertiary hospital.

Fibroids are the most common benign tumours of the pelvis in women, with a prevalence estimated at 20-50%. They are more common towards the end of the reproductive years. There is a racial preponderance, being more common in black than white women. This may relate to the aetiology, which is still poorly understood. Generally, fibroids do not cause symptoms but some sufferers do complain about pressure symptoms, abnormal vaginal bleeding and infertility. For these reasons, myomectomy is often resorted to after failure of medical interventions on the premise that it brings about improvement/cure of symptoms and enhancement of fertility. However, the evidence for these indications for surgery is hazy. An analysis of the 109 medical records of symptomatic patients who had myomectomy over a 5-year period at a tertiary centre revealed the following. Single-symptom presentation in 41 (38%), menorrhagia in 20 (18%) being the most common. Only 52 (48%) patients had medical treatment of one form or another before myomectomy. Additional operative findings included pelvic adhesions, evidence of PID and endometriosis. Thirty-four (31%) had an estimated blood loss 500 ml and 23 of these patients needed blood transfusion. There were four cases of unscheduled hysterectomies due to uncontrollable bleeding. Pyrexia was the most common (38%) postoperative complication followed by superficial wound infection in 5%. We observed improvement of symptoms, assessed over a range of 2-24 months, in 34 cases (68%) in patients without fertility symptoms who accounted for 50 of these women. The symptomatic benefit was less (36%) in the 'infertility group'. Following an observation period of over 12-36 months, 17 patients in the 'infertility group' were lost to follow-up. Two (14%) of the 14 patients who attempted in vitro fertilisation (IVF) were successful. In the non-IVF group, 13 (46%) of the 28 achieved natural conception. These results suggest that symptomatic improvement and fertility enhancement may be possible in some patients with fibroids. In view of the risks and potential failure of treatment associated with myomectomy these results, yet again, support the fact that patients should be properly counselled before embarking on myomectomy and we strongly advocate local data to form the basis of the advice given during the consultation rather than what obtains in the literature.

Four zona pellucida glycoproteins are expressed in the human.

BACKGROUND: The zona pellucida (ZP) is an extracellular glycoprotein matrix which surrounds all mammalian oocytes. Recent data have shown the presence of four human zona genes (ZP1, ZP2, ZP3 and ZPB). The aim of the study was to determine if all four ZP proteins are expressed and present in the human. METHODS: cDNA derived from human oocytes were used to amplify by PCR the four ZP genes. In addition, isolated native human ZP were heat-solubilized, trypsin-digested and subjected to tandem mass spectrometry (MS/MS). RESULTS: All four genes were expressed and the respective proteins present in the human ZP. Moreover, a bioinformatics approach showed that the mouse ZPB gene, although present, is likely to encode a non-functional protein. CONCLUSIONS: Four ZP genes are expressed in human oocytes (ZP1, ZP2, ZP3 and ZPB) and preliminary data show that the four corresponding ZP proteins are present in the human ZP. Therefore, this is a fundamental difference with the mouse model

A postal survey of hydrosalpinx management prior to IVF in the United Kingdom.

BACKGROUND: In the last decade, numerous studies have demonstrated concern about the presence of hydrosalpinx and its management in patients undergoing IVF. We evaluated the current management of hydrosalpinx prior to IVF treatment in the UK. METHODS: A total of 117 postal survey, anonymous, sealed questionnaires were sent to all IVF centres in the UK, to determine the policy for the management of hydrosalpinx in infertile women prior to IVF treatment. RESULTS: There were 88 (75%) responders, of which 80 (91%) indicated that they discussed the effect of hydrosalpinx on IVF outcome. Ten (12%) units did not recommend treatment of hydrosalpinx prior to IVF treatment, while 30 (36%), 27 (33%) and 16 (19%) recommended treatment weakly, strongly and very strongly respectively. The treatment options offered by clinicians were laparoscopic salpingectomy (75%), open salpingectomy (45%), salpingostomy (40%), proximal tubal occlusion (34%), transvaginal songraphic (TVS) aspiration during oocyte collection (23%) and TVS aspiration before oocyte collection (10%). The frequency of use varied from one option of treatment to another. Only 28% of the responders had a protocol or guidelines for the management of hydrosalpinx. CONCLUSIONS: More attention should be given to patients with hydrosalpinx prior to IVF treatment and patients should be counselled about the negative effect of hydrosalpinx on IVF outcome. There is a wide variation in the management of hydrosalpinx prior to IVF treatment in the UK and many treatment options may be questionable, as they are not yet based on evidence.

Spontaneous disappearance of a normal adnexa associated with a contralateral polycystic-appearing ovary.

BACKGROUND: Absence of the adnexa may be congenital or acquired. However, the etiology is often uncertain. CASE: A 27-year-old woman presented with a 3-year history of subfertility. Her irregular menstruation was associated with acne vulgaris, alopecia, and elevated body mass index. Transvaginal ultrasonography of the pelvis showed a normal uterus, a normal right ovary, but a polycystic-appearing left ovary. A hysterosalpingogram demonstrated a normal uterine cavity, prompt filling and spilling of contrast material from the left fallopian tube, but no filling on the right. Subsequent laparoscopy showed an unexpected absence of right adnexa and presence of a solitary rounded free-floating mass enshrouded in the omentum. She did not have a history of abdominal pain or surgery. CONCLUSION: The evidence suggests that the patient might have had an asymptomatic infarction of the right adnexa.