Reproductive outcomes of patients with T-Shaped and septate uterus following metroplasty: an observational study.

INTRODUCTION: Uterine malformations are common and may contribute to infertility and adverse pregnancy outcomes. After an accurate diagnosis, correcting the abnormal uterine morphology is the main goal to optimize reproductive outcomes. The principal objective of this study was to assess the impact of metroplasty for T-shaped (U1a) and septate uteri (U2) on live birth rates in infertile patients. METHODS: This was a prospective observational study of infertile women with either U1a or U2 uterine anomaly. Patients with unexplained infertility and repeated (IVF/ICSI) failure were included. Hysteroscopic metroplasty was performed by a single experienced surgeon. Fertility outcomes of all cases were evaluated prospectively evaluated. The main outcome parameter was a live birth rate either achieved spontaneously or with assisted conception. RESULTS: A total of 48 patients were included in U1a group and bilateral longitudinal uterine-lateral wall incision was carried out. A total of 63 patients were included in the U2 group and septum incision was carried out, 60 out of these 63 patients with U2 uterine anomaly required further lateral wall incision during septoplasty. During the first 12 months following surgery, nearly half of the patients in both groups achieved spontaneous pregnancy; 45% in the U1a group and 39% in the U2 group delivered at term. CONCLUSIONS: Hysteroscopic metroplasty offers promising reproductive outcomes in the presence of U1a and U2 uterine anomalies for those with unexplained infertility and repeated IVF/ICSI failures. In addition, uterine septum cases should be carefully evaluated intra-operatively to detect and repair concurrent lateral uterine wall anomalies.

Testicular versus ejaculated spermatozoa in ICSI cycles of normozoospermic men with high sperm DNA fragmentation and previous ART failures.

As a part of male assessment, conventional sperm parameters including morphologic features have been dedicated as major factors influencing fertilisation and pregnancy rates in assisted reproductive technology (ART). Genomic integrity of spermatozoa has also been found to influence fertility prognosis, and hence, sperm DNA fragmentation index (DFI) has been adopted by many centres to document this entity. Despite several suggested approaches, there is lack of universal consensus on optimising fertility outcomes in males with high sperm DFI. In this context, the results from cycles using testicular spermatozoa (TESA) obtained by aspiration were compared with those of ejaculated spermatozoa (EJ) in normozoospermic subjects with high sperm DFI and previous ART failures. Clinical (41.9% versus 20%) and ongoing pregnancy rates (38.7% versus 15%) were significantly better and miscarriages were lower in TESA group when compared to EJ group. Sperm DFI should be a part of male partner's evaluation following unsuccessful ART attempts. When high DFI is detected (>30%), ICSI using testicular spermatozoa obtained by TESA seems an effective option particularly for those with repeated ART failures in terms of clinical, ongoing pregnancies and miscarriages even though conventional sperm parameters are within normal range.

Combined progesterone (IM + V) versus vaginal progesterone for luteal support in cleavage-stage embryo transfer cycles of good prognosis patients.

Many reports led to the consensus on the use of progesterone (P) for luteal-phase support. Vaginal P application is the method of choice due to its simplicity and high patient convenience but is hampered by application difficulties and personal or cultural aversions. Inappropriate vaginal P use may alter successful implantation, leading physicians to consider alternate P application routes. A worldwide survey revealed that intramuscular plus vaginal P (combined P) is the method used in nearly one-third of in vitro fertilization (IVF) cycles, particularly in Asia and North America; unfortunately, the outcomes of this approach have not been clearly elucidated. In the current analysis, we evaluated any additional benefit of short course parenteral P in addition to vaginal P capsules during a specific period in terms of implantation, pregnancy rates, miscarriages and ectopic pregnancies in cleavage stage embryo transfer (ET) cycles of good-prognosis patients. Despite significantly higher implantation rates in the combined arm, clinical and ongoing pregnancies were comparable in both groups, whereas a trend toward increased pregnancy rates was observed with combined support. The available data are too limited to draw conclusions.

Uncommon but devastating event: total fertilisation failure following intracytoplasmic sperm injection.

Fertilisation with intracytoplasmic sperm injection (ICSI) is a consequence of complex molecular interactions between spermatozoon and oocyte. Disruption of the process obviously prompts a frustrating event called total fertilisation failure (TFF). Up to 3% of ICSI cycles may result in TFF, and brief counselling for subsequent cycle management is indispensable. Within this perspective, ICSI cycles of a centre over a 10-year period were analysed to document TFF cases. Initial TFF after ICSI and subsequent ICSI cycle of the same cases were documented to clarify predictive factors of successful outcomes after initial TFF. In subsequent cycles, assisted oocyte activation (AOA) with calcium ionophore and Hypo-osmotic swelling test (HOST)/pentoxifilline for sperm selection was used. In the current analysis, successful fertilisation was achieved in 85% of the cases with previous TFF. The significant contributing factors for successful fertilisation in the latter cycle were: improved oocyte quantity and better sperm morphology. In conclusion, sporadic TFF event in the first and only cycle is usually a technically modifiable condition, but repeated TFF could indicate possible gamete defects, which might not be overcomed in the next modified ICSI cycle.

Should repeated TESE be performed following a failed TESE in men with Klinefelter Syndrome?

The main goal of this study was to evaluate the success rate of repeated Testicular Sperm Extraction (TESE) in Klinefelter Syndrome (KS). Eighteen patients with the diagnosis of KS who had undergone micro TESE previously were re-evaluated between May 2007 and May 2012. Testes were measured and testicular volume was calculated by orchidometer and by scrotal ultrasonography in all patients All patients underwent repeated micro TESE. Serum follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone levels and testicular volume of the patients with and without successful sperm retrieval were compared statistically. A p value of less than 0.05 was considered statistically significant. The mean age of the patients was 30.3 years. The mean testicular volume was 2.08 and 2.1 mL for right and left testes respectively. The comparisons of serum FSH, LH, testosterone levels and testicular volume between patients with and without successful sperm retrieval did not show any significant difference. Three of the 18 patients who underwent repeated micro TESE, had successful sperm retrieval and repeated TESE failed in 15 patients. Three patients with successful sperm retrieval underwent intracytoplasmic sperm injection using retrieved testicular spermatozoa. Two embryos for each patient which were determined as healthy were transferred to the wives of the patients. Pregnancy occured in one of them and a healthy female infant was born. We conclude that consideration and hope must be given for a repeated micro TESE in patients with KS, even with a minimal chance of success.

Serum anti-Mullerian hormone levels correlate with ovarian response in idiopathic hypogonadotropic hypogonadism.

PURPOSE: The role of serum AMH levels in prediction of ovarian response in idiopathic hypogonadotropic hypogonadism (IHH) was evaluated. MATERIAL METHOD(S): Twelve patients with IHH underwent controlled ovarian hyperstimulation (COH) for IVF were enrolled in this prospective study. Serum AMH levels were studied on the 2nd or 3rd day of an induced menstrual cycle by a preceding low-dose oral contraceptive pill treatment. A fixed dose (150-300 IU/day) of hMG was given in all COH cycles. Correlations between serum AMH levels, COH outcomes and embryological data were investigated. RESULTS: Mean serum AMH levels was 3.47 ± 2.15 ng/mL and mean serum peak estradiol was 2196 ± 1705 pg/mL. Mean number of follicles >14 mm, >17 mm on hCG day and MII oocytes were 4.14 ± 3.2, 4 ± 2.5 and 7.28 ± 3.5, respectively. Mean number of grade A embryos and transferred embryos were 3.28 ± 2.4 and 2.5 ± 0.7, respectively. The clinical pregnancy rate per patient was 41.6 % (5/12). Positive correlations were observed between serum AMH levels and MII oocytes (r = 0.84), grade A embryos (r = 0.85), serum peak estradiol levels (r = 0.87), and number of follicles >14 mm (r = 0.83) and >17 mm (r = 0.81) on hCG day, respectively. CONCLUSION: AMH appears as a promising marker of ovarian response in patients with IHH undergoing IVF.

Comparison of the effects of atorvastatin and simvastatin in women with polycystic ovary syndrome: A prospective, randomized study.

UNLABELLED: Polycystic ovary syndrome (PCOS) is associated with hyperandrogenism, insulin resistance (IR), and chronic inflammation. Simvastatin improves endocrine/clinical aspects of PCOS and decreases systemic inflammation in PCOS. There have been no comparative studies carried out regarding the effects of different statin treatment in PCOS. We aimed to assess the effects of two different statin treatments on various metabolic, endocrine, oxidative and inflammatory factors in PCOS. DESIGN: Prospective, randomized clinical trial METHODS: Sixty-four (64) women with PCOS were included in the study. Group 1 had (atorvastatin, 20lmg daily; n=32) or group 2 had (simvastatin, 20l mg daily n=32). The metabolic, endocrine, inflammatory and oxidative profiles were evaluated. RESULTS: Group 1 resulted in a significant reduction in the HOMA index and fasting insulin (-26.9+/-9.6%, -26.2+/-10.8%, P<0.01, respectively).CRP levels decreased by 63.6+/-15.9% in group 1 (P<0.01), whereas in the group 2 it decreased by 34.6+/-10.7% (P<0.05). Serum levels of LH declined by 19.1+/-4.5% (P<0.05) in the group 1 and by 39.3+/-11.9% (P<0.01) in the group 2. FAI decreased by -20+/-9.9% in group 1 (P<0.05) and it decreased by -38.7+/-13.8% in the group 2 (P<0.01). MDA levels decreased by 32.6+/-9.6% in group 1 (P<0.05), whereas in the group 2 it decreased by 30.3+/-10.9% (P<0.01). HOMA index and fasting insulin showed a reduction but not reached statistically significance in the group 2 (8.3+/-1.9%, 3.0+/-0.8%, P>0.05, respectively). CONCLUSION: Both the statins are effective in reducing inflammation, hyperandrogenemia, oxidative stress and metabolic parameters. While atorvastatin has more noticeable effects on fasting insulin and insulin sensitivity, simvastatin has a dominant effect on total T in PCOS women.

Is adjuvant therapy necessary for peritoneal cytology-positive surgical-pathologic Stage I endometrial cancer? Preliminary results.

OBJECTIVE: To compare the clinical and laboratory findings between adjuvant therapy performed and not performed on peritoneal cytology-positive patients with cytology-negative cases of surgical-pathologic Stage I endometrial cancer. METHODS: Twelve peritoneal cytology-positive and 12 negative surgical-pathologic Stage I endometrial cancer cases were used in the study. Adjuvant radiotherapy was performed for six cytology-positive patients (group I); no adjuvant therapy was performed for six cytology-positive (group II) and 12 cytology-negative patients (control group). Pelvic examination, vaginal cytology, serum CA125 levels and routine blood tests were checked at two-month intervals for two years and at six-month intervals for the third year. Abdominopelvic computerized tomography was planned annually. RESULTS: There was no statistically significant difference among the three groups and no recurrence in any group. CONCLUSION: We do not recommend adjuvant therapy for cytology-positive patients if the tumor is confined to the uterus.

Hormone replacement therapy in postmenopausal women with benign fibrocystic mastopathy.

OBJECTIVE: To compare the effects of five different hormone replacement regimens on fibrocystic mastopathy in postmenopausal women. DESIGN: This was a randomized, prospective, clinical, case-control study. METHODS: Two hundred and twelve women with benign cystic mastopathy were studied. The largest diameters of the breast cysts were measured using ultrasonography at study entry. Forty-eight women were randomized to the control group and did not take any medication. One hundred and sixty-four women were randomized to the following study groups. Group I (n = 46) were given conjugated estrogen (0.625 mg/day) and medroxyprogesterone acetate (5 mg/day) continuously. Group II (n = 22) were given only conjugated estrogens (0.625 mg/day) continuously; these were hysterectomized women. Group III (n = 32) were given transdermal estrogen (50 microg/day) and medroxyprogesterone acetate (5 mg/day) continuously. Group IV (n = 32) were given only transdermal estrogen (50 microg/day) continuously; these were also hysterectomized women. Group V (n = 32) were given tibolone (2.5 mg/day) continuously. Hormone therapy was continued for 12 months. Every 3 months the women were rescanned using ultrasonography to determine cyst diameters and examine characteristics such as internal echogenicity, and thickness and regularity of the cyst wall. Statistical assessment used Students' t test and Friedman analysis. RESULTS: In the control group, there was no statistically significant change in cyst dimensions. However, tibolone was associated with a decrease in cyst dimensions which was statistically significant, but none of the other four hormone replacement therapy regimens caused any significant negative effect on the benign cystic mastopathy.

Predictive value of amniotic fluid volume measurements on perinatal outcome.

Amniotic fluid volumes were measured in 1,659 pregnant women to determine the predictive value of these measurements on perinatal outcome. All cases were evaluated by other tests of fetal well-being. 128 cases were oligohydramniotic, and 1,531 cases were normal. In all cases, several parameters were assayed, e.g. fetal distress, way of delivery, meconium in amniotic fluid, Apgar score, transfer to pediatric clinics and early-late neonatal complications. The results of the perinatal evaluation of oligohydramnios were as follows: assessing fetal distress: specificity 94.2%, sensitivity 18.4%, positive predictive value 35.9%, negative predictive value 86.7% and accuracy 82.8%, and assessing low Apgar score the values were 93.0, 21.3, 95.9 and 89.5%, respectively. As a result, measurement of the amniotic fluid volume is an important parameter predicting perinatal outcome, and its predictive value increases if it is combined with other fetal well-being tests with different end points.

Three sisters with septate uteri: another reference to bidirectional theory.

A case report of three sisters with different degrees of septate uteri, a rare familial aggregation, is presented. The youngest sister was diagnosed with a complete uterine septum with cervical duplication and complete longitudinal vaginal septum. She also had a bilateral partial ureteral duplication. Investigation of the family showed that the eldest sister had a complete uterine septum and her pregnancy had terminated with a vaginal delivery following premature rupture of the membranes. The asymptomatic middle sister showed an incomplete uterine septum. Finally, the mother was normal with respect to urogenital anatomy. These types of Müllerian anomalies cannot be explained by the classical theory of unidirectional Müllerian duct development; the alternative bidirectional theory is proposed instead. Additionally, the results are suggestive that the prevalence of major uterine malformations may be higher than generally thought, due to asymptomatic cases.

Hysteroscopic treatment of intrauterine adhesions is safe and effective in the restoration of normal menstruation and fertility.

OBJECTIVE: To assess the safety and efficacy of hysteroscopic adhesiolysis in patients with recurrent pregnancy loss and infertility. DESIGN: Retrospective case report series. SETTING: The obstetrics and gynecology clinic of a medical school. PATIENT(S): Forty women with recurrent pregnancy loss or infertility resulting from intrauterine adhesions. INTERVENTION(S): Hysteroscopic adhesiolysis in patients with recurrent pregnancy loss and infertility. MAIN OUTCOME MEASURE(S): Postoperative adhesion formation, intraoperative complication, conceivement after surgery, pregnancy rate, and pregnancies resulted in term or viable preterm infants. RESULT(S): Most patients with minimal or moderate adhesions were free of adhesions when compared with postoperative control subjects. However, adhesion re-formation was noted in 60% of the patients who initially had severe adhesions. Normal menstrual flow was restored in 81% of the patients. All the patients who had recurrent pregnancy loss conceived after treatment, and 71% of the pregnancies resulted in a term or viable preterm infant. Of the 16 infertile patients treated, 10 (63%) conceived and 6 (37%) were delivered of viable infants. CONCLUSION(S): Hysteroscopic adhesiolysis is a safe and effective procedure for restoring the normal menstrual pattern and fertility. The initial severity of the adhesions appears to correlate best with the reproductive outcome.

Anastomosis of the freshly divided uterine horns of rats with the CO2 laser vs. microsurgery.

We used the CO2 laser (group 1) and conventional microsurgery (group 2) for anastomosis of the freshly divided uterine horns of rats and compared the two methods. Each group was then compared with a control group in whom only exploration was carried out at laparotomy. Comparison was done regarding the clinical and histologic results. In addition, serum levels and tissue concentrations of alkaline phosphatase (ALP) and lactic dehydrogenase (LDH) were measured, and the three groups were compared. No significant difference was found between the mean adhesion scores of groups 1 and 2; however, when the control group was compared with the other groups, the differences were statistically significant. The tubal patency rates in groups 1 and 2 and the control group were 83.3%, 79.2% and 100%, respectively, and the pregnancy rates in those groups were 54.5% (6/11), 45.5% (5/11) and 100% (10/10). The differences in tubal patency and pregnancy rates between groups 1 and 2 were not significant, but when each was compared with the control group, the differences were significant. The mean scores for mucosal regeneration and disruption of the muscularis layer in group 1 were significantly lower than those in group 2. Serum levels and tissue concentrations of ALP and LDH in the control group were lower than in groups 1 and 2, and the differences between the control group and each of the other groups were significant; however, no significant difference was found between groups 1 and 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Microsurgical transposition of the human fallopian tube.

Reports of tubal microsurgical transposition techniques to restore fertility are quite rare. In this article, an interesting microsurgical procedure, in a woman with congenital uterine and tubal abnormality is presented. Under certain circumstances, microsurgical transposition of the human fallopian tube has the potential of being a useful therapeutic alternative.

Unexpected nature of a pelvic mass in pregnancy: Castleman's disease.

The obstetrician is rarely confronted with a pregnant patient who presents with a large suspicious pelvic mass. Diagnostic tools are not always of value and laparotomy may be performed for obstetric and histopathologic reasons. In this article we present an interesting case of an unusual pelvic mass in pregnancy secondary to benign lymphoepithelial disease (Castleman's disease). We could not find a case similar to the one reported in the medical literature.

Successful transplantation of a free fimbrial graft to the peritoneum.

Loss of fertility due to prior segmental resection of the fallopian tube (for ectopic pregnancy or sterilization) can be treated with a free fimbrial graft, especially when the fimbrial segment is contralateral to the proximal tube that is needed for the anastomosis. To evaluate the structure and function of the fimbria after free grafting, the fimbria was cut from the tube and sewn without a blood supply to the peritoneum in 14 rabbits. After convalescence, scanning electron microscopy showed fewer secondary mucosal folds in the grafted fimbria than in the normal fimbria. The ciliated and secretory cells in the graft were identical to those of normal cells. The transport rate of surrogate ova across the grafted fimbrial mucosa was consistent with that across the normal fimbrial mucosa, demonstrating that near-normal structure and function are preserved after a free graft of the fimbria.

Spironolactone in the treatment of hirsutism.

Spironolactone was used in 90 hirsute women because of its antiandrogenic effect. The drug was administered twice daily from the 4th to the 22nd day of six cycles (total dosage was 200 mg per day). The results suggest that spironolactone is suitable for the treatment of hirsutism.

Female tubal sterilization.

Tubal ligation has become the second most popular method of contraception in Canada, after oral contraception. Refinement of techniques has resulted in sterilization procedures which have minimal potential for failure and high potential for reversibility. Laparoscopic and minilaparatomy techniques allow outpatient "Band-Aid" sterilizations with less risk of complications than more destructive procedures. Laparoscopic application of tubal clips or rings is highly effective, with minimal tubal destruction. Tubal ligation following a pregnancy is more often regretted than is interval sterilization. The search continues for a satisfactory transcervical sterilization procedure.