Intraumbilical oxytocin for the management of retained placenta: a randomized controlled trial.

OBJECTIVE: To evaluate the ability of intraumbilical oxytocin injection as a treatment for retained placenta after vaginal delivery to reduce the incidence of manual removal and postpartum hemorrhage. METHODS: A randomized controlled trial was set up in a university and a district general hospital. We recruited 81 women with singleton pregnancies who underwent vaginal delivery and who failed to deliver the placenta after 20 minutes of active management of the third stage of labor. Study subjects were randomized to receive either 1) an intraumbilical injection of oxytocin (20 IU in 20 mL of saline); 2) an intraumbilical injection of saline (20 mL); or 3) no treatment. Outcome measures were expulsion of the placenta within 45 minutes of delivery, need for manual removal of the placenta under anesthesia, and postpartum hemorrhage (defined as a blood loss greater than 500 mL). RESULTS: Women given an intraumbilical injection of oxytocin had a significant increase in spontaneous expulsion of the placenta within 45 minutes of delivery and fewer manual removals of the placenta, compared with women without treatment (odds ratio [OR] 11.6, 99% confidence interval [CI] 1.4, 272.8; and OR 7.4, 99% CI 1.1, 86.5; respectively). When women given intraumbilical oxytocin were compared with women given only intraumbilical saline, the difference was not statistically significant (OR 6.6, 99% CI 0.9, 77.2 for spontaneous expulsion of the placenta; and OR 4.7, 99% CI 0.8, 39.5 for manual removal). There was no significant difference in the incidence of spontaneous expulsion and manual removal of the placenta between women given intraumbilical saline injection and women without treatment (OR 1.8, 99% CI 0.1, 53.9; and OR 1.6, 99% CI 0.1, 22.4; respectively). CONCLUSION: The results of our study suggest a clinically important beneficial effect of intraumbilical oxytocin injection in the management of retained placenta.

Long-term use of gonadotropin-releasing hormone analogs and hormone replacement therapy in the management of endometriosis: a randomized trial with a 6-year follow-up.

OBJECTIVE: To identify the effects of long-term GnRH agonist use (6-24 months), with and without add-back therapy, and spontaneous reversibility of bone mass density (BMD) up to 6 years after treatment. DESIGN: A prospective, randomized, long-term follow-up study. SETTING: Obstetrics and gynecology department in a university hospital in the United Kingdom. PATIENT(S): Forty-nine symptomatic women with a laparoscopic diagnosis of endometriosis who had been identified for treatment with long-acting GnRH agonist and volunteered to participate in the study. INTERVENTION(S): Women were randomly allocated to receive hormone replacement therapy (HRT) as a daily oral dose of estradiol, 2 mg, and norethisterone acetate, 1 mg, or no treatment in addition to monthly subcutaneous implants of goserelin acetate for up to 2 years, until cessation of symptoms. Bone mineral density (BMD) at the lumbar spine (C2-C4) and hip (Ward triangle) was measured every 6 months. MAIN OUTCOME MEASURE(S): BMD changes in both groups. RESULT(S): 45 women were followed up for 6 years, at the end of which the groups did not differ significantly in the reduction in mean BMD at the lumbar spine or hip. CONCLUSION(S): BMD reduction occurs during long-term GnRH agonist use and is not fully recovered by up to 6 years after treatment. Use of HRT does not affect this process.

Peritoneal fluid concentrations of interleukin-11 in women with endometriosis.

OBJECTIVE: To determine the peritoneal fluid concentrations of interleukin-11 (IL-11) in women with endometriosis as compared with the control group. DESIGN: A prospective, controlled study. SETTING: The obstetrics and gynecology department of a teaching hospital and a university immunology department. PATIENT(S): Sixty consecutive women undergoing laparoscopic surgery for benign gynecological indications. INTERVENTION(S): Peritoneal fluid was obtained during laparoscopy, and the concentration of IL-11 was measured. MAIN OUTCOME MEASURE(S): Concentration of IL-11 in correlation with the presence of endometriosis, its stage, and the phase of the menstrual cycle. RESULT(S): IL-11 was detectable in the peritoneal fluid of 64% of women tested. Concentrations of IL-11 showed no correlation with the presence of endometriosis, the American Fertility Society stage of the disease, or the phase of the menstrual cycle. CONCLUSION(S): We found no evidence to suggest that IL-11 is involved in the pathogenesis of pelvic endometriosis.

Follicular fluid concentrations of interleukin-12 and interleukin-8 in IVF cycles.

OBJECTIVE: To investigate the role of interleukin-12 (IL-12) and IL-8 in the periovulatory follicular fluid during in vitro fertilization cycles. DESIGN: A prospective study. SETTING: Reproductive Medicine Unit, Liverpool Women's Hospital, United Kingdom. PATIENT(S): Women undergoing in vitro fertilization treatment. INTERVENTION(S): IL-8 and IL-12 concentrations in follicular fluid samples that had been collected during transvaginal oocyte retrieval were measured using an enzyme-linked immunosorbent assay (ELISA). Cytokine concentrations were correlated to fertilization rates and treatment outcome. MAIN OUTCOME MEASURE(S): Fertilization rates and ultrasonographic evidence of intrauterine pregnancy by 4 weeks after embryo transfer. RESULT(S): Failed fertilization in women with detectable IL-12 was significantly higher (45.5%) than in the IL-12 negative group (6.1%), P=.01. None of the women with detectable IL-12 achieved a pregnancy at the end of the treatment (P=.01). IL-8 was present in the follicular fluid of all women, and no difference in its concentrations was found between the pregnant and nonpregnant groups. No correlation was found between the follicular fluid concentrations of IL-8 and fertilization rates. CONCLUSION(S): The presence of IL-12 in the follicular fluid appears to be associated with a negative outcome in IVF treatment. Interleukin-8 appears to be an essential part of folliculogenesis, although its concentration is not associated with fertilization or implantation rates.

High omega-3:omega-6 fatty acid ratios in culture medium reduce endometrial-cell survival in combined endometrial gland and stromal cell cultures from women with and without endometriosis.

OBJECTIVE: To study the effects of omega-3 and omega-6 polyunsaturated fatty acid (PUFA) on in vitro proliferation of endometrial cells and their production of the cytokine interleukin-8 (IL-8). DESIGN: In vitro study. SETTING: Obstetrics and gynecology department, University of Aberdeen. PATIENT(S): Women attending an infertility clinic. INTERVENTION(S): In vitro cell cultures using culture mediums supplemented with normal and high ratios of omega-3 PUFA and omega-6 PUFA. MAIN OUTCOME MEASURE(S): In vitro survival and production of IL-8 by dispersed endometrial cells. RESULT(S): In vitro survival of endometrial cells from women with and without endometriosis was significantly reduced in the presence of high omega-3:omega-6 PUFA ratios compared with cells incubated in the absence of fatty acids, in balanced omega-3:omega-6 PUFA ratios, and in high omega-6:omega-3 PUFA ratios. Endometrial cells from women with endometriosis secreted higher concentrations of IL-8, especially in the presence of high omega-3:omega-6 PUFA ratios. CONCLUSION(S): omega-3 PUFA may have a suppressive effect on the in vitro survival of endometrial cells and omega-3 PUFA be useful in the management of endometriosis by reducing the inflammatory response and modulating cytokine function.

Role of mitotic control in spermatogenesis.

OBJECTIVE: To study the correlation between the incidence of sex chromosome aneuploidies in the somatic cells and spermatozoa in karyotypically normal infertile men and fertile donors. DESIGN: A prospective, phase two, controlled study. SETTING: A teaching Hospital Reproductive Medicine and Medical Genetics Units. PATIENT(S): Ten patients with idiopathic oligozoospermia and 10 sperm donors with proven fertility, all with a normal karyotype 46, XY. INTERVENTION(S): Multicolor fluorescence in situ hybridization (FISH) of peripheral blood lymphocytes and spermatozoa using a probe cocktail containing the alpha satellite DXZ1 for the X centromere, DYZ1 for the heterochromatic region of the long arm of the Y, and cosmids D21S259, D21S341, and D21S342 for Down syndrome critical region of chromosome 21. MAIN OUTCOME MEASURE(S): The incidence of chromosome X, Y, and 21 aneuploidies in peripheral lymphocytes and spermatozoa in both groups. RESULT(S): The incidence of aneuploidies related to chromosomes X, Y, and 21 were significantly higher in peripheral lymphocytes and spermatozoa of infertile men compared with donors. There was a positive correlation between the incidence of chromosome aneuploidies in the somatic cells and sperm in all men. CONCLUSION(S): These findings provide suggestive evidence for the importance of mitosis in spermatogenesis and the role of mitotic instability in unexplained oligozoospermia.

Evaluation of the role of mitotic instability in karyotypically normal men with oligozoospermia.

OBJECTIVE: To estimate the incidence of sex chromosome aneuploidies in the somatic cells of karyotypically normal infertile men and fertile donors. DESIGN: A prospective, two-phase, controlled study. SETTING: Reproductive medicine and medical genetics units of a teaching hospital. PATIENT(S): Ten patients with oligozoospermia and 10 sperm donors with proved fertility, all with a normal karyotype 46 XY. INTERVENTION(S): Multicolor fluorescence in situ hybridization (FISH) of peripheral blood lymphocytes using a probe cocktail containing the alpha satellites DXZ1 for the X centromere and DYZ1 for the heterochromatic region of the long arm of the Y and the radiolabeled alpha satellite D18Z1 for chromosome 18. MAIN OUTCOME MEASURE(S): The incidence of sex chromosome aneuploidies in both groups. RESULT(S): A 13-fold increase in sex chromosome aneuploidies was observed in the somatic cells of infertile men with "unexplained" oligozoospermia compared to donors (P=.008). CONCLUSION(S): These findings provide suggestive evidence for the existence of an inherent mitotic instability in men with unexplained oligozoospermia.

Seminal plasma lactoferrin concentrations in normal and abnormal semen samples.

Although the iron-chelating protein lactoferrin is secreted by the seminal vesicles, the precise role of lactoferrin in semen is unclear. This study aimed to determine whether there is any association between seminal lactoferrin concentrations and normal and abnormal semen samples with and without leucocytospermia. Lactoferrin concentrations were measured by radial immunodiffusion of semen samples from 368 men attending a regional andrology referral center. Routine seminal analysis, including the presence of leucocytospermia, was also performed. Results showed increased seminal lactoferrin in samples showing oligospermia (13.3 mg/100 ml) and oligoasthenospermia (13.4 mg/100 ml) compared to normospermic samples (11.2 mg/100 ml). There were no significant differences in seminal lactoferrin between normospermic samples and azoospermic samples or asthenospermic samples with normal sperm density. Although there was a trend toward increased lactoferrin concentration with leucocytospermia, this was not significant. Possible causes for raised lactoferrin in association with oligospermia are discussed.

Intraperitoneal Enterobius vermicularis infection: a case report.

BACKGROUND: Enterobius vermicularis in an ectopic location usually represents an incidental finding in tissue specimens in a patient without symptoms. However, the parasite can lead to inflammation and symptoms in rare cases. CASE: A 36-year-old woman had an abdominal hysterectomy for menorrhagia, dyspareunia, and lower abdominal pain. Two small nodules from the posterior aspect of the left broad ligament as well as the uterus were sent for histologic examination. The pathologic findings confirmed the diagnosis of "granulomatous peritoneal nodules due to E. vermicularis." Within the nodules were aggregates of ova of E. vermicularis. CONCLUSION: This case reminds us that such granulomatous lesions can simulate leiomyoma, fibroma, endometrioma, and tuberculous or malignant lesions. It is important to be aware of this resemblance to avoid unnecessary surgical intervention.

Cystic fibrosis in infertility: screening before assisted reproduction: opinion.

Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasians. In 97-98% of men with CF, bilateral congenital absence of the vas deferens (CBAVD) blocks the transport of spermatozoa resulting in azoospermia. Abnormalities in sperm parameters have also been identified in males with CF. To date, over 800 disease-causing mutations of the CF transmembrane conductance regulator (CFTR) gene have been identified (also called ABCC7). Current legislation suggests that prior to intracytoplasmic sperm injection (ICSI) treatment, men with CBAVD or unexplained oligozoospermia should be considered for screening. If the male is negative with routine screening then the female partner is not screened. This is fundamentally wrong because if the female is screened and is found to be CF positive on routine testing, her partner would then need the fullest possible investigation of the CFTR gene. It is ideal to screen both partners in cases of oligozoospermia. However, if the resources are stretched, then only the female needs to be routinely screened because if she is negative, then the couple's residual risk of having a CF or CBAVD child will be reduced to 1:960. Only when the female is found to be a carrier does the male partner need routine screening followed by full testing for known mutations.

Mifepristone in combination with methotrexate for the medical treatment of tubal pregnancy: a randomized, controlled trial.

In the search for a more potent alternative to a single i.m. injection of methotrexate for ectopic pregnancy, a randomized trial was organized. The efficacy of a combination of methotrexate and mifepristone was compared with methotrexate alone in the treatment of unruptured tubal pregnancies. The diagnosis of an unruptured tubal pregnancy was confirmed laparoscopically in 50 patients during a 2 year period. Women were randomized to receive a single i.m. injection of 50 mg/m2 methotrexate alone or a single dose of 600 mg oral mifepristone in combination with the same dose of methotrexate. Both treatment protocols were successful in achieving the resolution of unruptured ectopic pregnancy (18/25 in the methotrexate group and 22/25 in the combination group) following the initial intervention. A second injection was needed in four (16%) cases in the methotrexate group and in one (4%) case in the combination group. Overall, a complete resolution was achieved in 22/25 and 23/25 cases respectively. Unruptured ectopic pregnancy resolved faster in women given the combination of methotrexate and mifepristone compared to women given methotrexate only (P = 0.01). The effect of the methotrexate and mifepristone combination was more pronounced in women with higher human chorionic gonadotrophin concentrations.

Assessment of testicular core temperatures using microwave thermography.

A new method for the reliable assessment of testicular core temperature using microwave technology is presented. This study was designed to assess whether alterations in testicular thermoregulation could be reliably demonstrated in patients with clinically apparent varicoceles (n = 36), in those with idiopathic male infertility (n = 52) and in fertile donors (n = 20) using this new microwave thermographic technique. The measurements obtained were found to be reliable and reproducible. Testicular core temperature measurements were significantly different between the groups (P < 0.001). Furthermore, there was a temperature gradient between the scrotal neck and the testicular core in all groups; testicular core temperatures were lower than scrotal neck temperatures. The magnitude of this temperature difference was also significantly different (P < 0.001) between the groups. Microwave testicular thermography is a new technique that is safe and accurate. Preliminary results suggest altered testicular thermoregulation in a group of patients with impaired spermatogenesis with and without varicocele. Testicular temperature profiles obtained by microwave thermography may be of value in the assessment of infertile men with or without a varicocele.

Conservative management of azoospermia following steroid abuse.

As well as athletes and competitive body builders, recreational body builders attending gymnasia are known to abuse anabolic steroids, using doses from 10- to 40-fold above physiological levels. Androgenic steroids induce hypogonadotrophic hypogonadism with associated azoospermia, leading to infertility. Little literature exists on the treatment of steroid-induced azoospermia following the cessation of abuse. We present four cases of steroid-induced azoospermia, its conservative management and eventual return of normal semen density.

Oncogenes and tumour suppressor genes in first trimester human fetal gonadal development.

Tumour suppressor genes and oncogenes that control proliferation and apoptosis are known to play an important role in embryogenesis, second trimester fetal oocyte loss, adult ovulation, and in adult male testicular degeneration. We have examined tumour suppressor genes, oncogenes and oestrogen receptors during first trimester human gonadal differentiation to investigate their role at this crucial phase in development. Immunohistochemistry was used to localize the gene products of Bcl-2, c-erB-2, c-myc, p53, nm23 and oestrogen receptor. As gonadal development occurred at 6-12 weeks gestation, a changing pattern of expression was observed that varied in different cell types. The oestrogen receptor was not present in oogonia, spermatogonia and supporting cells during the first trimester. This study highlights the importance of oncogenes and tumour suppressor genes in first trimester gonadal development.

Peritoneal fluid concentrations of interleukin-8 in women with endometriosis: relationship to stage of disease.

There is increasing evidence that immunological mechanisms play a role in the pathogenesis and pathophysiology of endometriosis. It was therefore of interest to study interleukin-8 (IL-8), a chemokine, in the peritoneal fluid and peripheral blood of women undergoing laparoscopic procedures. The presence and concentrations of IL-8 in relation to endometriosis, infertility and abdominal pain were evaluated. Samples of peritoneal fluid (n = 49) and peripheral blood (n = 50) were obtained from 50 consecutive patients undergoing laparoscopic surgery for various gynaecological indications (abdominal pain, infertility, sterilization). IL-8 was present in the peritoneal fluid of most women (87%). The concentration of IL-8 in the peritoneal fluid was higher in women with endometriosis compared to women without (P = 0.02). This difference was more pronounced in early (stage 1) endometriosis (P = 0.001). IL-8 concentrations in the peritoneal fluid were also higher in women with early endometriosis compared to women with later stages of the disease (P = 0.003). Peripheral blood concentrations did not correlate with peritoneal fluid concentrations of IL-8 and/or the presence of endometriosis. We conclude that IL-8 is an important factor that may contribute to the pathogenesis of endometriosis possibly by promoting neovascularization. This information can be a guide in the development of new therapeutic approaches for the treatment of endometriosis.

Peritoneal fluid concentrations of interleukin-4 in relation to the presence of endometriosis, its stage and the phase of the menstrual cycle.

BACKGROUND: Interleukin-4 (IL-4) is a cytokine with both stimulatory and inhibitory effects on the inflammatory system such as macrophage inhibition and T-cell activation. It is known to regulate several monocyte functions, including inhibition of the synthesis of cytokines such as IL-1, IL-6 and TNF-alpha as well as potentiating IL-8. METHOD: In an attempt to clarify the association between IL-4 and endometriosis, we measured the concentration of IL-4 in the peritoneal fluid of 52 women; 24 with endometriosis and 28 with no endometriosis, controlling for the phase of the cycle and the stage of disease. RESULTS: There was no difference in the concentrations of IL-4 between women with (n=28) and without endometriosis (n=24). No difference was found between the IL-4 concentrations in women with different stages of endometriosis. Levels of IL-4 did not show a difference according to the phase of the cycle in either group. CONCLUSION: Our results indicate no association between peritoneal fluid levels of IL-4 and endometriosis and hence suggest that IL-4 is not involved in the pathogenesis of endometriosis.

Comparison of ovarian response in right and left ovaries in IVF patients.

BACKGROUND: Anatomical and cyclical physiological differences exist between right and left ovaries which may affect their function and response to ovulation induction. Although authors have compared right and left ovarian response during IVF for patients with a unilateral diseased or absent ovary, no study has examined the response of normal ovaries to gonadotrophin stimulation within the same patient. We wished to determine if there were any significant differences between right and left ovarian response in patients with healthy ovaries having standard IVF treatment. METHODS: We performed a prospective observational case--controlled study in 200 consecutive IVF patients. The main outcome measures were the number of oocytes retrieved, fertilization rates, grade of embryos produced, pregnancy rates and live birth rates. RESULTS: Comparison of right versus left ovary revealed: number of oocytes 4.9 versus 4.7, percentage fertilization 61.3 versus 62.5%, percentage of grade 1 embryos 81 versus 83%, chemical pregnancy rate 33 versus 47% and live birth rate 27 versus 32% (all not significant). CONCLUSIONS: We conclude that there are no statistical differences between right and left ovarian response in IVF patients with healthy ovaries.