Transforming a conventional theatre into a gynaecological endoscopy unit.

OBJECTIVE: Most minimally invasive procedures are now performed in operating rooms that were originally designed for traditional open surgery. We designed an endoscopic theatre based on our experience with special features specific for gynaecological endoscopy. METHOD: We designed a detailed plan with an architect's aid of a gynaecological unit (based on a Greek presidential decree published in 1991). The space utilized was that of a conventional theatre. RESULTS: With the architectural plan we anticipated every area needed in a gynaecological endoscopic theatre. A twin theatre was considered appropriate in order for the surgical team to operate alternatively in one theatre while the other is being cleaned and prepared for use. CONCLUSION: The design of a unit dedicated to gynaecologic laparoscopy is a multidisciplinary task where the endoscopic surgeon undertakes an active and prominent role. It is a project with great benefits and rewards for all parties involved. We present our design for evaluation.

Comparison between "short" and "long" protocols in an ICSI programme.

In the present retrospective study we compare the efficacy of gonadotropin-releasing hormone (GnRH) agonist in a long protocol and a GnRH agonist in a short protocol administration for controlled ovarian hyperstimulation (COH) in an ICSI program. A total of 424 consecutive patients with a history of male factor were included in the present study. Three hundred and three patients were included in the long protocol and 121 in the short protocol. Patients treated with the short protocol were stimulated in a shorter time and achieved lower estradiol levels. A significantly higher percentage of oocytes transferred were found in the long protocol. The clinical pregnancy rate per embryo transfer was 39.3% in the long protocol and 19.2% in the short protocol (p=0.001).

Small doses of LH activity are needed early in ovarian stimulation for better quality oocytes in IVF-ET.

OBJECTIVE: To examine whether exogenous LH administration has a beneficial effect on the quality of oocytes, fertilization potential, as well as pregnancy rate in IVF-ET cycles. A randomized trial comparing r-FSH versus r-FSH and LH was employed. STUDY DESIGN: Forty-six infertile couples entering IVF-ET for the first time (either tubal or male factor) were divided after prospective randomization into two groups. In both groups the long protocol with GnRH-analogs was used. In group A, ovarian stimulation started with r-FSH (200 IU/day) for the first four days. In group B, the stimulation protocol started with one amp hMG (75 IU FSH + 75 IU LH activity) daily for four days, with simultaneous administration of r-FSH (150 IU/day). The outcome was compared. RESULTS: Statistical difference was observed in the number of mature oocytes, the number of fertilized oocytes as well as the number of transferable embryos. In all cases, results were statistically significantly better (p < 0.05) in group B. Clinical pregnancy rate, finally, was similar in the two groups. CONCLUSION: The relatively small sample size does not allow a definitive conclusion for the important role of LH during early oocyte maturation. Our results, however, indicate a beneficial effect when small doses of LH are used for ovarian stimulation in IVF-ET cycles. This effect may be more important in cases in which few embryos are available for transfer.

Saline contrast hysterosonography in infertile patients and in women with abnormal uterine bleeding.

OBJECTIVE: We conducted this prospective study to evaluate saline contrast hysterosonography (SCHS) as a diagnostic modality for intrauterine lesions in comparison to hysteroscopy and endometrial biopsy. MATERIALS AND METHODS: We included 135 patients, of whom 70 presented with abnormal uterine bleeding and 65 with subfertility problems. All cases were examined with conventional transvaginal sonography and were further investigated with SCHS using saline as contrast medium, and finally hysteroscopy with endometrial biopsy that was used as the reference test. RESULTS: SCHS revealed the presence of intrauterine pathology in 23 cases and failed in three (4.2%). SCHS had a sensitivity of 94%, a specificity of 71%, a positive predictive value of 76% and a negative predictive value of 95% in the abnormal uterine group. In subfertile patients, SCHS revealed the presence of intrauterine pathology in 34 cases and had a sensitivity of 96%, a specificity of 74%, a positive predictive value of 79% and a negative predictive value of 95%. CONCLUSIONS: We found that SCHS is an extremely accurate modality for the diagnosis of focal endometrial pathology, compared to diagnostic hysteroscopy.

EGF and IGF-I as predictors of ICSI outcome in human preimplantation embryo cultures.

PURPOSE OF INVESTIGATION: Detection of EGF and IGF-I in human embryo cultures and their effect on ICSI outcome. METHODS: Collection of culture medium from embryos of 50 women under ICSI program. EGF and IGF-I were measured via enzyme immunoassay. RESULTS: ICSI outcome was independent of age, infertility years, FSH, LH, prolactine and E2. EGF detection was higher in 48- (32%), than in 72-hour embryos (14%) (p < 0.001). EGF negative embryos are likely to be arrested at the morula stage (p < 0.001) and are associated with poor pregnancy rates (p < 0.05). IGF-I was undetected in 48-hour embryos. CONCLUSIONS: For the first time human embryos were surveyed from fertilization until embryo transfer, regarding EGF and IGF-I production. IGF-I is not a predictor of ICSI outcome. EGF is present in one-third of human embryo cultures at 48 hours, but this ratio wanes at the morula stage. EGF negative embryos are associated with lower pregnancy rates.

Endometriosis and reproductive disorders.

The classic concept of endometriosis as a cause of infertility is challenged. Traditionally, both surgical and medical therapy have focused on alleviation of symptoms, prevention of disease progression, and promotion of fertility. In spite of significant developments in medical and surgical approaches, the optimal therapy for treating endometriosis-associated infertility has yet to be established. The relationship between prevalence of fecundity and stage of the disease was studied according to the type of management. Of 151 women who were consecutively proved by laparoscopy to have endometriosis stage I and II, operative laparoscopy was performed in 49, medical treatment in 59, and expectant management in 43 cases. During a 24-month period, the cumulative pregnancy rates were 36.7%, 30.5%, and 20.9%, respectively. Survival analysis over the 20 weeks of pregnancy showed that the probability of carrying the pregnancy beyond this week was 30.6%, 25.4%, and 16.2%, respectively. Of 64 patients with advanced disease, 34 (53%) became pregnant during the 2-year follow-up period. A significantly increased pregnancy rate was found for the first year as compared to the second (76% vs. 24%). The existence of adhesions affected adversely the outcome of the treatment when early achievement of pregnancy is considered. Diagnosis and treatment of endometriosis was beneficial for the infertile women. Laparoscopic surgery seems to be the best treatment in these cases, as it increases the fecundity and involves minimal risk.

Biological factors in culture media affecting in vitro fertilization, preimplantation embryo development, and implantation.

Optimal culture conditions are of paramount importance for in vitro fertilization of gametes, preimplantation embryo development, and implantation for all species. Water is the basis of all culture media, and ultrapure water should be employed. The main energy sources of a medium are lactate, pyruvate, and glucose. The concentrations of the first two vary in different media, whereas the latter is necessary mainly for the later stages (morula to blastocyst) of development. A fixed nitrogen source is essential for implantation embryo development whether this is provided by amino acids, albumin, or serum. Suboptimal culture conditions can block development. Pronuclear zygotes of most species (but not human) arrest at some point between the two-cell and the 16-cell stage. Modifying culture conditions can lead the embryos to develop through this block. Hypoxanthine also causes a two-cell block to mouse pronuclear zygotes, and this again depends largely on culture conditions. Simple culture media are bicarbonate-buffered systems with pyruvate, lactate, and glucose. Complex media, such as Ham's F-10, contain in addition amino acids and other elements found in serum. Human tubal fluid simulates the fallopian tube microenvironment. EDTA, gonadotropins, growth factors, and other substances can be included in the media to stimulate development. Coculture of embryos with oviductal cells has shown promising results.

Adhesions: laparoscopic surgery versus laparotomy.

This study was undertaken to assess the effectiveness in pregnancy rates of microsurgery and operative laparoscopy in adhesiolysis. Adhesions were found to be the sole infertility factor in 15% of our patients. One hundred and ninety infertile patients with periadnexal adhesions as the only cause of their infertility were treated by microsurgery (86) or operative laparoscopy (104) and were followed up for 24 months. Our results indicate that advanced laparoscopic surgery in general is as effective as microsurgery in healthy infertile patients with adhesions but offers some advantages in comparison to laparotomy. Factors that adversely affect the postoperative success rates are the age of the women, the duration of infertility, and the severity of the adhesions.

Oocyte morphology correlates with embryo quality and pregnancy rate after intracytoplasmic sperm injection.

OBJECTIVE: To evaluate the relation of oocyte morphology with embryo quality and pregnancy rates (PRs) after intracytoplasmic sperm injection (ICSI). DESIGN: Retrospective study of patients undergoing ICSI. SETTING: University Hospital IVF Center. PATIENT(S): Sixty-eight patients who underwent ICSI and had transfer of good-quality embryos (grade 3), 60 patients with transfer of both good- and poor-quality embryos (grade 3 and grade 2), and 18 patients with transfer of poor-quality embryos (grade 2). INTERVENTION(S): Comparison of the outcome of ICSI in the three groups of patients and the relation of oocyte morphology to embryo quality. MAIN OUTCOME MEASURE(S): Oocyte morphology and embryo quality (grade). Fertilization, cleavage, and pregnancy rates. Serum E2 on the day of hCG administration. RESULT(S): Oocytes with poor morphology (dark cytoplasm; many vacuoles or fragments in cytoplasm) led to poor-quality embryos and consequently to lower PRs (5.5% versus 29.4%). Serum E2 on the day of hCG administration was significantly higher in the group with good-quality embryos compared with that with poor-quality embryos (2,047 +/- 135.7 versus 1,651 +/- 164.8 pg/mL, respectively). CONCLUSION(S): Serum E2 on the day of hCG administration is a marker of embryo quality. Oocyte morphology correlates well with embryo quality and PRs after ICSI.

Septic lithiasis of the pelvis.

Laparoscopic cholecystectomy has become a standard technique for the treatment of symptomatic cholelithiasis. Despite a significant reduction in the complication rate with increasing experience, bile duct injury and gallstone spillage still occur more frequently with this approach than with the open procedure. Unretrieved gallstones, in particular, have been associated with late infection and the formation of abscesses in virtually every area of the abdominal cavity. We present a rare case of an isolated pelvic abscess that developed in a postmenopausal woman 5 months after laparoscopic cholecystectomy for recurrent cholecystitis. The preoperative differential diagnosis of this case is also discussed.

Knowledge, attitude, and behavior of female students concerning contraception in Athens, Greece.

The aims of this study were to investigate the knowledge, attitudes and behavior of female high school and university students concerning contraception. The study was performed at the Alexandra University Hospital in Athens. A total of 297 female students participated in the study. A questionnaire was used to evaluate the depth of knowledge and attitude of respondents concerning contraception. Our findings suggest students have a defective knowledge of contraception. Their main source of information were friends but the majority would prefer to receive information from doctors. The most popular contraceptive method was the male condom. The attitude and behavior of young women in our study were consequently defective. In conclusion, there is a need to provide students with correct, detailed and broad-based information on conception and contraception as part of the school curriculum to help them acquire adequate knowledge and develop appropriate attitudes on contraception and sexual health.

Intrauterine insemination in male subfertility: a comparative study of sperm preparation using a commercial Percoll kit and conventional sperm wash.

In order to evaluate the possible benefit of sperm preparation using a commercially available, ready-to-use Percoll gradient kit (PerWash, FertiPro, Belgium) for intrauterine insemination (IUI), a two-centre study was performed comparing this method with conventional sperm preparation by means of centrifugation-resuspension. In the Percoll group, 25 couples out of 52 (48%) achieved pregnancy requiring 136 cycles of insemination, with a per cycle success rate of 18.4%. This result was significantly better (P < 0.01) than the per cycle pregnancy rate of 8.9%, which is 23 pregnancies out of 65 cases treated during 259 cycles of insemination with conventionally prepared semen. Also, the 10th percentile of sperm characteristics among successful cases was lower for sperm concentration, proportion and concentration of grade (a) motile spermatozoa in the Percoll group as compared to couples inseminated with conventionally prepared semen. In contrast, cases with elevated proportion of grade (a) motility (> 22%) were significantly less likely (P < 0.001) to obtain pregnancy with IUI, using either sperm preparation method. It is concluded that sperm preparation for intrauterine insemination using the Percoll gradient kit gives a better success rate and can be applied in cases with more severe sperm deficiency.

The value of semen characteristics and tests of sperm function in selecting couples for intra-uterine insemination.

In order to improve the selection of couples for intrauterine insemination (IUI) because of longstanding primary infertility of alleged male origin, we have performed a prospective study measuring conventional and advanced analysis of sperm characteristics, the hypoosmotic swelling test, the Shorr stain, the acidified aniline blue stain and alpha-glucosidase activity in seminal plasma, of 89 couples with no demonstrable abnormality of the female partner. Twenty-four couples attained spontaneous conception, 23 were successful within six cycles of IUI, and 42 remained without conception in spite of IUI during six unstimulated cycles. The proportion and concentration of spermatozoa with progressive motility was significantly lower (P < 0.01) in the successful IUI cases than in the couples attaining spontaneous conception, and the lower quartile value was lower in the former than in the latter. There were less pregnancies among IUI treated couples when sperm concentration and motility were within the range of normal fertile men, or when the concentration of white blood cells was elevated. More pregnancies occurred when markers of epididymal function, namely the result of the Shorr stain and alpha-glucosidase measurement, were normal. Total progressive motility and the result of the Shorr stain were the only independent variables selected by logistic regression to discriminate between successful and failed IUI cases. It is concluded that only a limited group of couples may benefit from IUI.

Carcinoembryonic antigen (CEA) in normal and pre-eclamptic pregnancies (values in maternal blood, amniotic fluid and umbilical cord blood).

Values of carcinoembryonic antigen (CEA) were measured by radioimmunoassay in 100 pregnant women divided into 4 groups. In group 1 (49 normal pregnancies) and 2 (17 pre-eclamptic pregnancies), the estimation of CEA was done in maternal vein blood, umbilical cord blood and in amniotic fluid. In group 3 (20 normal pregnancies) CEA was measured separately in blood of the two umbilical vessels as well as in maternal vein blood. In group 4 (14 pregnancies with small-for-date infants) CEA was estimated in umbilical cord blood. The values in amniotic fluid of normal and pre-eclamptic pregnancies were more than 20 times higher than in the other two compartments. A significant correlation was found between the amniotic fluid and umbilical cord blood values (r = 0.500; P < 0.05), as well as between the values in umbilical artery and vein (r = 0.792; P < 0.001). Thus, it is thought that CEA is transferred from the amniotic cavity to the umbilical cord while a part of CEA perhaps is produced by the placenta. Umbilical cord blood values of small-for-date fetuses do not differ significantly from the normal. On the contrary, significantly lower values were obtained in umbilical cord blood and in amniotic fluid of pre-eclamptic women as compared to the normal, but this finding is not useful clinically because of the large standard deviation.

The effect of the duration of GnRH-agonist down regulation before ovarian stimulation on the biological and clinical outcome after intracytoplasmic sperm injection.

The object of this study was to compare the biological outcome (oocyte maturity, fertilization, cleavage) and the clinical outcome after a 'long' (15-24 days) and a 'long-long' (25-40 days) protocol of GnRH-agonist administration for intracytoplasmic sperm injection. Group A consisted of 51 patients with a 15-24-day down regulation period and Group B consisted of 35 patients with a 25-40-day down regulation period, all of which entered ICSI due to severe male factor infertility. Duration and amount of gonadotropin stimulation, serum E2 on the day of hCG administration, number of oocytes retrieved, oocyte maturity, fertilization rate, cleavage rate and pregnancy outcome were comparable for the two groups of patients. Therefore, a flexible period of pituitary desensitization can be employed, allowing us to simplify planning for patients and for the medical staff without affecting the outcome of the trial.

Oocyte donation to women over 40 years of age: pregnancy complications.

Recently, oocyte donation to women of advanced age has led to a considerable number of conceptions, thus increasing the age limit for becoming pregnant. A main consideration encountered by physicians, though, is the potential medical and obstetric complications of a pregnancy at an advanced age. In this study, the obstetric complications, as well as the perinatal outcome, of pregnancies of aged recipients (above 40) are presented and compared to those of younger recipients. A significantly higher incidence of gestational diabetes (P < 0.001), an increased incidence of pre-eclampsia (at the 10% level of significance) and an increased risk for thrombophlebitis (again at the 10% level) was observed in the older patients, but a careful follow-up during their pregnancy led to a highly satisfactory obstetric and perinatal outcome. A rigorous precycle medical screening (especially for cardiovascular diseases and diabetes) and a careful follow-up during pregnancy is, therefore, imperative so that oocyte donation to older women is not withheld and continues to provide fertility possibilities to otherwise sterile patients.

Relation between leptin and cortisol values in umbilical vessels at normal vaginal delivery.

To study the role of various hormones in the control of fetal leptin secretion during labour, 33 pregnant women with normal singleton term pregnancy were recruited. At the time of spontaneous vaginal delivery, a venous blood sample was taken from the women together with a venous and an arterial cord blood sample. In all blood samples, leptin, cortisol, prolactin and progesterone were measured. Serum leptin and cortisol values were significantly higher, while those of prolactin and progesterone were significantly lower in the mother than in the two umbilical vessels (p < 0.01). Cortisol levels were significantly higher in the umbilical artery than in the umbilical vein (p < 0.01). Serum leptin values in the umbilical artery and vein correlated significantly with the corresponding values of cortisol (r = 0.523 and r = 0.580 respectively, p < 0.01), but not with those of prolactin and progesterone. A weak but significant correlation was found between leptin values in the two umbilical vessels and birth weight (r = 0.385 and r = 0.401 respectively, p < 0.05). In multiple regression analysis, cortisol values but not birth weight was the most important determinant of leptin values. Birth weight, however, correlated significantly with placental weight (r = 0.776, p < 0.001). These results demonstrate for the first time that leptin concentrations in the umbilical vessels at normal vaginal delivery correlate significantly with cortisol values, thus providing evidence that cortisol mediates a labour stimulating effect on fetal leptin secretion. It is suggested that cord blood leptin values at delivery are not a good predictor of neonatal weight.

Experimental remarks on leg ischemia following popliteal artery injuries.

Popliteal artery injuries are followed, in many cases, by amputation of the leg. Results after re-construction depend on the time of ischemia. In this experimental work 12 dogs with injury of the popliteal artery had a direct end to end anastomosis or an anastomosis using saphenous vein graft. Blood flow was checked by an electromagnetic flowmeter or ultrasounds, blood samples for Hb, oxyhaemoglobin saturation, Hct and ph were taken before and after operation. Changes in these values depend on the time elapsing between injury and re-establishment of circulation. Operative angiography was done in all dogs. Except in two dogs, no early or late thrombosis occurred. Three dogs required amputation. The outcome of the operation is related to the time elapsing between injury and restoration of circulation.

Experimental remarks after cervical sympathectomy.

The present experimental work was undertaken to determine some quantitative changes occurring after cervical sympathectomy applied for the treatment of Raynaud's diseases. The blood flow in the brachial artery was measured before and after sympathectomy as well as the temperature, haemoglobin concentration and oxyhaemoglobin saturation in arterial and venous blood, pH and PCO2 of the arterial blood.

Experimental remarks on the utilization of biological tissue adhesives in lymphovenous anastomosis.

The present experimental study deals with the utilization of biological tissue adhesives in an effort to estimate their value in lympho-venous anastomoses. The entire experimental work was carried out on 8 dogs, using the thoracic duct and the jugular vein for a lympho-venous anastomosis. The study also describes the experimental steps and overall technique. The anastomoses were carried out in an end to side fashion with four stitches and were completed with a biological adhesive substance later ( Fibrinkleber ). All the anastomoses were re-investigated for occlusion, formation of thrombus or a lymphatic fistula. There were no deaths. One of the anastomoses was occluded by a thrombus but no fistula was found in any of the dogs. The above results indicate that biological adhesive substances can be used satisfactorily as an adhesive substance in lymphovenous anastomosis.