Proportion of Tubal Factor Infertility due to Chlamydia: Finite Mixture Modeling of Serum Antibody Titers.

In this study, we examined whether the proportion of tubal factor infertility (TFI) that is attributable to Chlamydia trachomatis, the population excess fraction (PEF), can be estimated from serological data using finite mixture modeling. Whole-cell inclusion immunofluorescence serum antibody titers were recorded among infertile women seen at St. Michael's Hospital in Bristol, United Kingdom, during the period 1985-1995. Women were classified as TFI cases or controls based on laparoscopic examination. Finite mixture models were used to identify the number of component titer distributions and the proportion of serum samples in each, from which estimates of PEF were derived. Four titer distributions were identified. The component at the highest titer was found only in samples from women with TFI, but there was also an excess of the second-highest titer component in TFI cases. Minimum and maximum estimates of the PEF were 28.0% (95% credible interval: 6.9, 50.0) and 46.8% (95% credible interval: 23.2, 64.1). Equivalent estimates based on the standard PEF formula from case-control studies were 0% and over 65%. Finite mixture modeling can be applied to serological data to obtain estimates of the proportion of reproductive damage attributable to C. trachomatis Further studies using modern assays in contemporary, representative populations should be undertaken.

Prolonged laparoscopic surgery is associated with an increased risk of vertebral disc prolapse.

The benefits of laparoscopic surgery to the patient are well recognised, however it is more physically demanding on the surgeon. A survey was sent to members of the British Society of Gynaecological Endoscopy to ascertain musculoskeletal symptoms and vertebral disc prolapse thought to occur as a result of undertaking laparoscopic surgery. A total of 19 (15%) participants were diagnosed with a vertebral disc prolapse, for which one-third needed definitive treatment. There was a statistically significant association with length of practice and numbers of hours worked per week, with the risk of disc prolapse. There was a multitude of other musculoskeletal symptoms reported. These findings suggest that gynaecological laparoscopic surgery carries a high personal health risk to the surgeon, which is likely to increase as the capability and superiority of laparoscopic techniques develop. There is an urgent need to explore further the ergonomic impact of laparoscopic work to enable improvements to be made.

Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training.

OBJECTIVES: To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training. DESIGN: A prospective randomised controlled trial. SETTING: Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK. POPULATION: Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied. METHODS: Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre. MAIN OUTCOME MEASURES: Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention. RESULTS: There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1-23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training (P = 0.965). CONCLUSIONS: Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.

The effect of diclofenac and paracetamol on pregnancy and implantation rates in infertile women undergoing IVF treatment.

We set out to assess the effect of diclofenac on implantation rates, when administered as analgesia following transvaginal oocyte recovery. This was a prospective study of infertile women undergoing IVF treatment in a University Hospital. Subjects (n = 74) were divided in two groups (A and B). Group A (n = 38) received 1 g paracetamol and 100 mg diclofenac and group B (n = 36) received 1 g paracetamol only. All the medication was administered rectally immediately after the oocyte retrieval. Pregnancy and implantation rates were compared between group A and B using the chi2 test. In groups A and B, the implantation rates were 12.4% and 9.6% (p = 0.5) and the pregnancy rates were 28.9% and 19.4%, respectively (p = 0.67). Neither pregnancy nor implantation rates differed significantly between the two groups. Administration of diclofenac to patients at the time of egg collection does not appear to affect implantation or pregnancy rates, while it could be effective in reducing discomfort and pain associated with oocyte retrieval.

Likelihood of natural conception following treatment by IVF.

PURPOSE: To predict the ongoing likelihood of natural conception, when a couple has ceased to try to conceive by assisted conception. METHODS: A postal questionnaire survey obtained information on further attempts to conceive and have a baby, either without treatment or by treatment elsewhere. RESULTS: From a response rate of 44%, there were 116 couples who fulfilled the study criteria. The data presented are based on this group. The overall likelihood of conception was 18%. Cumulative results were analysed up to 3 years following treatment. Univariate analysis showed that likelihood of conception was affected by infertility diagnosis (p = 0.024), woman's age (> 38 years; p < 0.005) (negatively) and duration of infertility (< 3 years; p < 0.005) (positively), while primary infertility did not. Effects of diagnosis and infertility duration were confirmed by multivariable analysis, controlling for age and primary infertility. These latter variables had no independent effect. CONCLUSION: The likelihood of natural conception following IVF treatment was determined by duration of infertility and diagnosis; tubal disease in particular was associated with a very poor likelihood of natural conception.

Levonorgestrel hormone releasing intrauterine system (Mirena) as a contraceptive in egg donors: case report.

We report the safe use of levonorgestrel hormone releasing intra uterine system (Mirena) as a contraceptive in egg donors during a treatment cycle. In the first case report, a 29-year-old egg donor using the Mirena coil for contraception and two egg recipients, aged 41 years and 32 years respectively underwent standard IVF treatment, oocyte retrieval in the egg donor and in vitro fertilization followed by embryo transfer in the recipient. The outcome of IVF cycle using donor eggs was satisfactory with successful pregnancy in the egg recipient. The second case involved a 34-year-old egg donor using the Mirena coil and a 44-year-old recipient. Our findings suggest that egg donors can safely use the (Mirena) as a contraceptive device during treatment, without compromising follicular development and oocyte quality.

Serum IGF-1 concentrations following pituitary desensitization do not predict the ovarian response to gonadotrophin stimulation prior to IVF.

BACKGROUND: Insulin-like growth factor-1 (IGF-1) is known to play a role in ovarian follicular development augmenting the action of FSH. Low intrafollicular concentrations have been detected in women who respond poorly to gonadotrophins. This study addresses the relationship between serum IGF-1 levels following pituitary desensitization and ovarian response to gonadotrophin stimulation. METHODS: This is a case-control study of 78 patients undergoing IVF-embryo transfer treatment. Thirty-nine strictly-defined poor responder patients requiring 50 or more ampoules (75 IU FSH) to reach oocyte retrieval were compared with 39 age-matched normal responders, requiring fewer than 50 ampoules. IGF-1 concentrations were determined by extraction radioimmunoassay on serum samples obtained after pituitary desensitization but prior to gonadotrophin stimulation. RESULTS: Despite highly significant differences in measures of ovarian response between groups, the mean serum IGF-1 concentration was not statistically significantly different between poor and normal responders [(31.5 nmol/l [95% confidence interval (CI) 28.5-34.5] versus 34.5 nmol/l (95% CI 31.8-37.2)] respectively. No correlation between oocyte number or total gonadotrophin used and serum IGF-1 concentration was observed. CONCLUSION: Whilst IGF-1 influences ovarian follicular development this study suggests that serum IGF-1 does not predict ovarian response and does not differentiate between critically-defined poor and normal responders.

Biological versus chronological ageing of oocytes, distinguishable by raised FSH levels in relation to the success of IVF treatment.

BACKGROUND: The present study addresses the issue of biological ageing of the oocyte (as indicated by basal serum FSH levels) versus chronological ageing. METHODS: 1019 infertile but ovulating women were studied in their first cycle of IVF treatment. A series of logistic regression models were developed to assess statistical significance of effects of age and FSH on implantation rates and live babies born. RESULTS: The number of oocytes retrieved and embryos available for transfer declined with increasing age and basal serum FSH concentrations. Fertilizing ability of oocytes increased with advancing age but was not affected by FSH concentrations. Although the number of oocytes or embryos available for transfer had no independent effect on implantation rates, the implanting ability of fertilized oocytes (embryos) was inversely related to increasing age and independently to FSH. The chance of a baby being born, however, was determined more by age than by serum FSH. CONCLUSIONS: Ovarian ageing affecting oocyte quality and fecundity can occur independently of chronological age. This has important practical implications whereby serum basal FSH measurement may be a valuable prognostic index, though chronological age remains important.

The contribution of subtle oocyte or sperm dysfunction affecting fertilization in endometriosis-associated or unexplained infertility: a controlled comparison with tubal infertility and use of donor spermatozoa.

This study aims to determine the relative contribution of oocyte and/or sperm dysfunction to the reduction of fertilization rates in vitro in cases of minor endometriosis and prolonged unexplained infertility. The results of in-vitro fertilization (IVF) treatment with ovarian stimulation have been compared between couples with the above conditions and women with tubal infertility (as control for oocyte function) and the use of donor spermatozoa (as control for sperm function). Fertilization and cleavage rates using husband's spermatozoa were significantly reduced in endometriosis couples (56%, n = 194, P < 0.001) and further significantly reduced in couples with unexplained infertility (52%, n = 327, P < 0.001) compared with tubal infertility (60%, n = 509). Using donor spermatozoa the rates were the same as using husband's spermatozoa in tubal infertility (61%, n = 27) or endometriosis (55%, n = 21) but significantly though only partly improved with unexplained infertility (57%, n = 60, P < 0.02). In unexplained infertility, a significantly increased proportion of couples experienced complete failure of fertilization and cleavage in a cycle (5-6% versus 2-3%). However, complete failure was not usually repetitive, and the affected couples did not account for the overall reduction in fertilization and cleavage rates, which remained significantly lower in the rest of the unexplained and endometriosis groups. Implantation and pregnancy rates appeared similar in all groups. The benefit of IVF treatment in cases of minor endometriosis and prolonged unexplained infertility is due to superabundance of oocytes obtained by stimulation. The reduction in natural fertility associated with endometriosis appears to be at least partly due to a reduced fertilizing ability of the oocyte. In unexplained infertility, there is distinct impairment due to otherwise unsuspected sperm dysfunction but probably also oocyte dysfunction.

Is the outcome of in-vitro fertilization and embryo transfer treatment improved by spontaneous or surgical drainage of a hydrosalpinx?

A pilot study was designed to examine whether the outcome of embryo transfer in women with a hydrosalpinx might be improved by surgical drainage of the hydrosalpinx at the time of oocyte collection for in-vitro fertilization treatment. A comparative, controlled but retrospective analysis of the results was performed of all women with infective tubal damage aged <40 years old, who had ovulatory cycles, a normal uterus and a partner with normal spermatozoa. A standardized treatment regimen was used. A maximum of three embryos were transferred. Hydrosalpinx was defined by prior hysterosalpingography and/or laparoscopy with transcervical dye injection. A total of 237 embryo transfer cycles in women with hydrosalpinges (tubal distension not visible in 151, visible but not drained in 30 and drained in 56) were compared with 705 embryo transfer cycles in women with tubal disease but no hydrosalpinx. Results were analysed in the first three cycles but also separately in the first cycle to check for bias. Success rates were higher in the first cycle, but did not significantly influence overall differences. Implantation rates were significantly reduced overall in the hydrosalpinx group (8.0 versus 13.2% for controls; P < 0.001), being 8.3% (P < 0.01) in the subgroup without evident tubal distension and 7.5% (not significant) in the drained hydrosalpinx group. This study shows that tubal damage with distal occlusion is associated with a marked reduction in embryo implantation, even in the absence of obvious fluid distension. Surgical drainage of distended hydrosalpinges appears to offer no benefit.