Airway evaluation on placental support.

UNLABELLED: BACKGROUND Prenatal ultrasonography predicting airway obstruction can facilitate intrapartum management, revolutionising the approach to potential airway difficulties at birth. AIMS: This report presents the first case of this procedure attempted in Ireland. RESULT AND CONCLUSION: This case was unsuccessful in securing an airway, but the potential for intubation or tracheostomy with an intact maternal-foetal circulation provides encouragement for the management of future cases.

Are seminal fluid microorganisms of significance or merely contaminants?

OBJECTIVE: To determine the contribution of urethral and skin flora to seminal fluid cultures and the relation between bacteriospermia and seminal leukocytes. DESIGN: Prospective study. SETTING: IVF-ET unit at a university teaching hospital. PATIENT(S): Sixty men starting an IVF-ET program. INTERVENTION(S): Culture of sequential first-catch urine, midstream urine, and semen samples with evaluation of seminal leukocytes. MAIN OUTCOME MEASURE(S): A comparison of microbes from first-catch urine, midstream urine, and semen samples and the correlations of seminal microbes, elevated leukocyte concentrations, and pregnancy. RESULT(S): Microorganisms were detected in 37% of first-catch urine samples, 27% of midstream urine samples, and 51% of semen samples. Most microorganisms were gram-positive microbes and were common to both urine and semen samples. Mean and median leukocyte concentrations were 0.98 x 10(6)/mL and 0.10 x 10(6)/mL, respectively. There was no correlation between seminal microbes and raised leukocytes or between leukocytospermia and/or bacteriospermia and pregnancy. CONCLUSION(S): Microorganisms are commonly found in insignificant quantities in the semen of asymptomatic men. The frequent isolation of gram-positive microbes common to both urine and semen and the absence of a correlation with raised leukocyte concentrations suggest that bacteriospermia most commonly represents contamination.

Efficacy of medroxyprogesterone treatment in infertile women with endometriosis: a prospective, randomized, placebo-controlled study.

OBJECTIVE: To determine the efficacy of medroxyprogesterone acetate (MPA), 50 mg/d for 3 months, in treating endometriosis, with a follow-up of 6 months. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Academic infertility unit in a teaching hospital. PATIENT(S): One hundred infertile women found to have endometriosis at laparoscopy, with 50 recruited to each treatment arm. INTERVENTION(S): Laparoscopy within 3 months of finishing therapy. MAIN OUTCOME MEASURE(S): Initial and second-look laparoscopy for revised American Fertility Society stages and scores, pregnancies achieved, effects on well-being via symptomatic improvement, and side effects. RESULT(S): Whether initially high or low, both MPA and placebo therapy achieved similar statistically significant reductions in stages and scores at second-look laparoscopy. MPA was rated more effective in improving overall well-being. Side effects were minimal in both groups (10% MPA; 2% placebo). Six pregnancies occurred without other endometriosis therapy being instituted in the placebo group (3 during therapy), and one with MPA (0 during therapy). CONCLUSION(S): Both MPA and placebo appear equally and significantly effective in treating endometriosis over a 3-month period, as judged by comparative laparoscopy. Therefore, not only must the use of MPA at 50 mg/d over 3 months be questioned, but the performance of placebo also suggests the need to review whether therapy should be instituted at all as well as the present concept that endometriosis is frequently a spontaneously progressive phenomenon.

Strategies for reduction of neonatal mortality.

Infant mortality rates in developed countries have shown significant decreases in recent years. Two-thirds of infant mortality still occurs in the neonatal period and our aim in this study was to review the causes of these neonatal deaths and see where further improvements may be possible. A 6-yr review of all neonatal deaths of live-born infants over 500 g birthweight from 1991 to 1996 was made. The 1989 amended Wigglesworth classification was used to categorize cause of death and other perinatal variables were also recorded. Results show there were 34,375 births and 153 neonatal deaths. Classification of these deaths by Wigglesworth found 78 (51 per cent) due to congenital malformations, 58 (38 per cent) due to prematurity, 6 (4 per cent) due to asphyxia and 11 (7 per cent) due to specific other causes. The corrected neonatal mortality was 2.18. Neural tube defects alone accounted for 10 per cent of the total neonatal mortality. Fifty-five out of 58 infants who died due to prematurity had birthweight < 1000 g and survival rates in this group compared well to international standards. We conclude that a reduction in neonatal mortality is possible but is most likely to result from community focused measures such as increased use of pre- and peri-conceptional folate.

Processing of semen in an antibiotic-rich culture medium to minimize microbial presence during in vitro fertilization.

OBJECTIVE: To identify and determine the prevalence of microorganisms in preprocessed and postprocessed semen in an IVF-ET program. DESIGN: Prospective study. SETTING: University Teaching Hospital. PATIENT(S): Seventy-four men undergoing preprogram evaluation, each producing two semen samples. INTERVENTION(S): Semen processing with a wash and swim-up technique in a penicillin- and streptomycin-rich medium. MAIN OUTCOME MEASURE(S): The identity and prevalence of seminal microorganisms before and after processing. RESULT(S): Sixty-three percent of individual unprocessed semen samples grew microorganisms, the majority of which were nonpathogenic. Thirty-three men (44.6%) had microbes identified in repeat samples, four had identical organisms each time. Twenty (27%) had positive cultures in one sample, negative in the other. Twenty-one (28.4%) had consistently sterile semen. After seminal processing, the recovery rate for microbes was 5%. Microbial presence after processing did not correlate with either the sperm swim-up concentration or the initial microbial concentration. CONCLUSION(S): Bacteriospermia is common. The microorganisms found rarely are replicated and most likely represent contamination. Wash and swim-up semen preparation in an antibiotic rich culture medium effectively eliminates 95% of organisms.

The effect of transmission bandwidth on diagnostic accuracy in remote fetal ultrasound scanning.

Six subspecialists with considerable experience in fetal ultrasound viewed a selection of pre-recorded ultrasound scans. Scans from 18 patients recorded on VHS video-tape were supplied from five centres in the UK and Ireland, each made on a high-resolution ultrasound machine by an experienced sonologist at a referral centre. Each observer viewed the scans on a large display monitor in an individual viewing booth. The scans were viewed in random order, at randomly selected bandwidths. Observers, who were blinded to both recording and bandwidth, assessed the technical quality on a five-point Likert scale. They also recorded their diagnosis. The six observers each carried out 32 viewing sessions, which gave a total of 192 viewings. There was no significant difference in the perceived technical quality of the scans between the two bandwidths used (P = 0.09). Of the 84 recordings transmitted at 1920 kbit/s, 71 (85%) were diagnosed correctly or 'half correctly' and 13 (15%) were misdiagnosed. Of the 95 recordings transmitted at 384 kbit/s, 66 (69%) were diagnosed correctly or 'half correctly' and 29 (31%) were misdiagnosed. This difference was significant (P = 0.03). The results indicate that although there were no perceived differences in technical quality between recordings transmitted at 384 or 1920 kbit/s, diagnostic accuracy was marginally worse at the lower bandwidth. This suggests that the higher bandwidth conveys more detail and information to the observer, which in turn enables more accurate diagnosis. However, further work is required before a definitive choice can be made about the optimum transmission bandwidth for remote fetal ultrasound studies.

A randomized prospective study of early follicular or midluteal initiation of long protocol gonadotropin-releasing hormone in an in vitro fertilization program.

OBJECTIVE: To determine the optimum menstrual cycle time to initiate a long-protocol gonadotropin-releasing hormone agonist (GnRH-a) down-regulation regimen before hMG stimulation before IVF. DESIGN: Randomized, prospective, single, first cycle study. SETTING: University teaching hospital. PATIENTS: Eighty-six infertile couples undergoing IVF-ET attempt under rules for Ireland. INTERVENTION: Gonadotropin-releasing hormone agonist administered intranasally from day 1 or 21 of menstrual cycle. Human menopausal gonadotropin commenced when pituitary down-regulation was confirmed. MAIN OUTCOME MEASURES: Ovarian response, cancellation, fertilization, and pregnancy rates. RESULTS: No significant differences found between day 1 and day 21 initiation. But starting on day 1 is more easily recognizable by patients and avoids the possibility of administering GnRH-a in the presence of an unsuspected pregnancy. CONCLUSIONS: Both follicular and luteal phase initiation of GnRH-a long-protocol down-regulation are equally efficacious. In our clinical context, patients and management favor commencing on day 1.

Course and outcome of IVF pregnancies and spontaneous conceptions within an IVF setting.

The study determines mortality and morbidity levels during pregnancy and the perinatal period in those conceiving through IVF in the Republic of Ireland in comparison with other parts of the world and a peer infertile group conceiving spontaneously whilst on the IVF clinic books. Six hundred and sixty couples had 187 IVF pregnancies from whom 220 babies were born to 151 deliveries. There were also 78 spontaneous conceptions which produced 78 offspring from 73 deliveries. The majority had trouble free pregnancies. The incidence of all complications was less than has been reported elsewhere. Of the IVF group, 16.5% aborted completed as did 5% of the spontaneous conceptions. A further 7% and 3.8%, respectively, aborted one sac of a multiple pregnancy. Of the IVF deliveries, 35.8% were multiple as were 6.8% of the spontaneous conceptions. Higher order multiple presence detrimentally influenced delivery mode, gestational age and birth weights in the IVF group. Of IVF patients, 55.7% were section deliveries as were 10.9% of the spontaneous conceptions. Incidence of IVF-group significant congenital abnormality was 1.8%. The perinatal mortality rate was 4.2 per 1000 births. This series suggests the final take-home baby outlook of 81% from conception by IVF is not as poor as previously portrayed. However, attention should be given to abortion, section and multiple pregnancy rates.

The influence of peritoneal fluid from patients with minimal stage or treated endometriosis on sperm motility parameters using computer-assisted semen analysis.

The aim of this study was to determine the influence of peritoneal fluid from patients with minimal stage or treated endometriosis on sperm motility parameters. Peritoneal fluid aspirated at diagnostic laparoscopy for unexplained infertility from women during the luteal phase of the menstrual cycle (days 20-23) was incubated for 5 h with fresh semen samples obtained from men of recently proven fertility. Spermatozoa were prepared by a swim-up technique from unprocessed semen. Using computer-assisted semen analysis (Hamilton-Thorn Research, MA, USA), sperm motility and motion parameters were observed at 0, 120, 180 and 300 min. Compared with spermatozoa incubated in Earle's balanced salt solution/human serum albumin, the percentage motility, percentage progressive motility and progressive velocity of spermatozoa incubated in peritoneal fluid from patients without visible endometriosis were significantly higher (P < 0.05). Maximal effect was observed at 3 h and maintained until 5 h. We conclude that in an in-vitro study, in contrast to peritoneal fluid from patients with minimal stage endometriosis, peritoneal fluid from patients with unexplained infertility and no visible endometriosis can improve sperm motility when compared with culture medium.

Should gonadotropin-releasing hormone down-regulation therapy be routine in in vitro fertilization?

OBJECTIVE: To compare the classic clomiphene citrate (CC) and hMG regime for ovarian stimulation before IVF in women who received hMG post-long protocol down-regulation with either 3 mg triptorelin [INN] IM or 150 mg buserelin acetate four times daily intranasally. Furthermore, if possible, to determine the preferred method of down-regulation. DESIGN: A prospective study of 150 women randomized blind to the clinician to one of three alternative ovarian stimulation regimes when passing for the first time through an IVF program during 1992. RESULTS: Triptorelin [INN] down-regulated significantly more quickly than buserelin acetate. The non-down-regulated group CC and hMG used significantly less hMG in a shorter time. In these women LH levels at hCG administration were significantly higher. No other intergroup differences were found. Pregnancy and take-home baby rates for the overall study were, respectively, 32%:25% (per cycle) and 42%:33%; (per ET) for the triptorelin [INN] group 28%:22% and 39%:31%; the CC group 32%:24% and 46%:34%; and the buserelin acetate group 34%:28% and 42%:34%. CONCLUSIONS: Triptorelin [INN] and buserelin acetate were comparable in all parameters except down-regulation. The former was significantly quicker and more sure. In none of the clinical end points measured, however, was the classic CC and hMG non-down-regulation regime significantly less effective or troublesome than where down-regulation was used. These results therefore show that although indications for down-regulation before IVF exist, it should not be used on all patients.

Sixth nerve palsy: an unusual manifestation of preeclampsia.

BACKGROUND: Neurologic abnormalities may occur in pregnancy as a manifestation of neurologic or systemic disease. We present an unusual case of preeclampsia presenting with a sixth nerve lesion. CASE: A 33-year-old woman, gravida 2, presented at 38 weeks' gestation with sixth nerve palsy. She was hypertensive and proteinuric, with plasma urea of 24 mg/dL. Labor was induced and hypertension escalated in the early puerperium, with concomitant worsening diplopia. Blood pressure control and resolution of preeclampsia were followed by resolution of the sixth nerve lesion. There was no evidence of other pathology on extensive investigations. CONCLUSION: Sixth nerve palsy is an unusual manifestation of preeclampsia.

Does patient semen quality alter during an in vitro fertilization (IVF) program in a manner that is clinically significant when specific counseling is in operation?

PURPOSE: It has been shown that the stress of infertility may impair semen quality. Whether counseling can attenuate this affect is unproven. This study examines, in an IVF program setting, where specific counseling is in operation, whether semen collected on the day of oocyte recovery is significantly different from that obtained during the prior clinical suitability assessment of the couple. RESULTS: In the 125 consecutive couples examined, there were no significant overall differences in semen volume or sperm density. There was a significant increase in sperm motility on the day of oocyte retrieval (P < 0.001). Twenty-three patients (18.4%) showed an increase in quality, and 21 (16.8%) a decrease, on the day of oocyte recovery. The environment of production appeared to exert no influence. Fertilization failure occurred in seven couples, three (14%) of whom presented for the first time with decreased semen parameters on the day of IVF. This compares with 1 of 23 (4%) fertilization failure in those whose parameters increased. CONCLUSION: The semen quality of the vast majority of the patients studied in this highly counseled program does not appear to be significantly affected by the superstress of participation in the day of oocyte recovery.

Mid to late luteal phase steroids in minimal stage endometriosis and unexplained infertility.

Serum and peritoneal fluid concentrations of progesterone and 17 beta-oestradiol were measured during days 20-27 of the luteal phase in 33 women with minimal stage endometriosis and 21 with unexplained infertility. The results were analysed using Student's t-test and straight line regression analysis. In both groups, 17 beta-oestradiol and progesterone values were several-fold higher than the corresponding serum values and there were significant correlations between the peritoneal fluid and the serum steroid values. In the peritoneal fluid there was a significant reduction in both progesterone and its ratio with 17 beta-oestradiol in women with minimal stage endometriosis (P < 0.03, P < 0.04, respectively). The peritoneal fluid levels of 17 beta-oestradiol in women with minimal stage endometriosis were, however, not significantly altered. Despite the correlations between peritoneal fluid and serum steroid levels, there were no significant changes in the serum concentrations of progesterone, 17 beta-oestradiol or the ratio of progesterone to 17 beta-oestradiol in women with minimal stage endometriosis. It is concluded that luteal phase progesterone and its relationship to 17 beta-oestradiol are subtly altered in infertile women with minimal stage endometriosis compared with women with unexplained infertility. These alterations may be more clearly demonstrated in peritoneal fluid rather than in peripheral blood, possibly because the latter contains steroids which are of non-ovarian origin and are also constantly affected by the liver enzyme activity and enterohepatic circulation of individual subjects.

A mid-luteal phase comparison of peritoneal fluid volume and its content of PGF2 alpha and PGE2 in women with minimal stage endometriosis and a normal pelvis.

The study was carried out following the approval of our Hospital Ethics Committee and an informed patient consent. Samples of peritoneal fluid were collected from the Pouch of Douglas at laparoscopy from 32 subjects with minimal stage endometriosis (MSE) and 16 without any visible signs of endometriosis (normal group). All the subjects were in 20 to 23 day period of their menstrual cycle which was histologically confirmed. The endometriosis score was estimated according to the American Fertility Score, 1985 and the fluid samples were collected in tubes containing heparin/indomethacin and standing in ice. The samples were estimated for volume, erythrocyte count, prostaglandin(PG) F2 alpha, and PGE2. Radioimmunoassay techniques were used for the estimation of PGs. Prostaglandin F2 alpha, was measured in its parent form while PGE2 was converted into bicyclic-PGE2 before estimation. The results indicate that the peritoneal fluid in women with MSE has higher than normal levels of PGF2 alpha and lower than normal levels of PGE2 and its PGE2: PGF2 alpha ratio is also below normal. There is no difference in the volume of peritoneal fluid in the two groups. Provided the fluid sample is not contaminated with abdominal blood its erythrocyte count is not related to its prostaglandin content.

Setting up a specialist menopause clinic in Ireland: the initial experience.

The Rotunda Hospital Dublin set up a Menopause Clinic in February 1990. Eighty-one new patients were seen in the first 6 months of operation. Most presented either with symptoms attributable to oestrogen deficiency (36%) or non-specific symptoms associated with depression or ageing (26%). There was a high incidence of significant family/social/martial problems (25%) and abnormal vaginal bleeding (20%). The case is made for such specialised clinics; expertise with respect to hormone replacement therapy and its manipulation develops, problems of specific socio-cultural settings can be identified, and screening programmes for disease coordinated.