Fertilization and development of a blastocyst-stage embryo after selective intracytoplasmic sperm injection of a mature oocyte from a binovular zona pellucida: a case report.

PURPOSE: Our purpose is to describe the development of a blastocyst-stage embryo after the selective fertilization of a mature oocyte from a binovular zona pellucida by intracytoplasmic sperm injection (ICSI). METHOD: A 34-year-old woman underwent intracytoplasmic sperm injection due to severe male-factor infertility. After oocyte retrieval, a binovular zona pellucida including one mature metaphase II oocyte and one immature oocyte at the germinal vesicle stage as well as nine metaphase II oocytes was injected with spermatozoa using a one-to-one approach. RESULTS: The injected mature oocyte of the binovular zona pellucida showed fertilization as evidence by the presence of two pronuclei and cleaved to a four-cell embryo on the second day, while the uninjected oocyte showed signs of degeneration. On the third day, this embryo further cleaved to six blastomeres with slight fragmentation and it reached the blastocyst stage on the sixth day. CONCLUSIONS: Selective fertilization of one oocyte from a binovular zona pellucida by ICSI may lead to the development of a morphologically normal blastocyst-stage embryo which can be used for embryo transfer in the presence of a limited number of embryos.

The results of in vitro fertilization-embryo transfer in couples with unexplained infertility failing to conceive with superovulation and intrauterine insemination.

OBJECTIVE: To determine the results of IVF-ET in couples with long-standing unexplained infertility who had failed to conceive with four to six cycles of superovulation and IUI. DESIGN: Retrospective case control series. SETTING: University IVF-ET center. PATIENTS: One hundred seventeen couples with unexplained infertility who had failed to conceive with superovulation and IUI underwent 157 cycles of IVF-ET. Results were compared with 194 tubal factor couples subjected to 250 IVF-ET cycles within the same time period. RESULTS: Total fertilization failure events were more common (20.4% versus 7.6%) and tended to be repetitive in couples with unexplained infertility. When total fertilization failure events were excluded, fertilization rates (57.8% versus 60.9%) and cumulative clinical pregnancy rates over three cycles (55.4% versus 46.5%) were similar in unexplained infertility and tubal disease groups. CONCLUSIONS: Couples with unexplained infertility failing to conceive with superovulation and IUI have a favorable outcome when treated subsequently with IVF-ET. Conception rates similar to couples with tubal disease may be expected despite a higher incidence of total fertilization failure events.

Results of treatment in 182 consecutive patients with genital fistulas.

OBJECTIVES: To evaluate genital fistulas with the aim of improving strategies to prevent them. METHOD: An institutional, retrospective, clinical analysis. One hundred eighty-two patients with genital fistulas managed consecutively between 1970 and 1993 were analyzed. RESULTS: About 60% of all fistulas were attributable to obstetric traumas whereas gynecologic surgery constituted only 24.7% of cases. The contribution of gynecologic surgery increased from 11.1% in 1970-75 to 60.6% in 1988-93. Approximately half of the patients had vesico-vaginal fistulas. Of the 45 patients with fistulas occurring following gynecologic surgery, 19 had undergone simple hysterectomy and eight had undergone radical hysterectomy. All cesarean sections had been performed after failed labor. Hysterectomy was performed due to myoma in nine patients, endometrial hyperplasia in two patients and pelvic relaxation in eight patients. As regards management of fistulas, the transvaginal approach was chosen in the vast majority of patients. The overall success rate after the primary repair of fistulas was 91.5% (162/177). Fifteen patients with failure of the primary repair were subjected to repeat repairs. The second repair was successful in 11 patients but the remaining four needed further repairs. The maximum was seven repairs to a recto-vaginal fistula before a satisfactory result could be achieved, which had initially occurred after a cesarean section. CONCLUSION: Although the results of reparative surgery are promising, it would be more useful to encourage national measures to prevent in particular obstetric trauma.

Salpingoscopic findings in women with occlusive and nonocclusive salpingitis isthmica nodosa.

STUDY OBJECTIVE: To characterize ampullary endosalpingeal findings in women with occlusive or nonocclusive salpingitis isthmica nodosa. DESIGN: Prospective case study. SETTING: Obstetrics and Gynecology Department of a University Hospital. PATIENTS: Twenty women (38 tubes) with occlusive or nonocclusive salpingitis isthmica nodosa were studied. INTERVENTIONS: Salpingoscopy was performed during diagnostic laparoscopy in 20 women (38 tubes) with hysterosalpingographic evidence of salpingitis isthmica nodosa. MAIN OUTCOME MEASURES: Salpingoscopic findings were recorded and the patients were managed accordingly. RESULTS: Of the 38 tubes 10 appeared radiographically and laparoscopically normal. Two tubes were occluded distally. Of the 26 tubes with occlusive or nonocclusive salpingitis isthmica nodosa, 5 (19.2%) showed varying degrees of endosalpingeal abnormality. Patients with abnormal salpingoscopy were regarded as having bipolar tubal disease and were referred for assisted conception. The remaining patients were scheduled for microsurgical tubal reconstruction. CONCLUSIONS: One in five patients with proximal tubal disease may have ampullary endosalpingeal damage of varying degrees. However, the significance of this finding in relation to subsequent management strategies and fertility outcome is yet to be characterized.

Trends in maternal mortality at a university hospital in Turkey.

OBJECTIVE: To highlight recent trends in maternal mortality in Hacettepe University Hospital. METHOD: A retrospective clinical analysis of 117 maternal deaths between 1968 and 1992. RESULTS: The overall maternal mortality ratio was 180/100,000 (108/59,993). In terms of 5-year periods, the maternal mortality ratio declined from 417.7 in 1968-72 to 73.7 in 1988-92. Infection was the most common cause of death (59.8%), followed by cardiac disease (8.5%) and hemorrhage (8.5%). Infection related deaths were either due to septic abortion (75.7%) or puerperal sepsis (24.3%). While 73.9% of all deaths were due to infection in 1968-72, this figure contributed only 9.1% of the deaths in 1988-92. When infection, hemorrhage, cardiac disease ad toxemia are investigated together, percentages of their contribution varies from 95.7% in 1968-72 to 54.5% in 1988-92 period. CONCLUSIONS: Maternal mortality ratios are decreasing significantly in our institution. An another promising finding is the further reduction in direct causes especially in recent years. However, an improvement in the care of pregnant women is necessary to continue this declining trend.

Outpatient management of Bartholin gland abscesses and cysts with silver nitrate.

This study reports results of 52 patients with Bartholin abscesses or cysts who were managed by silver nitrate stick insertion into the cyst or abscess cavity for 48 hours. All patients showed complete healing within 15 days. However, 2 (3.8%) had recurrences within the first 2 months; 1 of these patients was treated with excision and the other by repetition of the same method with no further complaints. Silver nitrate application for Bartholin cysts or abscesses was found to be an effective, simple, inexpensive and the least anaesthetic requiring procedure, which can easily be carried out in the outpatient setting.

Colour Doppler hysterosalpingosonography: a simple and potentially useful method to evaluate fallopian tubal patency.

The diagnostic efficacy of colour Doppler hysterosalpingosonography to evaluate Fallopian tubal patency was studied in 17 women. Of the 17 women, 12 were infertile and the remaining five were fertile and requested elective tubal ligation. Colour Doppler sonography was performed using the transabdominal approach 1-4 weeks after diagnostic laparoscopy during infertility work-up in the former, and 1-2 weeks after bilateral isthmic tubal ligation in the latter group. Sterile saline was used as the contrast agent. Laparoscopic chromopertubation was considered as the gold standard. The sensitivity and specificity of colour Doppler sonography were found to be 93 and 83%, respectively. A kappa value of 0.73 reflected good clinical agreement between the two techniques. Colour Doppler hysterosalpingosonography is concluded to be a relatively accurate and simple procedure to test tubal patency. The other advantages include absence of radiation and avoidance of potential allergic reactions to iodinated contrast agents employed for hysterosalpingography. However, the inability to delineate the inner architecture of the genital canal and to determine the exact location of tubal obstruction, when present, remain the disadvantages of this technique.

Postconceptional cervical cerclage.

OBJECTIVE: To determine the outcome and morbidity of pregnancies following cervical cerclage. METHOD: Records were reviewed for 326 patients with 374 singleton pregnancies between 1980 and 1990. RESULT: McDonald and Shirodkar procedures were carried out in 323 and 51 pregnancies, respectively. The procedure was classified as elective if based on past history (n = 330). In 44 pregnancies, cervical dilatation prompted operation. The overall fetal survival rate has increased from 17.7% to 79.1% after cervical cerclage. While the presence of cervical dilatation at suture placement had a prognostic value, the surgical technique, gestational age at suture placement and progestin therapy had no significant effect on survival. Premature rupture of membranes and chorioamnionitis were found to be the leading causes of morbidity. CONCLUSION: Cervical cerclage seems to the treatment of choice in patients with cervical incompetence. Only the presence of cervical dilatation at operation was found to have a prognostic value among the factors analyzed.

Human follicular fluid from pre-ovulatory follicles in patients undergoing in-vitro fertilization inhibits the in-vitro growth of gram-positive micro-organisms.

In this study, we assessed the antibacterial activity of human follicular fluid obtained from patients undergoing oocyte aspiration for in-vitro fertilization and embryo transfer. Gram-positive and Gram-negative microorganisms and Candida albicans were added to the follicular fluid and broth cultures which served as controls. Follicular fluid was shown to be inhibitory against Gram-positive microorganisms; this inhibition was probably due to lysosyme and progesterone. Growth of Gram-negative micro-organisms and C. albicans were, however, supported by follicular fluid incubation.

Circulating CA-125 levels in superovulated women are mainly derived from the ovaries.

A prospective study was designed to determine the individual contribution of the ovaries and the endometrium to total circulating levels of CA-125. Luteal phase CA-125 levels were measured in five women superovulated before and after vaginal hysterectomy performed for pelvic relaxation. The difference in the preoperative and postoperative luteal CA-125 levels of superovulated cycles were similar, suggesting a mainly ovarian source for the antigen although endometrial and other sites of contribution cannot be excluded in view of the small number of patients studied.

Laparoscopic CO2 laser uterine nerve ablation for treatment of drug resistant primary dysmenorrhea.

Twenty women with drug-resistant primary dysmenorrhea were subjected to laparoscopic CO2 laser uterine nerve ablation. Menstrual pain assessed by a linear analog pain score showed a reduction of 33%, decreasing from 7.5 +/- 0.5 preoperatively to 5.0 +/- 1.7 postoperatively. The procedure was free of major complications and should be considered as a second-line therapeutic option in women who have failed medical treatment using nonsteroidal antiinflammatory agents or OCs.

The effect of short-interval laparoscopic lysis of adhesions on pregnancy rates following Nd-YAG laser photocoagulation of polycystic ovaries.

Laparoscopic Nd-YAG laser photocoagulation of the ovaries was performed in 40 anovulatory women with clomiphene citrate-resistant polycystic ovary disease. Following this procedure, the subjects were randomly assigned to have either a second-look laparoscopy with lysis of adhesions within 3-4 weeks of the initial laparoscopy (N = 19) or expectant management (N = 20). One patient assigned to the laparoscopy group refused the procedure. Minimal and mild adhesions that did not distort the normal tubo-ovarian relationship were encountered in 13 patients (68%) in the second-look laparoscopy group; these adhesions were easily lysed using sharp or blunt dissection. The pregnancy rates over 6 months were similar in the two groups (47% in the second-look group and 55% in the expectant-management group; P greater than .05). These data suggest that early laparoscopic lysis of adhesions does not improve short-term conception rates following laparoscopic Nd-YAG laser photocoagulation of polycystic ovaries.

Reproductive performance after conventional metroplasty: an evaluation of 102 cases.

OBJECTIVE: To evaluate the influence of conventional metroplasty on reproductive performance of symmetric uterine anomalies and determine the complications of these procedures. DESIGN: A retrospective clinical analysis of consequently operated 102 women. SETTING: Institutional. PATIENTS AND PARTICIPANTS: One hundred two patients with bicornuate and septate uterus and a history of late recurrent abortion and/or preterm delivery were included in this study. INTERVENTIONS: Jones, Strassman, and Tompkins procedures for metroplasty and McDonald operation for cervical cerclage. MAIN OUTCOME MEASURE: The fetal survival rate has increased from 3.7% before operation to 75.0% afterwards. In only two patients uterine rupture was observed. RESULTS: Conventional metroplasty improves the fetal survival rate in women with symmetric uterine anomalies. CONCLUSIONS: Our results confirm the view that conventional metroplasty seems to be an operation of choice in women with symmetric uterine anomalies and a history of recurrent late abortion and preterm delivery. However, uterine rupture and postoperative infertility may be potential complications.

Remission rates and significance of prognostic factors in gestational trophoblastic tumors.

The clinical courses of 82 women with gestational trophoblastic tumors were evaluated in accordance with International Federation of Gynecologists and Obstetricians staging, traditional criteria and the modified World Health Organization prognostic scoring system. The overall remission rate was 79.3% (65/82), and the mortality rate was 20.7% (17/82). All the patients with nonmetastatic stage I disease and all with prognostic scores less than or equal to 4 attained remission, whereas patients at high risk and with stage IV disease had the lowest remission and survival rates. The results support the validity of each system. However, the World Health Organization scoring system, a combination of traditional criteria and International Federation of Gynecologists and Obstetricians staging seemed to be the most reliable for predicting treatment failures.

Evaluation of adhesion formation after laparoscopic treatment of polycystic ovarian disease.

The incidence and fertility effects of postoperative adhesion formation after laparoscopic ovarian electrocautery or laser photocoagulation of polycystic ovaries has not been adequately analyzed. Short-interval second-look laparoscopy appears to be a useful method for addressing this issue. Employing short-interval second-look laparoscopy 3 to 4 weeks after the initial laparoscopic intervention, we were able to demonstrate adhesions in 6 of 7 patients (85%) treated with ovarian electrocautery and 8 of 10 patients (80%) submitted to laser therapy. The adhesions were amenable to laparoscopic lysis in 12 of 14 patients (85%). The subsequent conception rates within 6 months of second-look laparoscopy that were 57% and 40% in the electrocautery and the Nd:YAG laser groups, respectively, may in part be attributed to the restoration of normal pelvic anatomy during this procedure.

Radionuclide hysterosalpingography. A simple and potentially useful method of evaluating tubal patency.

A prospective study was undertaken to evaluate the efficacy of radionuclide hysterosalpingography (RN-HSG) using 99mTc-labeled human albumin microspheres to assess the patency of the fallopian tubes in 36 women (72 tubes). The study group consisted of 20 women with proven fertility undergoing laparoscopic tubal ligation, 8 with male factor infertility and 8 with bilateral isthmic tubal occlusion. All RN-HSG scan results were correlated with the findings at laparoscopy when tubal patency was ultimately assessed with chromopertubation. The sensitivity and specificity of RN-HSG were 100% and 94.6%, respectively. The positive predictive value (probability of occlusion when RN-HSG was positive) was 84%, whereas the negative predictive value (probability of no occlusion when RN-HSG was negative) was 100%. RN-HSG is a simple and potentially useful method of assessing the patency of the fallopian tubes.

The value of human menopausal gonadotropin treatment in patients with unexplained infertility.

The role of multiple ovulation with human menopausal gonadotropin (HMG) in the treatment of unexplained infertility is evaluated. Of a total 73 patients with unexplained infertility, 39 received four cycles of HMG, whereas, 34 were left untreated. Eight (20.5%) women conceived during HMG treatment, in comparison to only 1 (2.9%) in the control group (P less than 0.05). This study gives further credit to the value of HMG treatment for unexplained infertility.

Pregnancy and its complications after cardiac valve replacement.

The outcome of 64 pregnancies in 40 women who conceived after cardiac valve replacement were reviewed. Fetal wastage was 53.2% (25/47) in coumarin administered pregnancies, 36.4% (4/11) using heparin and 16.7% (1/6) without anticoagulants. Two fetal malformations were noted in coumarin administered pregnancies. There were two maternal deaths. Maternal morbidity due to antenatal bleeding, atrial fibrillation, thromboembolic episodes and cardiac failure were found to be 20.0% (8/40), 17.5% (7/40), 10.0% (4/40) and 10.0% (4/40), respectively.

Evaluation of the functional status of the fallopian tubes in unexplained infertility with radionuclide hysterosalpingography.

The functional status of the Fallopian tubes in patients with unexplained infertility (UI) was evaluated with radionuclide hysterosalpinography (RN-HSG). The rate of bilateral tubal occlusion with RN-HSG in women with UI (3/18 = 16.7%) was considerably higher than in a group of fertile and male-infertile women (0/28 = 0%), implying that a number of cases with UI might be associated with functional rather than anatomical tubal defects. RN-HSG is a simple, innocuous and potentially useful method for assessing functional tubal occlusion, and it might give a better understanding of the functional status of the tubes in UI.