Pregnancy rates in a donor sperm program using cryopreservation: effects of total number of motile sperm inseminated and of a procedure to concentrate sperm.

OBJECTIVE: To determine the relationship between the total number of motile sperm per insemination (TMSI) and pregnancy rates in a donor insemination program. To determine the effect of sperm concentration and resultant increase of TMSI on pregnancy rates. DESIGN: Retrospective analysis of pregnancy rates. SETTING: University hospital with tertiary service. PATIENTS: 179 women undergoing donor insemination. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Calculation of pregnancy rates according to TMSI. RESULTS: The pregnancy rate with insemination of thawed donor sperm increases when the TMSI of unconcentrated sperm is > or = 80 x 10(6). Pregnancy rates with previously concentrated sperm are as good as or better than rates of unconcentrated specimens. CONCLUSION: TSMI is important in determining pregnancy rates in donor insemination programs, and concentration of sperm prior to freezing may enhance pregnancy rates by increasing the TMSI.

A comparative analysis of adhesion reduction, tissue effects, and incising characteristics of electrosurgery, CO2 laser, and Nd:YAG laser at operative laparoscopy: an animal study.

In this study, the relative efficacy and tissue effects of lasers and electrosurgery at operative laparoscopy were evaluated. Thirty rabbits underwent surgical procedures to create extensive intraperitoneal adhesions. The animals were then randomly assigned to laparoscopic adhesiolysis utilizing either electrosurgery, CO2 laser, or Nd:YAG laser exclusively for the assigned group. Each surgical tool was utilized at its optimal power density to achieve the best results. The depth of thermal injury on ovarian and uterine tissues, and the speed at which various segments of the uterine horn were transected were also compared. All three modalities significantly reduced (p < 0.01) intraperitoneal adhesions by approximately 50%. The depth of thermal injury was threefold greater with the Nd:YAG laser than either electrosurgery or the CO2 at both ovarian and uterine tissues (p < 0.001). The speed of transection across the uterine horn was significantly slower (p < 0.001) with the Nd:YAG (2.6 +/- 0.3 sec) than either the CO2 laser (1.4 +/- 0.2 sec) or electrosurgery (1.5 +/- 0.2 sec). From this study, the authors conclude that the Nd:YAG laser causes more tissue damage and is less efficient at incising tissue than either CO2 or electrosurgery, but that all three modalities are equally effective for laparoscopic adhesiolysis.

Laser laparoscopy versus laparotomy in lysis of pelvic adhesions.

Severe adhesions were induced at laparotomy by laser ablation of the surface of one uterine horn and 1 cm2 of pelvic sidewall in 20 rabbits. Three weeks later the rabbits were selected at random for laparoscopy or laparotomy. Adhesions at the horn, sidewall and incidental sites were scored and lysed with laser at similar power densities. Three weeks later animals were killed and adhesions were blindly scored. We found a significant and similar reduction in severe adhesions at uterine horns after either laser laparoscopy or laser laparotomy, better lysis of sidewall and incidental adhesions by laser laparoscopy and formation of de novo adhesions at nonoperative sites after laparotomy but not after laparoscopy. We conclude that (1) de novo adhesions are common after laparotomy; (2) severe uterine horn adhesions can be reduced equally well by both laparoscopy and laparotomy but laparoscopy is superior to laparotomy with less severe peripheral adhesions; (3) outcome of adhesiolysis depends on several variables, including adhesion density and location and approach (laparotomy or laparoscopy), even when the tool (laser) is constant.

Evaluation of Astroglide, a new vaginal lubricant: effects of length of exposure and concentration on sperm motility.

Traditional vaginal lubricants have been shown to adversely affect sperm motility. Astroglide, a new vaginal lubricant, and K-Y Jelly were tested at varying concentrations to assess their suitability for infertility patients requiring a lubricant. The vaginal lubricants tested impaired sperm motility in a concentration-dependent but not time-dependent manner. We conclude that all traditional vaginal lubricants should be avoided in patients desiring conception. Future studies should attempt to mimic in vivo conditions and focus on concentration-dependent effects.

The thrombotic diathesis associated with the presence of phospholipid antibodies may be due to low levels of free protein S.

PURPOSE: To determine if abnormalities in the protein C/protein S anticoagulant system exist in patients with phospholipid antibodies who had the primary clinical complaint of fetal wastage. PATIENTS AND METHODS: Eleven patients with fetal wastage and phospholipid antibodies were selected for study. Some patients also gave a history of previous thrombotic events related to oral contraceptives and/or pregnancy, but patients were not selected because of a history of clinical thrombosis. The levels of protein C (chromogenic assay), protein S (both free and bound) (Laurell rocket), and C4b-binding protein (Laurell rocket) were measured, and assays for the presence of antibodies against protein S or protein C were performed. RESULTS: Seven of the 11 patients were found to have low levels of free protein S. Total protein S and protein C levels were within the normal range in all patients. Antibodies to protein C and protein S were not found in any patient. These findings suggest that free protein S levels may be abnormally low in some patients with phospholipid antibodies. CONCLUSION: Free protein S levels are abnormally low in some patients with phospholipid antibodies, and this abnormality may be a factor contributing to the thrombotic diathesis associated with phospholipid antibodies.

Slow excretion of exogenous human chorionic gonadotropin simulating repeated pregnancies and pregnancy losses.

We report a patient undergoing hMG-induced superovulation who demonstrated delayed excretion of hCG, originally believed to be because of successive biochemical pregnancies. However, sequential hCG titers after administration of exogenous hCG demonstrated a longer than normal half-life for the excretion of hCG in this patient. To what extent delayed excretion of hCG contributes to the diagnosis of biochemical pregnancy in assisted reproductive technology programs has yet to be determined.

Preoperative versus postoperative dextran 70 for preventing adhesion formation.

Since serosal drying and tissue abrasion play an important role in adhesion formation, we tested the hypothesis that the peritoneal instillation of 32% high-molecular-weight dextran 70 (H) before, rather than after, a surgical procedure results in less postoperative adhesion formation and reformation. Twenty rabbits were subjected to a standardized surgical injury on one ovary, the ipsilateral uterine horn and adjacent parietal peritoneum. Three weeks later the animals underwent a second laparotomy to blindly score the adhesions and subsequently lyse them using microsurgical techniques. The animals were randomly assigned to one of two treatment groups, with H administered either before or at the end of each surgical procedure. Three weeks after the second surgical procedure, the animals were killed to blindly score adhesions. There was no difference in the mean adhesion scores between the two groups after either the first (2.0 versus 2.9, NS) or second surgical procedure (5.5 versus 5.1, NS). Thus, we conclude that preoperative instillation of H does not offer any advantage over postoperative instillation in the prevention of either adhesion formation or reformation.

A comparative study of postoperative adhesions following laser surgery by laparoscopy versus laparotomy in the rabbit model.

In this study, we tested the null hypothesis that intraperitoneal adhesion formation and reduction after laser surgery are the same whether the surgery is performed by laparoscopy or laparotomy. Twenty rabbits were randomly assigned to either laparoscopy or laparotomy and subjected to standardized laser incisions over one uterine horn and over the peritoneal surface of either lower quadrant. Three weeks later, five animals from each group underwent laparoscopy and the other five received laparotomy to score the extent of postoperative adhesions formed and to carry out laser adhesiolysis. The same power density was delivered to tissues in both procedures. Three weeks after the second operative intervention, the animals were killed and the intraperitoneal adhesions blindly scored (scale of 0-3). After the initial procedure, adhesions were absent in the laparoscopy group, but in the laparotomy group, adhesions were frequently present not only at the operative sites of the peritoneal surfaces and uterine horn, but also on the bowel, bladder, and opposite uterine horn where no apparent injury had been inflicted (P less than .005). Three weeks after adhesiolysis, a significant reduction was observed in the mean adhesion scores in the laparoscopy group, but not in the laparotomy group (P = .001). These results lead to the rejection of the null hypothesis and confirm the clinical observation that besides reducing operative trauma, discomfort, and cost, laparoscopic laser surgery is very effective in reducing intraperitoneal adhesions and causes significantly less postoperative adhesion formation than does laparotomy.

Human chorionic gonadotropin localization and morphometric characterization of human granulosa-luteal cells obtained during in vitro fertilization cycles.

The area and cytoplasmic-to-nuclear ratio (C/N) of cells aspirated from follicles with mature oocytes was determined using a computerized image analysis system. The presence of human chorionic gonadotropin (hCG) on the surface membrane and/or within the cytoplasm of each cell also was determined using a horseradish peroxidase immunocytochemical procedure. Based on morphometric characteristics, follicular cells were classified as granulosa or luteal. Granulosa cells were less than 75 micron 2 in area with a C/N of approximately 0.5. Luteal cells were classified as small (less than 75 micron 2, C/N approximately 1.5), midluteal (76 to 100 micron 2, C/N greater than 1.5) and large luteal (greater than 100 micron 2, C/N greater than 1.5). Compared with aspirates from follicles containing fertilizable oocytes, aspirates from follicles with nonfertilizable oocytes had fewer granulosa cells and more large luteal cells. HCG was localized on the membranes of granulosa and small luteal cells and within the cytoplasm of midluteal cells. Human chorionic gonadotropin was generally not observed on either the membranes or cytoplasm of luteal cells over 120 micron 2. These data support the concept that granulosa cells bind hCG to membrane receptors, internalize hCG, and begin to luteinize in response to hCG stimulation. Since the aspirates from follicles containing nonfertilizable oocytes possessed a higher percentage of large luteal cells, it is postulated that the cells from these aspirates began the luteinization process earlier than those from follicles containing fertilizable oocytes.

Subclinical autoimmunity in recurrent aborters.

Thirty-four women with habitual abortion (HA) were evaluated for the presence of lupus-associated autoantibodies, antisperm antibodies, and evidence of complement abnormalities. A control group of women who had only successful pregnancy outcomes also was studied. Fourteen HA women had anatomic, genetic, or hormonal causes for their pregnancy losses ("explained losses"), and 20 had no apparent causative factors ("unexplained losses"). Fifty percent of HA women with unexplained losses and 34% of women with explained losses had at least one abnormal result, but multiple autoimmune abnormalities were found only in women with unexplained losses. Anticardiolipin antibodies were found most commonly (30% of all HA women and 8% of controls). Two clinically normal HA women had multiple autoantibodies detected. This study suggests that recurrent pregnancy loss may be a marker for subclinical autoimmune disease.

Stimulation of uterine prolactin secretion by human chorionic gonadotropin and progesterone in the cynomolgus monkey.

The ovulating cynomolgus monkey secretes immunoreactive prolactin (PRL) into the uterine cavity. Consistent with human endometrial explant data, uterine PRL is undetectable in the early secretory phase, then increases from the mid to late secretory phase, peaking premenstrually. The anovulatory monkey does not produce detectable uterine PRL. Human chorionic gonadotropin given repeatedly fails to induce PRL secretion in anovulatory monkeys but prolongs the luteal phase and thereby PRL secretion in ovulatory monkeys. Progesterone (P) induces PRL secretion in anovulatory monkeys after estrogen priming with a time delay of several days, indicating probable de novo synthesis. P appears to be an important stimulating factor in the control of uterine PRL secretion.

Human uterine luminal fluid volumes and prolactin levels in normal menstrual cycles.

Human uterine luminal fluid has not been well characterized. Prolactin is produced in vitro by decidualized human endometrium and is secreted in vivo into the uterine luminal fluid of cynomolgus monkeys. Uterine luminal fluid prolactin has not been demonstrated in vivo in human beings. To study cyclic uterine luminal fluid volumes and prolactin levels, uterine luminal fluid was aspirated 8 to 13 times each during a single menstrual cycle in six ovulatory women. No anesthesia was used. Seventy of 75 (93%) attempts were successful; there were no complications. Serum estradiol, progesterone, luteinizing hormone, and prolactin levels were assayed every 1 to 3 days. Uterine luminal fluid volume and prolactin were normalized to the luteinizing hormone peak (day 0). Uterine luminal fluid volumes were relatively constant until the early luteal phase, when they then decreased. Uterine luminal fluid prolactin was detectable in all samples. Mean values were stable until day +3 or +4, after which they rose to a peak at day +9 or +10. This study establishes that (1) frequent uterine luminal fluid sampling is possible; (2) uterine luminal fluid volume decreases in the luteal phase; (3) uterine luminal fluid prolactin is detectable in vivo in women and its concentration increases in the luteal phase; and (4) cyclic human uterine luminal fluid prolactin levels differ from those in cynomolgus monkeys and from those anticipated from human in vitro studies.

A comparison of thermal injury, healing patterns, and postoperative adhesion formation following CO2 laser and electromicrosurgery.

To further define the role of CO2 laser in infertility surgery, the authors compared the immediate tissue damage and the subsequent healing patterns that followed the randomized use of CO2 laser and electrocautery on opposite sides of the reproductive tracts of 20 mature, female rabbits. Blind histopathologic evaluations were performed on the ovarian and uterine tissues immediately to compare the extent of the acute thermal damage, and 4 weeks postoperatively to compare the healing patterns. There were no differences in the depth of thermal damage, extent of collagen deposition, or in postoperative adhesion formation between CO2 laser and electrocautery. However, the mean depth of the acute thermal damage was significantly less on the ovary than on the uterus, and the area of fibrosis was significantly less when the incised uterine surfaces were approximated.

Ultrasonographic monitoring of follicular growth for luteal phase defects.

In the evaluation of 39 patients with untreated and treated luteal phase defect (LPD), serial ultrasonographic monitoring of follicular development identified three morphologically distinct growth patterns: normal-sized follicles, small follicles, and luteinized-unruptured follicles. All three patterns were observed in both untreated (46% had normal-sized follicles, 39% had small follicles, 15% had luteinized-unruptured follicles) and treated patients. A small follicle was observed uncommonly in histologically corrected LPD patients (6%). However, a luteinized-unruptured follicle (38%) may persist or be induced in situations where clomiphene citrate has been used to correct LPD or induce ovulation. Ultrasonographic evaluations of follicular growth in luteal phase defect support the theory that luteal phase defect represents a spectrum of normal and abnormal ovarian cycle events.

An evaluation of late luteal phase endometrium in women requesting reversal of tubal ligation.

It has been suggested that tubal ligation may cause luteal phase defects. To assess this possibility, we performed a retrospective analysis of the incidence of luteal phase defects in 72 women who had undergone tubal sterilization. In preparation for tubal reanastomosis, late luteal phase endometrial biopsy was performed. The biopsy was dated in a blind manner and designated either normal or out of phase. This group of patients was compared with a group of 32 women seen for artificial insemination with donor sperm. Luteal phase defect was defined as two biopsies out of phase by two or more days. There were no cases of luteal phase defect in either of the two groups; luteal phase defects were found in 4% of all infertility patients seen during the time of this study. These data do not support the contention that sterilization by tubal ligation leads to an increased incidence of luteal phase defect.

Successful pregnancy outcome after therapy for a müllerian anomaly with concomitant sex chromosomal mosaicism. A case report.

Recurrent abortion associated with both a chromosomal abnormality and a müllerian anomaly has been reported previously only once. A 31-year-old woman was referred for secondary habitual abortion and found to have sex chromosome mosaicism, subseptate uterus and chronic endometritis. Following hysteroscopic resection of the subseptum and antibiotic therapy for the endometritis, a term pregnancy ensued. Complete evaluation and treatment of all correctable etiologies of recurrent pregnancy loss are essential in such cases.

Comparison of real-time ultrasonography, hysterosalpingography, and laparoscopy/hysteroscopy in the evaluation of uterine abnormalities and tubal patency.

In a study to assess real-time ultrasonography (US) as an alternative to hysterosalpingography (HSG) in the evaluation of uterine abnormalities and tubal patency, 61 women underwent US immediately before hysteroscopy/laparoscopy. Saline was instilled into the uterus to provide contrast during US. The findings were compared with surgical and preoperative HSG findings. With surgical findings as the standard, US was as accurate (sensitivity 98%, specificity 100%) as HSG (sensitivity 98%, specificity 92%) in demonstrating uterine abnormalities and provided a more complete assessment of the abnormality. US was as accurate (sensitivity 100%, specificity 91%) as HSG (sensitivity 96%, specificity 94%) in demonstrating the presence of tubal patency but less accurate in establishing which tubes were patent. Thus real-time US with fluid instillation provides an accurate alternative to HSG in screening for uterine abnormalities and tubal patency.

Uterine fluid and prolactin secretion in the ovulating cynomolgus monkey.

Immunoreactive prolactin is produced by late secretory human endometrium in vitro. Human myometrium in explant culture also produces prolactin. A primate model with the use of the cynomolgus monkey is described that allowed repeated samplings of uterine secretions in vivo. The uterine secretory prolactin thus measured appears immunoreactively similar to human serum prolactin, and the pattern of secretions reflects the previously described pattern of endometrial prolactin production in vitro.

Prenatal diethylstilbestrol exposure alters murine uterine responses to prepubertal estrogen stimulation.

Prepubertal estrogen stimulation was used to investigate the effects of prenatal diethylstilbestrol (DES) exposure on subsequent growth, secretory activity, and cellular differentiation of the mouse uterus in vivo. Secretory activity was examined using sensitive silver staining of two-dimensional gel electrophoresis of uterine luminal fluid (ULF). Decreased uterine growth response, decreases in ULF quantity and protein concentration, alterations in specific ULF proteins, and altered cellular differentiation were found. This system provides a method for evaluation of the effects of prenatal exposure to DES or other compounds on the estrogen-induced secretory activity of the uterus. The alterations found in this study may be partially responsible for the decreased fertility in this mouse model and may have implication for DES-exposed women.