Human uterine transplantation: a review of outcomes from the first 45 cases.

Uterine transplantation restores reproductive anatomy in women with absolute uterine factor infertility and allows the opportunity to conceive, experience gestation, and acquire motherhood. The number of cases being performed is increasing exponentially, with detailed outcomes from 45 cases, including nine live births, now available. In light of the data presented herein, including detailed surgical, immunosuppressive and obstetric outcomes, the feasibility of uterine transplantation is now difficult to refute. However, it is associated with significant risk with more than one-quarter of grafts removed because of complications, and one in ten donors suffering complications requiring surgical repair. TWEETABLE ABSTRACT: Uterine transplantation is feasible in women with uterine factor infertility, but is associated with significant risk of complication.

A decade of the sperm-washing programme: correlation between markers of HIV and seminal parameters.

OBJECTIVES: The aim of the study was to use a decade of experience of sperm washing to assess the effect of HIV disease on semen parameters and to highlight the continuing importance of risk reduction when some controversially advocate the safety of timed unprotected intercourse for conception in the 'stable' HIV-positive man. METHODS: Semen parameters of 439 fresh samples used for sperm washing/intrauterine insemination (IUI) were correlated against markers of HIV disease [CD4 cell count, viral load (VL), duration of HIV infection and use of antiretroviral therapy] and the risk of detectable virus in semen was assessed. RESULTS: A significant positive correlation was observed between CD4 cell count and total sperm count, progressive motility, post-preparation/insemination concentration, progressive motility and total motile count inseminated (TMCI), and a significant negative correlation was observed between CD4 cell count and normal sperm morphology (Spearman's correlation; P<0.05). There was no significant difference in any parameter between samples in which VL was detectable and those in which it was undetectable. The use of highly active antiretroviral therapy (HAART) significantly decreased total sperm count, progressive motility, post-preparation count and TMCI and significantly increased proportion of abnormal forms (Mann-Whitney tests; P<0.05). There was a significant negative correlation between duration of HAART use and concentration, total sperm count and post-preparation motility and between years since diagnosis and post-preparation motility. In 9.7% of IUI cycles performed with fresh sperm in men on HAART with undetectable VL, detectable HIV was found in either pre- or post-wash seminal samples. CONCLUSION: Our data suggest a negative effect of low CD4 cell count and the use of HAART on semen. The significant proportion of 'stable'; men with undetectable serum VL but virus in semen confirms the continued importance of such risk reduction.

The role of sperm aneuploidy as a predictor of the success of intracytoplasmic sperm injection?

BACKGROUND: We present the first powered prospective study to assess whether sperm aneuploidy can predict the outcome of ICSI. METHODS: Our null hypothesis was that aneuploidy rates (AR) are identical in men who achieve successful (Group A) and unsuccessful (Group B) ICSI outcome. A power calculation yielded a sample number of 56 to achieve 80% power to reject our hypothesis at the 5% significance level. Samples for testing were obtained on the day of embryo transfer and tests were performed on raw pre-preparation samples. Sperm AR of chromosomes 13, 18, 21, X/Y were assessed using fluorescence in-situ hybridization (FISH) techniques (mean of 1223 sperm). RESULTS: There was no significant difference in any patient, seminal, cycle or laboratory characteristic between groups that may have affected outcome. Total AR (2.37 versus 1.18%, P = 0.01), as well as AR of chromosomes 18, X/Y and 18 + X/Y (1.48 versus 0.67%, P = 0.005) were significantly higher in Group B compared with Group A. Regression analysis confirmed these differences to be independent of other variables and showed a 2.6-fold change in odds of achieving a pregnancy for every 1% change in total AR. CONCLUSIONS: Our findings confirm a potential role for aneuploidy testing in the work-up of ICSI patients as a predictor of success, as well as in future genetic counselling. If confirmed, there may also be a place for a study of preimplantation genetic screening to improve ICSI success in men found to have high AR and ICSI failure.

HIV and reproductive care--a review of current practice.

In developed countries, antiretroviral treatment has increased life quality and expectancy of HIV-infected individuals and led to a drop in mother-to-child transmission (MCT) risk to below 1%. Fertility has been shown to be reduced in both men and women with HIV. As a result of these factors, the demand for reproductive care in this population is rising. In discordant couples where the man is positive, sperm washing significantly reduces viral transmission risk to the uninfected female partner over unprotected intercourse. Positive women do not necessarily need specialised fertility treatment but should be monitored closely during pregnancy to minimise MCT risk.

Male-factor infertility: do we really need urologists? A gynaecological view.

The Royal College of Obstetricians and Gynaecologists state that male factor infertility is responsible for up to 25% of all cases of infertility and may contribute in a further 25%. Where the role of the urologist ends and gynaecologist begins in these couples is a matter of debate. We therefore discuss the management of these couples and the need for a multidisciplinary approach.

Does the cause of obstructive azoospermia affect the outcome of intracytoplasmic sperm injection: a meta-analysis.

OBJECTIVE: To define whether the outcome of intracytoplasmic sperm injection (ICSI) using sperm surgically retrieved from men with obstructive azoospermia (OA) depends on the cause of obstruction. PATIENTS AND METHODS: We first analysed our data and then used a meta-analysis of published data (including ours) to compare the outcome of ICSI in OA, classified in terms of congenital and acquired causes. The present study comprised 82 couples who underwent 127 ICSI cycles using surgically retrieved sperm. The cause was classified as congenital bilateral absence of vas deferens (CBAVD, in 20), after vasectomy (56), infective/inflammatory (21), noninfective (24) and ejaculatory (five). Five reports (687 cycles) including the present were identified as suitable for meta-analysis. RESULTS: Analysis of the present data showed that fertilization and live-birth rates were highest in men with a previous vasectomy and no infective cause (vasectomy 51% and 23%; not infective 53% and 29%, respectively) and lowest in men with infective or inflammatory causes. There was no difference in outcome if the sperm was fresh or frozen, or whether epididymal or testicular. Meta-analysis comparing congenital (CBAVD) and acquired causes showed a significantly increased fertilization rate (95% confidence interval, 0.84-1) with acquired causes. Meta-analysis of the three papers reporting delivery outcome showed no difference in live-birth rate but a significantly higher miscarriage rate in the congenital group (relative risk 2.67). CONCLUSION: In ICSI cycles in men with OA the cause appears to influence the outcome, but outcome is not affected by whether the retrieved sperm is fresh, frozen, epididymal or testicular. The meta-analysis suggested a higher fertilization rate and lower miscarriage rate in acquired causes of OA.

The results of 154 ICSI cycles using surgically retrieved sperm from azoospermic men.

BACKGROUND: The effects of source of sperm, aetiology and sperm cryopreservation on ICSI cycles in azoospermic men were evaluated. The effect of aetiology of azoospermia on embryo development was also assessed. METHODS: This study was a retrospective analysis of 154 cycles (91 couples) using surgically retrieved sperm. Outcome measures were fertilization rate (FR), implantation rate (IR), and clinical pregnancy rate (CPR) and livebirth rate (LBR) per transfer. RESULTS: Our data demonstrated similar outcome between the use of epididymal or testicular sperm in men with obstructive azoospermic (OA). FR and IR were significantly lower (P < 0.05) using sperm from men with non-obstructive azoospermic (NOA), but although pregnancy outcome appeared lower, this did not reach statistical significance (P = 0.08). Cryopreservation of epididiymal sperm did not alter outcome, but the use of frozen-thawed testicular sperm did demonstrate a lower FR, with no statistical difference in IR or pregnancy outcome. Embryos derived from NOA sperm had impaired development beyond day 2 post-oocyte retrieval (OA, 44% <5 cell; NOA, 71% <5 cell; P = 0.002). CONCLUSIONS: The use of sperm from men with NOA significantly affects fertilization and implantation in ICSI cycles. The use of frozen-thawed testicular sperm affects fertilization rate without significantly altering pregnancy outcome. The use of such data on which to base clinical decisions needs to be supported by the meta-analyses of previous reports.

'Midwifery is not a fit occupation for a gentleman'.

From the earliest-known visual representation of a birth scene in an ice-age relief, through the anatomical works of De Vinci, to images from the 17th-century artists, there is a plethora of works accompanied with anecdotes that make any journey into the history of obstetrics a fascinating one. I do not profess that my intriguing period locked away in various archives and libraries has left me an expert on the history of my speciality; it has merely wet my appetite and opened up a sphere of interest that clinicians all too often neglect.

From zero to one hundred million in six months: the treatment of azoospermia in congenital adrenal hyperplasia.

In the majority of the 25% of couples in which a male factor is responsible for their infertility, no identifiable pathology is found. It is unusual to be faced with an etiology that is readily amenable to successful treatment without the eventual dependence on assisted reproductive techniques for pregnancy. The diagnosis of congenital adrenal hyperplasia has variable implications on fertility. A case is presented of azoospermia in a man diagnosed with classical non-salt-losing congenital adrenal hyperplasia. Within 9 months of treatment with dexamethasone, his sperm count had risen to above 100 million per milliliter, enough to overcome very poor morphology and a naturally conceived pregnancy ensued. The pregnancy is ongoing. Although an increase in sperm count has been shown in such cases, the degree of improvement in semen parameters is unique, especially in an azoospermic patient.

Significant improvement in quality of caesarean section documentation with dedicated operative proforma--completion of the audit cycle.

In the current climate of rising caesarean section rates coupled with the increasingly litigious nature of modern medical practice, and particularly obstetrics, well-documented operative notes are important. We therefore set out to audit the quality of caesarean section documentation in a busy Greater London University Hospital with over 4500 deliveries per annum. The study involved 137 case notes between 1 November and 31 December 1999 and the same number at re-audit 2 years later. The results of the initial audit showed important omissions in a high percentage of operative delivery notes, with less than 80% of case notes documenting skin incision time and type, surgical findings of note, type of uterine incision, presenting part, explanation of fetal delivery, uterine cavity check, presence of a paediatrician, adnexal check and complete sutures used. CNST (Clinical Negligence Scheme for Trusts) guidelines were not adhered to, with only 41% and 35% of delivery notes having complete signature with printed name and correct time and date, respectively. There was considerable confusion at the use of the terminology for level of urgency of non-elective sections and the umbilical cord blood gas results were also poorly documented. As a consequence of these findings a dedicated 'operative delivery note' proforma was designed according to CNST guidelines, with clear areas for particular details of note such as the clinician's name and grade, cord pH results as well as the more important surgical findings. It also simplified the documentation of the urgency of the procedure. There was a significant improvement in almost all items assessed. We therefore conclude that the use of a specific dedicated operative proforma leads to significantly improved documentation with potentially beneficial medicolegal implications.

Audit of primary care and initial secondary care investigations set against RCOG guidelines as standard in cases of subfertility.

Subfertility affects one in seven couples in the United Kingdom and is associated with considerable patient stress and anxiety. The RCOG, with the publication of the evidence-based guidelines, gives us clear recommendations on the initial investigation of the infertile couple. Against these guidelines we audited patient care over a period of 5 months in a dedicated consultant-led infertility clinic. Our results show that a considerable number of patients failed to have the correct advice clearly documented, and the initial primary care investigations of mid-luteal progesterone and semen analysis were performed correctly with results available in only 33% and 2% of occasions, respectively. There were, however, areas where the guidelines were adhered to very efficiently. To improve care we recommend the use of an infertility referral form for use in primary care upon which the practitioners can fill in the appropriate details and be guided on the necessary investigations.