The role of sperm banking in fertility preservation.

OBJECTIVE: To investigate factors that influence sperm banking before cancer therapy and assess the use and disposal of banked sperm after cancer treatment. STUDY DESIGN: Database exploratory study combined with questionnaire survey of a cohort of 55 men who cryopreserved their sperm at an Andrology Clinic. MAIN OUTCOME MEASURE(S): Rate of use, disposal and abandonment of banked sperm, current fertility, and patient satisfaction with sperm banking. RESULTS: Using logistic regression, we analyzed the factors associated with use and disposal of banked sperm, current fertility status, reproductive outcomes and quality of life in 55 survivors of cancer therapy who cryopreserved sperm at our facility. Most (93%) of the patients undergoing sperm banking before cancer treatment did not use their samples and 33% requested sperm disposal following completion of cancer therapy. Married status and fatherhood before cancer therapy were associated with higher rates of sperm disposal. Sperm disposal was requested because the subjects remained fertile, spontaneously fathered a child, or completed their family. The families of four patients (7%) who died from their cancer also requested disposal of the stored sperm. Six (11%) patients could not be located or failed to contact the clinic and were considered to have abandoned their banked sperm. Only 7% of the patients used their cryopreserved sperm for assisted reproduction. Most of the patients that banked sperm achieved pregnancy with their partners through spontaneous conception compared to through the use of cryopreserved sperm. CONCLUSIONS: The rates of disposal and abandonment of banked sperm were high following cancer therapy. Retention of fertility appears to contribute to the low utilization of banked sperm, which emphasizes the need for appropriate consent and directives regarding disposal of unused cryopreserved sperm.

Ovarian follicular development is initiated during the hormone-free interval of oral contraceptive use.

We evaluated ovarian follicular development in women during compliant use of oral contraceptives (OC). Thirty-six healthy women received: [35 microg ethinyl estradiol (21)/180 microg norgestimate (7), 215 microg norgestimate (7), 250 microg norgestimate (7)]; [30 microg ethinyl estradiol (21)/150 microg desogestrel (21)]; or [20 microg ethinyl estradiol (21)/100 microg levonorgestrel (21)] for 3 consecutive 28-day cycles. Transvaginal ultrasonography was performed every third day to monitor follicular development. If a follicle reached > or = 14 mm, ultrasonography was performed daily and blood drawn every other day to determine estradiol-17beta concentrations. Seventeen of 36 women (47%) grew follicles > or = 10 mm. Nine of the 17 women (53%) grew follicles > or = 14 mm, in association with increased serum concentrations of estradiol-17beta. Thirty-seven of 43 follicles > or = 10 mm (86%) emerged during the hormone-free interval (HFI). No ovulations were observed. Our results supported the hypothesis that follicular development to an ostensibly ovulatory diameter occurs during compliant OC use, in association with loss of endocrine suppression during the HFI.

A prospective study of induction of labor with prostaglandin vaginal gel: ambulatory versus in-patient administration.

BACKGROUND: Elective induction of labour is a common obstetrical practice. Dinoprostone (prostaglandin E2 in triacetin base gel) has been shown to be an effective and fairly safe agent for this purpose in inpatient settings. Currently published work does not assess the effectiveness and safety of dinoprostone in an ambulatory setting. OBJECTIVE: To assess the difference between inpatient and outpatient use of dinoprostone for elective induction of labour with regard to effectiveness, safety, length of hospital stay, and patient satisfaction. METHODS: A prospective non-randomized study, in which two groups of low risk obstetrical patients who were undergoing elective induction of labour were studied. The outpatient group was drawn from Regina Health District while the inpatient (control group) was drawn from Saskatoon. The maternal and fetal morbidity was compared in both groups as well as the efficacy, length of hospital stay and degree of patient satisfaction. RESULTS: There were statistically significant reductions in the length of hospital stay and greater patient satisfaction in the outpatient group. No difference was found in efficacy and safety of prostaglandin use. CONCLUSIONS: The findings suggest that ambulatory use of prostaglandin gel for induction of labour reduces the length of hospital stay, and leads to greater patient satisfaction. Further randomized studies with a larger number of patients are needed to evaluate the safety of this agent in an ambulatory setting.

Screening of potential semen donors for sexual transmitted diseases.

BACKGROUND AND OBJECTIVES: The risk of infection with sexually transmitted diseases (STDs) is of great concern to couples undergoing therapeutic donor insemination. GOAL OF STUDY: We sought to determine the prevalence of STDs in potential semen donors and assess the rate of acquisition of new infection during the follow-up period. STUDY DESIGN: 29 potential semen donors were screened for common STDs. RESULTS: The study population had a prevalence of the following STDs: 27.5% ureaplasma, 13.8% mycoplasma, 6.9% cytomegalovirus 6.9% group B streptococcus, and 3.4% human papillomavirus infection. No participant tested positive for gonoccoccal or HIV infection. Over all, evidence of STD was present in 10 of 29 (34.5%) prospective donors. A follow-up infection rate of 22.2% (6 of 27 enrolled donors) was found and 3 (11.1%) of these were excluded from semen donation. CONCLUSION: A high prevalence of sexually transmissible infections is present in potential semen donors. New infections are also common during the follow-up period.

The teaching of evidence-based reproductive health in developing countries.

Evidence-based medicine is gaining increased importance in clinical practice. Unfortunately, prevailing circumstances have prevented this application of the best available evidence to clinical decision-making for reproductive health in developing countries. Poor infrastructure, inadequate personnel, gross underfunding of services for health and education as well as a conservative education system are obstacles in effecting change. By examining these impediments, we suggest strategies for clinical education and research with the aim of improving reproductive health care in developing countries. Evidence-based reproductive health will be promoted through access to appropriate information, interest from government and consumers, curriculum changes, application of research findings and finally, the judicious use of its principles in clinical practice.

How important is health promotion in the lifestyle of infertile couples?

UNLABELLED: We sought to elucidate the current attitudes and practices of infertile couples concerning unhealthy lifestyle practices, and examine the extent to which the couples engaged in health promoting activities. METHODS: The study population consisted of consecutive couples who first attended an infertility clinic at a tertiary care clinic between July 1, 1995 and June 30, 1996, and voluntarily completed a questionnaire centered on knowledge, attitude and practices pertaining to unhealthy lifestyles as well as health promoting activities. RESULTS: The majority of the 106 couples 53%, reported cigarette smoking by at least one partner; 69% admitted to alcohol consumption; and 77% were using over-the-counter drugs. Only 28% of the smokers were knowledgeable about the value of smoking cessation intervention. In 11 of the 50 (22%) nonsmoking couples, both partners had stopped smoking because of their infertility. Awareness of the adverse effects of smoking on fertility was more common among nonsmokers and females. A large proportion of respondents failed to appreciate the periconceptional risks of alcohol consumption and over-the-counter drugs. Only 59 per cent of alcohol users considered its consumption to be undesirable when trying to conceive. Over-the-counter drugs were not considered to impair fertility by 71% of respondents. Compared to males, females were more conducive to health promotion practices as exemplified by smoking cessation, avoidance of second hand smoking, and regular exercising. CONCLUSIONS: Infertile couples seeking medical intervention often disregard lifestyle factors having adverse effects on fertility. Clearly, there is a need for early education on the value of health promotion and prevention in relation to the management of infertility.

Spontaneous ovarian hyperstimulation syndrome in four consecutive pregnancies.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is almost exclusively associated with ovulation induction with gonadotropins or occasionally, clomiphene citrate. Severe ovarian hyperstimulation associated with a spontaneously conceived pregnancy is rare with only two previous reports. Misdiagnosis as a neoplastic process may result in inappropriate intervention. CASE: A patient with polycystic ovarian disease experienced severe spontaneous OHSS in four consecutive singleton pregnancies. Serial color and pulsed Doppler ultrasonographic imaging facilitated adequate evaluation of the patient and permitted conservative therapy. She achieved live births in two of the pregnancies. This is the third reported case of spontaneous OHSS associated with pregnancy and the first to result in live births. In one previous report, misdiagnosis resulted in inadvertent castration. CONCLUSIONS: Spontaneous ovarian hyperstimulation syndrome and pregnancy may occur in patients with polycystic ovarian disease. Color Doppler ultrasonography is a useful aid in the diagnosis and management of this rare complication, and in avoiding inappropriate intervention.

Delayed interval delivery in quadruplets.

Prolonged interdelivery periods in preterm twin and triplet gestations have resulted in a good outcome for the fetus(es) remaining in utero. This is the second reported case of delayed delivery intervals in quadruplets who were born on 3 separate days. We report on a set of quadruplets following gonadotropin induction of ovulation, in which preterm delivery of the first infant occurred at 26 weeks' gestation. Active uterine contractions ceased and ultrasonography confirmed the remaining triplets to be in separate amniotic sacs with satisfactory heart rate tracings. With bed rest and tocolysis, the delivery of the second infant did not occur until 8 days later. After a further 36-h delay, placental abruption prompted cesarean delivery of the remaining twins. The first infant died of sequelae of prematurity at 7 months, while the remaining triplets survived and are neuro-developmentally normal 1 year after delivery. This report demonstrates the feasibility of prolonging the delivery interval of the fetus(es) in higher order multiple gestations, using tocolysis and watchful expectancy, after the preterm birth of one or more fetuses.

Emergency cerclage compared with bed rest for advanced cervical dilatation in pregnancy.

In a cohort of 43 women with viable, singleton pregnancies, cervical dilatation greater than 4 cm, and absent labor between 20 and 27 weeks gestation, 22 women who underwent emergency cerclage within six hours of admission, were compared prospectively with 15 women who elected conservative bed rest treatment. The two groups were demographically similar. Emergency cervical cerclage resulted in a longer mean gestational age at delivery compared to bed rest (p = 0.001). Women treated with cerclage required a significantly shorter period of antepartum hospitalization (p = 0.001), required less tocolysis (p = 0.005), and experienced fewer preterm membrane ruptures compared to women in the bed rest group (p = 0.01), although the latency period, following preterm rupture of membranes was shorter in the cerclage group (p = 0.005). There was no statistical difference in the frequencies of chorioamnionitis, maternal morbidity and cesarean section between the two groups. Although the perinatal mortality in the two groups was not significantly different (p = 0.3), emergency cerclage resulted in a significantly higher mean birth weight compared to conservative bed rest treatment (p = 0.02). This study demonstrates the superiority of emergency cerclage to bed rest in women with advanced cervical dilatation and absent labor in late second-trimester of pregnancy.

Induction of labor using prostaglandin E2 (PGE2) vaginal gel in triacetin base. An efficacy study comparing two dosage regimens.

OBJECTIVE: To compare two dosage regimens for the administration of vaginal prostaglandin gel in triacetin base for induction of labor. METHODS: Seventy subjects planned for elective induction of labor at term were randomized to treatment with PGE2 vaginal gel every 6 or 12 hours. The 6-hourly group received an initial dose of 1 mg, followed by 2 mg at 6 hour intervals for a maximum of two additional doses if not in active labor. The 12-hourly group had an initial dose of 2 mg followed by two additional doses at 12 hour intervals if not in active labor. RESULTS: Successful induction rate was higher in the 12-hourly as compared to 6-hourly gel regimen (100% vs. 91%, P > 0.05). Twelve hours after the initial dose, delivery occurred in 34% delivery had occurred in 57% and 37% respectively (P < 0.01). We found no difference in the induction-active labor interval (P > 0.05), and the induction-delivery interval (P > 0.05) between the two groups. Active labor followed a single dose of gel in 66% of the 12-hourly group compared to 40% of the 6-hourly group (P < 0.01). Syntocinon augmentation was needed in 6% of subjects in the 12-hourly group as compared to 26% in the 6-hourly group (P < 0.01). The cesarean section rate was similar in both groups. Uterine hyperstimulation occurred less frequently in the 12-hourly group (P < 0.05). The perinatal outcome was similar in both groups. CONCLUSIONS: The 12-hourly regimen was more effective than the 6-hourly regimen in initiating labor. The majority of the subjects in the 12 hourly group achieved labor following a single dose of gel. Induction delivery interval, however, was similar in both groups.

Outcome of cryosurgery for cervical intraepithelial neoplasia in a developing country.

Over a 2-year period cryosurgery was used to treat 73 women who were diagnosed by colposcopy and histologic studies to have cervical intraepithelial neoplasia (CIN). Follow-up was achieved for 70% at 5 years, a significant attendance rate in a developing country. The primary cure rate was 88.5% at 1 year and 90% at 5 years (excluding those lost to follow-up) in all patients with different grades of CIN. The therapy was free of major complications and we found no adverse effect of cryosurgery on subsequent reproductive function in those desiring pregnancy. We conclude that cryosurgery has gained wide acceptance in our geographic area particularly because of its low cost, efficacy and preservation of fertility. For these reasons we would strongly recommend its use provided adequate attention is paid to meticulous pretreatment evaluation and long-term follow-up after therapy.

Ventriculoperitoneal shunt and pregnancy.

A pregnancy in a patient with ventriculoperitoneal (VP) shunt was recently managed at the authors's institution. Review of the literature showed only six previous case reports. The management of this uncommon neurosurgical condition in pregnancy is presented along with a review of the literature. We conclude that pregnancy in a patient with a VP shunt for maternal hydrocephalus, generally has a normal outcome and that the function of the shunt is unaffected by pregnancy.

Screening for cervical neoplasia in an African population: simultaneous use of cytology and colposcopy.

In many countries cytologic screening for cervical cancer has become firmly established and accepted. This has not been the case in some developing countries because of limited financial and manpower resources. In a series of 1564 patients, simultaneous colposcopy and cytology revealed 31 women with varying degrees of cervical intraepithelial neoplasia. We feel that an initial combination of colposcopy and cytology provides a more reliable diagnosis of cervical lesions and a case is made for the establishment of mass cytologic screening in Nigeria.

Early experience with in vitro fertilization-embryo transfer and gamete intrafallopian transfer in a Nigerian hospital.

We present our early experience with in vitro fertilisation-embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT) in a Nigerian Hospital. Twenty-one patients were recruited, 11 patients for the IVF-ET program and 10 for the GIFT program. In the IVF program the oocyte recovery rate was 100%, the fertilization rate was 66% and the cleavage rate was 97% but no live pregnancies were achieved. In contrast, one live delivery was achieved with GIFT. These results suggest that both IVT-ET and GIFT are feasible in developing countries.

Cesarean versus vaginal delivery in abruptio placentae associated with live fetuses.

In order to test the relative effectiveness of cesarean section and vaginal delivery in mild abruptio placentae associated with live fetuses, 23 consecutive patients were delivered vaginally and 18 by cesarean section over an 18-month period at the University of Ife Hospital in Nigeria. The perinatal mortality of the vaginal delivery group (52.2%) was significantly greater than that of those delivered by cesarean section (16.7%) (P greater than 0.02; less than 0.05; chi 2 test). The 1-min Apgar score test was also significantly greater than that of those delivered by cesarean section (P greater than 0.001). These differences have been attributed to the admission-to-delivery interval, which was significantly longer in the vaginal delivery group (12 h vs. 2 h). It is concluded that cesarean section is clearly superior to vaginal delivery in the management of abruptio placentae associated with live fetuses.

Delayed interval delivery in triplet pregnancy: report of a single case and review of the literature.

A case report of delayed delivery of 99 days in a triplet pregnancy is presented. A triplet pregnancy in a single uterus resulted from Pergonal stimulation of ovulation. At 23.5 weeks' gestation, the first triplet delivered after spontaneous rupture of membranes. Ninety-nine days later, the remaining two fetuses were delivered, the second one stillborn after intrauterine death at 37 weeks of gestation, and the third fetus a normal viable female consistent with 37.5 weeks' gestation. This is the longest interval of delayed delivery discovered from a literature review, and the only such instance of triplet pregnancy in a single uterus.

Cervical cerclage operation for a dilated cervix.

Twelve pregnant women with previously undiagnosed cervical incompetence each presented with membranes bulging through a widely dilated cervix and were treated by a cerclage procedure. This emergency closure of the open cervix resulted in a high rate of fetal salvage; 10 of the 12 women were delivered of surviving infants.