Improved pregnancy outcome in a patient with renal allograft nephropathy undergoing temporary hemodialysis.

We report a case of a woman with a poorly functioning renal allograft and a positive anti-cardiolipin antibody who was dialysis-independent and conceived 18 months following her transplant. She was electively maintained on hemodialysis during the pregnancy and delivered a live infant at 31 weeks gestation. Her renal function returned to prepregnancy levels post partum and she remained dialysis-independent.

Invasive testing for the karyotyping of mid-trimester intrauterine fetal death (IUFD): a pilot study.

INTRODUCTION: Aneuploidy remains a common cause of fetal loss after the first trimester. Conventional karyotyping from fetal solid tissues post-delivery unfortunately has a poor success rate particularly where the fetus is macerated. To overcome this we obtained amniocentesis and/or chorionic villus samples from mid-trimester intrauterine fetal deaths (IUFDs) prior to medical termination of pregnancy. SUBJECTS: Ten women with diagnosed IUFD between 12 and 24 weeks' gestation underwent amniocentesis and/or CVS performed after counselling. RESULTS: Successful karyotypes were obtained in all pregnancies. Five of the ten pregnancies were complicated by aneuploidy (two with trisomy 21, two with trisomy 18, and one with trisomy 13). CONCLUSION: The high rate of aneuploidy (50%) in this small cohort emphasises the need for karyotyping. A successful karyotype in all ten pregnancies demonstrates the value of offering these procedures before a termination of pregnancy. We would recommend the adoption of this approach in the management of IUFD occurring after the first trimester.

Anaesthetic management of a pregnant patient in a persistent vegetative state.

Pregnancy in a patient in a persistent vegetative state presents challenging therapeutic questions about the level of supportive management required, the assessment of fetal well-being, the timing and mode of delivery and the anaesthetic management of labour and delivery. We report the case of a 29-yr-old woman who had a favourable fetal outcome despite suffering hypoxic brain damage after a suicide attempt by a drug overdose. She was managed until the onset of labour on an intensive care unit and had a spontaneous vaginal delivery assisted by epidural anaesthesia.

Endodermal sinus tumour of the ovary in pregnancy.

We present a case of a 30-year-old pregnant woman in whom an ovarian mass was identified by ultrasonography at 15 weeks' gestation. A markedly elevated maternal serum alphafetoprotein (MSAFP) suggested a diagnosis of endodermal sinus tumour of the ovary. A right salpingo-oophorectomy at 19 weeks' gestation enabled histological confirmation of the diagnosis and suggested a stage 1 tumour. Unfortunately tumour recurrence necessitated further laparotomy and delivery by caesarean section at 32 weeks' gestation. A total abdominal hysterectomy and left salpingo-oophorectomy was undertaken with resection of the splenic flexure and formation of a double-barrelled colostomy after which no gross intraperitoneal tumour remained. Three weeks later a new suprahepatic tumour mass was excised and the colostomy was closed. The patient then received four cycles of combination chemotherapy with cisplatin, etoposide, and bleomycin. Unfortunately she developed a faecal fistula at the site of the colostomy. Germ cell tumours are highly responsive to chemotherapy. Over-zealous surgery particularly involving bowel resection may cause unnecessary morbidity and compromise the outcome.

Greater numbers of human spermatozoa associate with endosalpingeal cells derived from the isthmus compared with those from the ampulla.

A simple co-culture bioassay system was used to investigate whether or not the anatomical origin affected the ability of epithelial cells from the human uterine (Fallopian) tube to 'bind' spermatozoa. This study was also used to identify some of the factors which may be involved in the regulation of sperm-epithelial interactions in vitro by comparing different tissue culture models and assessing the effect of oestradiol concentration. Epithelial explants harvested from different regions of human uterine tubes were co-incubated with a known concentration of motile donor spermatozoa. All results were adjusted to reflect a standard sperm concentration of 5 x 10(6)/ml. More spermatozoa associated per field of isthmic compared to ampullary epithelium [isthmus 9.5 +/- 0.9, ampulla 7.1 +/- 0.7 (mean +/- SEM); n = 36, P < 0.05, ANOVA] and cells from post-menopausal patients had an apparently reduced ability to bind spermatozoa [isthmus 5.5 +/- 2.0, ampulla 4.3 +/- 1.4 (mean +/- SEM); n = 4]. Neither menstrual cycle stage nor addition of mid-cycle concentrations of 17beta-oestradiol (750 pmol/l) affected the number of spermatozoa which bound to epithelium from either tubal region. In addition, the number of spermatozoa which bound per field of polarized explants was greater (P < 0.05) than that bound to dissociated primary and passaged epithelial cell monolayers. This report is the first to provide evidence suggestive of a role for sperm-epithelial binding in the formation of an isthmic sperm reservoir in the human uterine tube. Results also indicate that oestrogen is not involved in the regulation of these interactions, and that cell polarity is an important factor for such associations in vitro.

Using the medical audit cycle to reduce cesarean section rates.

OBJECTIVE: Our purpose was to determine whether completion of the medical audit cycle in labor ward practice could safely reduce cesarean section rates. STUDY DESIGN: A retrospective medical audit of all deliveries from 1984 to 1988 was performed. The groups of women contributing most to the overall cesarean section rate were identified. Strategies for labor management directed at the primary indication for cesarean section (dystocia) were developed and introduced. The effect was monitored prospectively from 1989 through 1992. Data were analyzed with the chi 2 test. RESULTS: A total of 21,125 deliveries were studied. After management change the overall cesarean section rate was decreased (9.5% vs 12%, p < 0.0001). In our population spontaneously laboring nulliparous women with a singleton, cephalic, term pregnancy contributed a significant number of cesarean sections 1982 to 1988 (19.7% of all cesarean sections). Applying principles of early diagnosis and treatment of dystocia in these women resulted in a decrease in the cesarean section rate (2.4% vs 7.5%, p < 0.0001). This was primarily responsible for the overall decrease in the cesarean section rate. CONCLUSION: Effective medical audit of labor management can reduce cesarean section rates.

The interaction in vitro of human spermatozoa with epithelial cells from the human uterine (fallopian) tube.

The physical interaction between human spermatozoa and the epithelium of the human uterine (Fallopian) tube was investigated in vitro using a variety of techniques. The 'live' observation of human spermatozoa incubated with 1 day old cultures of tubal epithelium demonstrated that spermatozoa can show a strong physical interaction with epithelial cells; contact with the epithelium appeared to be random and there was no evidence of any taxis toward epithelial cells. The physical interaction (or 'binding') was resistant to gentle washing and was maintained following the addition of glutaraldehyde fixative. The intimate nature of the interaction was confirmed ultrastructurally where both spermatozoa and epithelial membranes were observed to be in close apposition. These results are the first descriptions of sperm-epithelial 'binding' in the human. They are similar to other observations made in a variety of non-human mammalian species. It is suggested that this interaction may be an important feature of normal sperm transport in the human uterine tube in vivo.

Comparison of ampullary assessment by falloposcopy and salpingoscopy.

The purpose of this study was to compare and contrast falloposcopic and salpingoscopic ampullary assessments in a series of 20 women undergoing tubal microsurgery for distal tubal or peritubal disease. Four women had an extrinsic cause for their peritubal adhesions, and would have been expected to exhibit a normal oviductal canal. All of the falloposcopic examinations were performed as an outpatient procedure. Salpingoscopic examinations were undertaken at the time of microsurgery. The endoscopic examinations were undertaken by two clinicians, who were blinded to each other's assessments and to the indication for surgery. Of the 31 Fallopian tubes which were examined, 24 were found to be abnormal by salpingoscopy and 23 were found to be abnormal by falloposcopy. Total score and scores for epithelial appearance, vascularity, intraluminal adhesions and dilatation were found to be significantly associated. Furthermore, falloposcopy predicted salpingoscopic status correctly in 84% of cases. These data suggest that falloposcopy is a useful method of assessing ampullary condition.

Falloposcopic comparison of unilateral and bilateral proximal tubal occlusive disease.

The purpose of this study was to compare the appearance of the entire length of the oviductal canal in women with unilateral versus bilateral proximal tubal occlusion. Eleven women had apparent unilateral disease and 18 had apparent bilateral occlusion. Proximal occlusion was confirmed both by hysterosalpingography and laparoscopy. Falloposcopic examination was performed by retrograde visualization using the linear eversion catheter, in office. Bilateral apparent proximal occlusion was found to have a significantly higher incidence of actual proximal occlusion and distal intralumenal abnormalities. However, five proximal segments and six distal segments were found to be abnormal where the pre-examination diagnosis was unilateral occlusion. Furthermore, the contralateral oviductal canal was found to be abnormal in four women with apparent unilateral disease, indicating that apparent unilateral proximal tubal occlusion is associated with actual pathology. These data demonstrate the value of intralumenal assessment of apparent proximal occlusion.

Sperm numbers and distribution within the human fallopian tube around ovulation.

This study aimed to determine the number and distribution of spermatozoa within the human Fallopian tubes around ovulation. Parous women, undergoing total abdominal hysterectomy for menorrhagia, were inseminated with either partner's semen (3/10) or donor semen (7/10). Approximately 18 h later both Fallopian tubes were ligatured into ampullary, isthmic and intramural regions. These were removed and assessed for sperm content by flushing, scanning electron microscopy (SEM) or homogenization. A median of 251 spermatozoa were recovered (range, 79-1386). The number of spermatozoa within each tube was not significantly different. The ovulatory ampulla contained a significantly (P < or = 0.01) larger percentage of spermatozoa than the non-ovulatory ampulla. The number of motile spermatozoa inseminated was not significantly correlated to the number of spermatozoa recovered, but a trend was identified. The time between the onset of the luteinizing hormone surge and hysterectomy was significantly correlated (P < or = 0.01) to the number of spermatozoa within the intramural regions, but not to the tubal sperm distribution. Spermatozoa were not observed, by SEM, bound to the tubal epithelium. These data suggest that, after artificial insemination at least, sperm access to the human Fallopian tube may be controlled, but that ovulation does not affect the redistribution of spermatozoa between tubal regions and that the isthmus does not appear to act specifically as a sperm reservoir.

Outpatient falloposcopy: intra-luminal imaging of the fallopian tube by trans-uterine fibre-optic endoscopy as an outpatient procedure.

OBJECTIVE: To develop trans-uterine falloposcopy using the linear eversion technique in outpatients. DESIGN: A prospective, descriptive study of the introduction and application of this new technique. SETTING: A tertiary referral University Research Clinic independent of operating theatres and inpatient admission. SUBJECTS: Twenty-one infertile women with previous evidence of fallopian tube disease. MAIN OUTCOME MEASURES: Rate of successful tubal cannulation and procedure completion, tubal section visualized, condition of the tubal epithelium, subsequent treatment plan. RESULTS: A bilateral examination was attempted in 19/21 patients and completed in 18. Two early falloposcopies with inadequate analgesia were aborted due to pain after only one tube had been examined without an attempt to identify or cannulate the contralateral tubal ostium. In one patient, neither ostium was identified or cannulated. After ostial localization, 37/37 tubes were cannulated. If the ostium was not localized but 'blind' cannulation attempted, 1/3 were cannulated successfully. Epithelium characteristic of the ampulla was seen in 31/38 (82%) tubes, and of the proximal tube only in 3/38 (8%). Successful bilateral assessment noted complete bilateral proximal obstruction in 2/18 patients, non-obstructive bilateral endotubal damage in 7/18, unilateral damage in 3/18 and bilateral healthy tubes in 6/18. Unilateral examination in two patients found minimal evidence of damage in one and severe intra-tubal adhesions in the other. After falloposcopy, 11/21 patients elected for IVF, 9/21 tubal surgery and 1/21 for IVF whilst awaiting surgery. CONCLUSION: Falloposcopy is a technique which can be performed in an outpatient clinic. It is well tolerated, and high rates of luminal cannulation and visualization are possible. Atraumatic access to the tube and visualization of its lumen offer exciting opportunities for diagnosis and treatment of tubal conditions.