Comparison of the outcome of intracytoplasmic sperm injection using fresh and frozen-thawed epididymal spermatozoa obtained by percutaneous epididymal sperm aspiration.

The study was conducted to compare the outcome of intracytoplasmic sperm injection (ICSI) between fresh and frozen-thawed epididymal spermatozoa retrieved by percutaneous epididymal sperm aspiration (PESA) from obstructive azoospermic men. Overall, 53 PESA procedures were performed in 42 obstructive azoospermic men, followed by ICSI procedures with either fresh (n = 40) or frozen-thawed (n = 13) epididymal spermatozoa. Comparing all ICSI cycles with fresh and frozen-thawed epididymal spermatozoa, the fertilization rates (77.4 vs 86.8%) and the cleavage rate (91.3 vs 95.1%) were not statistically different. A total of 64 embryo transfers were performed: 48 embryo transfers after the use of fresh epididymal spermatozoa and 16 embryo transfers after the use of frozen-thawed spermatozoa. The overall pregnancy rate per embryo transfer was also similar between both groups (40.8 vs 40%). The implantation rate per embryo (18.2 vs 12.7%), clinical pregnancy per embryo transfer (36.7 vs 33.3%) and delivery/ongoing pregnancy rate (36.7 vs 33.3%) were not statistically different. In conclusion, there were no significant differences of the outcome of intracytoplasmic sperm injection using fresh and frozen-thawed epididymal spermatozoa obtained by PESA.

Effects of contaminated endometriotic contents on quality of oocytes.

The mechanism of infertility associated with endometriosis is poorly understood. There is evidence supporting that women with ovarian endometriosis have a lower pregnancy rate than women with peritoneal lesions only. This study aimed to evaluate the effects of endometriotic contents contamination while retrieving oocytes on oocytes' quality. Thirty-eight infertile patients with endometriotic cysts from January 1993 to June 2000 were enrolled in this study. There were no statistically significant differences among the quality of oocytes and embryos from the contaminated, non-contaminated, and control group. However, the fertilization rate and pregnancy rate were impaired by the contamination of endometriotic contents. We conclude that ovarian endometriosis should be treated before starting in vitro fertilization program in order to increase the pregnancy outcome.

Unilateral deep vein thrombosis associated with a large myoma uteri. A case report.

BACKGROUND: Deep vein thrombosis is a rare complication of myoma uteri. There have been few reports on this association. CASE: A 42-year-old woman presented with a myoma uteri, 24 weeks in size, that had compressed the pelvic veins and caused unilateral deep vein thrombosis of the left leg. After anticoagulation therapy, a total abdominal hysterectomy was performed, with an uneventful recovery. CONCLUSION: Although deep vein thrombosis associated with myoma uteri is a rare event, it can be managed successfully with anticoagulants and hysterectomy. Myoma uteri with deep vein thrombosis is an indication for hysterectomy.

The outcome of sperm retrieval and intracytoplasmic sperm injection for obstructive azoospermia.

OBJECTIVES: To study the outcome of sperm retrieval and intracytoplasmic sperm injection (ICSI) from obstructive azoospermic men. METHOD: Overall, 50 sperm retrieval procedures were performed in 45 obstructive azoospermic men, followed by 57 ICSI procedures with fresh epididymal spermatozoa (n=40), fresh testicular spermatozoa (n=4) or frozen-thawed epididymal spermatozoa (n=13). RESULTS: Sperm retrieval was accomplished via percutaneous epididymal sperm aspiration (PESA) in 42 cases, testicular sperm aspiration (TESA) in 1 case and testicular sperm extraction (TESE) in 2 cases. TESA and TESE were only applied when PESA failed to produce enough spermatozoa for simultaneous ICSI. PESA was successful in 92 per cent of cases. Fertilization rate after ICSI was 79.6 per cent of the metaphase II oocytes. Seventy one embryo transfers were performed using both fresh and frozen thawed embryos resulting in clinical pregnancy in 39.4 per cent. Ongoing pregnancy was achieved in 35.2 per cent. CONCLUSION: ICSI has been shown to give a high fertilization and pregnancy rate with epididymal and testicular spermatozoa retrieved from obstructive azoospermic men. PESA is a noninvasive and simple technique for retrieving spermatozoa from obstructive azoospermic men. Therefore, it is suitable as the primary sperm recovery technique in patients with obstructive azoospermia.

No differences in outcome of surgical sperm retrieval with intracytoplasmic sperm injection at different intervals after vasectomy.

PIP: In view of the widespread use of vasectomy as a method of contraception, there is an increasing demand for vasectomy reversal. However, the pregnancy rate after vasectomy reversal is inversely related to the duration of the time interval following vasectomy. Reports document that intracytoplasmic sperm injection (ICSI) has been found to dramatically improve the results for the treatment of men who require surgical sperm retrieval because of obstructive azoospermia. This study examined the effects of time interval after vasectomy on the outcome of surgical sperm retrieval with ICSI. A total of 17 patients with obstructive azoospermia from vasectomy underwent 21 cycles of ICSI and sperm retrieval at the Center for Assisted Reproduction and Embryology from January 1997 to August 1999. Results have showed that microsurgical vasectomy reversal can be a highly successful procedure; however, surgical sperm retrieval with ICSI can bypass all of the factors that interfere with fertility in men with a prolonged time interval after vasectomy and can also reduce female fertility problems that may occur concomitantly. Results also revealed no statistically significant differences in fertilization rates, implantation rates, or pregnancy rates among three groups with different time intervals since vasectomy. It is suggested that the time interval between vasectomy and surgical sperm retrieval with ICSI treatment has no effect on the outcome.^ieng

Transvaginal hysterosalpingo-contrast sonography (HyCoSy) compared with chromolaparoscopy.

OBJECTIVE: To compare the efficacy and safety of HyCoSy with chromolaparoscopy for the diagnosis of tubal occlusion and uterine abnormalities. METHODS: Sixty infertile women in whom the cause of infertility was thought to be tubal occlusion or uterine abnormalities and who satisfied the inclusion and exclusion criteria as specified in the study protocol were included. HyCoSy was performed during the first half of the menstrual cycle at least 24 hours prior to chromolaparoscopy. The results from both HyCoSy and chromolaparoscopy were compared in assessing tubal occlusion and uterine pathology. RESULTS: For the evaluation of fallopian tubes, we found corresponding results between HyCoSy and chromolaparoscopy in 80.0%. The agreement between both procedures in assessing the uterine pathology was 80.4%. Twenty-two women experienced adverse events. The most common complaint was pelvic pain. Other events encountered were: nausea (3 women) and vaginal bleeding (2 women). All events were thought to be not related to the study drug. CONCLUSION: HyCoSy showed good diagnostic performance in the evaluation of the fallopian tubes and uterus in infertile women. The adverse events reported in this study are minor and procedure-related (catheter insertion) rather than the trial substance.

Effects of clomiphene citrate on the endometrium of regularly cycling women.

OBJECTIVE: To study the effects of clomiphene citrate (CC) on the endometrium of regularly cycling women. DESIGN: Prospective, controlled study. SETTING: Department of Obstetrics and Gynaecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. PATIENT(S): Thirty healthy, regularly cycling, female volunteers. INTERVENTION(S): All volunteers were studied for two consecutive cycles, one control cycle and one CC-treated cycle. Clomiphene citrate (100 mg/d) was given on days 3-7 of the CC-treated cycles. Ultrasonography was performed daily to assess ovulation. Ultrasonography and endometrial biopsy were performed, and blood samples were obtained for determination of E2 and progesterone levels 7 days after ovulation in both the control and CC-treated cycles. MAIN OUTCOME MEASURE(S): Histologic dating, morphometric analysis, and ultrasonographic appearance and thickness of the endometrium. RESULT(S): Histologic dating and ultrasonographic appearance and thickness of the endometrium were similar in the control and CC-treated cycles, but morphometric parameters were different. The number of glands per square millimeter and the mean diameter of the glands were lower in the CC-treated cycles than in the control cycles, but the number of vacuolated cells per 1,000 glandular cells was higher. CONCLUSION(S): Clomiphene citrate has effects on the endometrium of regularly cycling women, as demonstrated by a reduction in glandular density and an increase in the number of vacuolated cells.

Clinical effects of gestrinone for the treatment of pelvic endometriosis in infertile patients.

The clinical efficacy and side effects of oral gestrinone, 2.5 mg twice weekly, were evaluated in this prospective study involving 22 patients with laparoscopically confirmed endometriosis. All patients came to the hospital with infertility problem. After 6 months of treatment, 81 per cent of patients had amenorrhea. Dysmenorrhea and pelvic pain were reduced from 90.9 per cent to 14.3 per cent and 81.8 per cent to 9.5 per cent respectively. Pelvic tenderness and induration were improved from 55.6 per cent and 50.0 per cent to 15.8 per cent and 10.5 per cent respectively. Androgenic effects such as acne was founded in 18.2 per cent of the patients. Return of fertility was observed in 25 per cent (5 patients) after 30-254 days post treatment. No serious side effect was detected during the treatment. The results suggest that gestrinone may be considered an option for the treatment of endometriosis related infertility.

Comparison of the fertilization rate after intracytoplasmic sperm injection (ICSI) using ejaculated sperms, epididymal sperms and testicular sperms.

Intracytoplasmic sperm injection (ICSI) has been successfully used to achieve fertilization and pregnancies for patients with extreme oligoastheno-zoospermia using ejaculated sperms or patients with azoospermia using epididymal or testicular sperms. The aim of this study was to compare the fertilization rate after ICSI using ejaculated, epididymal and testicular sperms. Between January and September 1997, 10 azoospermic men underwent percutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE) to recover sperm for ICSI. A total of 5 PESA cases and 5 TESE cases were performed at the Center for Assisted Reproduction & Embryology. Thirty-one patients performed ICSI using ejaculated sperms during the same period of time were used as a control group. ICSI using ejaculated sperms, epididymal sperms from PESA and testicular sperms from TESE was a highly successful technique, achieving fertilization rates of 78.5 per cent, 83.3 per cent and 80.8 per cent, respectively. Good fertilization rates were achieved without significant differences among the various sperm sources.

Transvaginal hysterosalpingo-contrast sonography (HyCoSy) compared with chromolaparoscopy: a preliminary report.

Fifteen infertile women who required tubal passage evaluation by chromolaparoscopy were recruited. Those who had lower genital tract infection or abnormal uterine bleeding were excluded from the study. Transvaginal HyCoSy was performed during the first half of the menstrual cycle at least 24 hours prior to chromolaparoscopy. The results from both transvaginal HyCoSy and chromolaparoscopy were compared in assessing tubal patency and uterine pathology. A high correlation was noted regarding uterine examination using transvaginal HyCoSy compared with chromolaparoscopy (sensitivity, specificity, PPV and NPV were 91.7%, 33.3%, 84.6% and 50%, respectively). The correlation of the outcome between the two procedures in assessing tubal patency, when combining both tubes, was also high (sensitivity, specificity, PPV and NPV were 100%, 55.6%, 80% and 100%, respectively). The most common adverse event was only mild pelvic pain which did not necessitate any treatment. These preliminary results reveal the potential value of transvaginal HyCoSy as an alternative in infertility investigations. It seems to be as effective but less invasive than conventional chromolaparoscopy. The adverse events reported in this study relate more to the procedure (catheter insertion) rather than the trial substance.

Successful pregnancy in a case of azoospermia from congenital bilateral absence of vas deferens (CBAVD) using percutaneous epididymal sperm aspiration (PESA) and intracytoplasmic sperm injection (ICSI).

In men with obstructive azoospermia, bypass surgery would obviously be the most acceptable form of treatment as it gives the couple an opportunity to conceive naturally. However, when this has failed to restore patency or when surgery is not feasible (congenital absence of vas), fertility treatment using spermatozoa aspirated from the epididymis should be considered. Percutaneous epididymal sperm aspiration (PESA) is more acceptable to patients than micro epididymal sperm aspiration (MESA) because it eliminates the requirement for a general anaesthetic, post-operative pain, and the risk of haematoma formation, thus allowing a rapid return to normal activity of the husband. To our knowledge, this is the first reported case in Thailand where a pregnancy resulted in a couple whose infertility was due to azoospermia from the congenital absence of vas deferens. Spermatozoa collected through PESA were used in ICSI to achieve fertilization. The PESA technique, due to its simplicity is the choice of treatment for obstructive azoospermia.

Sperm morphology evaluated by computer (IVOS) cannot predict the fertilization rate in vitro after intracytoplasmic sperm injection.

OBJECTIVE: To evaluate sperm morphology assessment using the IVOS (Hamilton-Thorne Research Version 3 Dimension Program, Beverly, MA) system in prediction of fertilization rate in vitro after intracytoplasmic sperm injection (ICSI). DESIGN: A prospective clinical study. SETTING: Diagnostic andrology laboratory and assisted conception service. PATIENT(S): Thirty-five patients from the ICSI program were evaluated. Semen samples were analyzed using a computerized system for conventional semen parameters, sperm movement characteristics, and sperm morphology. Only patients with three or more metaphase II (MII) oocytes available were studied. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Fertilization rates in vitro after ICSI were compared according to the sperm morphology obtained from the IVOS system. RESULT(S): Linear regression analysis of fertilization rates against the sperm parameters assessed by computer (IVOS), which included conventional semen parameters, sperm movement characteristics, percentage of normal sperm morphology, and percentage of each specific abnormal sperm morphology, did not reveal any significant correlations. The mean (+/- SEM) fertilization rates in the healthy prognosis group (normal sperm morphology > or = 4%) and poor prognosis group (normal sperm morphology < or = 4%) were 82.4 +/- 4.0% and 75.0 +/- 3.8%, respectively. There was no statistically significant difference in the mean fertilization rate between both groups. Moreover, no statistically significant difference was found in overall fertilization rates in vitro between the two prognosis categories (79.6% versus 78.0%). CONCLUSION(S): Sperm morphology obtained from the IVOS system is not related to the outcome of ICSI and cannot be used for prediction of fertilization rate in vitro after ICSI.

The effect of transdermal oestradiol on bleeding pattern, hormonal profiles and sex steroid receptor distribution in the endometrium of Norplant users.

The most common side-effect and reason for discontinuation with Norplant use is bleeding disturbance. The aim of this study was to investigate whether the 6 week application of a patch which released 100 micrograms/day oestradiol would reduce the number of abnormal bleeding days or eliminate the problem. Another objective was to find out the correlation between the bleeding pattern and endometrial concentrations of oestrogen receptor (ER) and progesterone receptor (PR). Of 98 Norplant users, 34 patients had normal bleeding patterns and 64 patients had abnormal bleeding patterns. An oestradiol patch or a placebo patch were randomly used to treat 33 and 31 women with abnormal bleeding respectively. There was a clinical improvement in the oestradiol group compared with the placebo group, although this was not statistically significant. There were no correlations between PR and ER concentration and the serum oestradiol, progesterone, levonorgestrel and sex hormone-binding globulin concentrations. Significantly increased mean immunostaining scores of stromal PR were observed in those Norplant users whose endometrium had an atrophic histological appearance. The serum oestradiol concentration did not show a significant change after treatment with the oestradiol patch compared with the placebo patch.

PIP: The potential of an estradiol patch (100 mcg/day for 6 weeks) to reduce the menstrual disturbances associated with progestogen-only contraception was investigated in 98 Norplant users. Of the 64 subjects reporting abnormal bleeding, 33 were given an estradiol patch and 31 received a placebo patch; the 34 Norplant users with normal bleeding patterns served as controls. Clinical improvement was recorded in 23 estradiol patch and 13 placebo patch subjects, a nonsignificant difference. Ovarian activity, demonstrated by fluctuating high levels of estrogen, occurred in most Norplant users, but without ovulation. Serum levonorgestrel concentrations ranged from 1000 to 1500 pmol/l, with no significant differences according to group. Sex hormone-binding globulin (SHBG) levels were low (range, 20-50 nmol/l), again with no significant group differences. Both levonorgestrel and SHBG concentrations were steadier in women with normal bleeding patterns. Histology revealed that endometrial specimens from Norplant users were more atrophic than proliferative. Significantly increased mean immunostaining scores of stromal progesterone receptor were noted in Norplant users whose endometrium appeared atrophic. Also observed were low estrogen receptor concentrations in both glandular and stromal compartments. Overall, these findings suggest that progestogen-related bleeding abnormalities are related to the bioavailability of estrogen and progesterone receptors in the endometrium rather than histological changes.

Long-acting triptorelin for the treatment of endometriosis.

OBJECTIVE: To evaluate the efficacy and adverse effects of monthly triptorelin injection for the treatment of endometriosis. METHODS: A multicenter clinical trial including 45 women with endometriosis, treated with triptorelin 3.75 mg i.m. every 4 weeks in six consecutive doses. The main outcome measures were symptom relief, reduction according to revised American Fertility Society (rAFS) scores, reduction in size of ovarian endometrioma, effects on hormone and lipid profiles, changes in bone mineral density (BMD), adverse effects, and return of menstruation. Data were analyzed using repeated measures analysis of variance and paired t-tests. RESULTS: Pain-related symptoms decreased in all cases after 8 weeks of treatment. Laparoscopic assessment revealed a reduction in rAFS scores in 21 out of 25 cases (mean pretreatment scores 43.44 +/- 5.75 vs. post-treatment scores 22.30 +/- 3.40, P < 0.001). The size of ovarian endometrioma decreased in eight of nine women but none disappeared. Serum luteinizing hormone, follicle-stimulating hormone and estradiol levels were effectively suppressed during treatment. A slight increase in cholesterol and triglyceride levels was observed but all values were within normal limits. After 24 weeks of treatment there was a slight decrease in BMD of total body, lumbar vertebrae and femoral neck but not radius. The main adverse effects included hot flushes, night sweating, vaginal dryness, headache, dizziness and nausea Menstruation returned 83.76 +/- 2.91 days after the last injection of triptorelin. CONCLUSION: Long-acting triptorelin is efficacious in the treatment of endometriosis and has tolerable side effects.

Basal follicle--stimulating hormone levels on day 3 of previous cycle are predictive of in vitro fertilization outcome.

Serum FSH level may be an indicator of the functional potential of the ovary. The basic control of LH and FSH is by a negative feedback system involving the hypothalamus, anterior pituitary, and ovary. Basal serum FSH on day 3 of previous cycles in 36 patients underwent ovarian stimulation with a combination of GnRH agonist and FSH and hMG in an IVF program were evaluated. The results in this study show that a high basal serum FSH level is associated with a higher cancellation rate, a lower peak serum E2 level, lower number of oocytes retrieved and a lower clinical pregnancy rate.

Growth and development of infants conceived by in vitro fertilization: a preliminary report.

This is a preliminary report on the first 24 babies born during the period of 1 year follow-up after IVF-ET in Chulalongkorn Hospital. Based on this study, our data suggests that these children have a normal range of growth and development. There was also no evidence of major congenital anomalies identified in spite of some minor ones. However, a need for more detail and on-going long-term follow-up at least until school age is being planned.

Relative binding affinity of various progestins and antiprogestins to a rabbit myometrium receptor.

Relative binding affinity (RBA) of various progestins and antiprogestins to a cytoplasmic receptor prepared from the myometrium of estrogenized immature female rabbits was investigated. The cytosol was incubated with tritiated promegestone (3H-R5020) in the presence of various concentrations of non-radioactive promegestone (R5020) as standard on the one hand, and several progestins and antiprogestins on the other hand. The incubate was subjected to isoelectric focusing in slabs of polyacrylamide gel and the bound radioactivity in the peak of the receptor was measured, RBA was expressed as a percentage given by the ratio of those concentrations of R5020 and the compound tested which were required for a 50% displacement of 3H-R5020. The RBA's of the progestins tested were in the following order: R5020 greater than norethisterone greater than levonorgestrel greater than progesterone greater than medroxyprogesterone acetate. There was practically no binding to dextronorgestrel, cortisol, testosterone, and estradiol. In the group of antiprogestins, there were no significant differences in the RBA of the compounds RU 486, RU 42633 (monodemethyl derivative of RU 486) and ZK 98.734. Another two derivatives of RU 486, RU 42848 (didemethyl) and RU 42698 (propargyl), had lower RBA's than RU 486. Two 13,17-stereoisomers related to the above antiprogestins (i.e. compounds ZK 98.299 and ZK 115.716) exhibited a decreased RBA in comparison with the compound ZK 98.734.

The interaction between sex hormone binding globulin and levonorgestrel released from Norplant, an implantable contraceptive.

Two-hundred-and-eighty Indonesian women were provided with Norplant, a levonorgestrel-releasing implant. At various time intervals, up to 5 years after Norplant insertion, levonorgestrel and sex hormone binding globulin (SHBG) were assayed in blood plasma. After an initial burst of approximately 7 nmol/l, the levels of levonorgestrel rapidly decreased during the first month. The decrease continued to a nadir (1.1 nmol/l) which was reached 10 months later. The decrease was followed by an increase to a broad peak of 1.5 nmol/l which was reached 2 years after insertion. Thereafter, a slow-decrease at a rate of approximately 18 pmol/month was seen. SHBG levels decreased significantly already 1 week after insertion. A nadir of levels (25 nmol/l) was reached 3 months later. The levels increased slowly again and remained constant (32 nmol/l) from about 15 months to 5 years. During the entire period of study highly significant correlations of levonorgestrel with SHBG were seen. In another group of 25 women the levels of levonorgestrel and SHBG were studied before and one week after insertion of Norplant. A significant correlation (r = 0.77) was found between the preinsertion levels of SHBG and postinsertion levels of levonorgestrel.

PIP: 288 Indonesian women were provided with Norplant a levonorgestrel-releasing implant. At various time intervals, up to 5 years after Norplant (R) insertion, levonorgestrel and sex hormone binding globulin (SHBG) were assayed in blood plasma. After an initial burst of approximately 7 nmol/1, the levels of levonorgestrel rapidly decreased during the 1st month. The decrease continued to a nadir (1.1 nmol/1) which was reached 10 months later. The decrease was followed by an increase to a broad peak of 1.5 nmol/1 which was reached 2 years after insertion. Thereafter, a slow decrease at a rate of approximately 18 pmol/month was seen. SHBG levels decreased significantly already 1 week after insertion. A nadir of levels (25 nmol/1) was reached 3 months later. The levels increased slowly again and remained constant (32 nmol/1) from about 15 months to 5 years. During the entire peiod of study highly significant correlations of levonorgestrel with SHBG were seen. In another group of 25 women the levels of levonorgestrel and SHBG were studied before and 1 week after insertion of Norplant. A significant correlation (r=0.77) was found between the preinsertion levels of SHBG and postinsertion levels of levonorgestrel.