[Involvement of histocompatibility and allosensitization in recurrent abortions]. / Implicación de la histocompatibilidad y la alosensibilización en los abortos de repetición.

BACKGROUND: The aim of this study was to know the possible implication of human histocompatibility (HLA) antigens in the etiology of repeated abortions. METHODS: Antigen typing for the major histocompatibility system was carried out in 65 couples with 2 or more abortions and comparative analysis was performed with 40 fertile couples by the odds ratio. Likewise, the possible relationship between cytotoxic antibodies in maternal serum and reproductive prognosis was determined. RESULTS: The couples with abortions did not present a significantly different phenotypic frequency from that of the fertile couples in regard to the HLA antigens (loci HLA-A, HLA-B, and HLA-DR). On considering the 3 loci studied, the infertile couples presented significantly higher antigenic HLA identity than the fertile couples. This significance was demonstrable both by association and by odds ratio (OR: 4.9; CI 95%; 1.1-9.2). No differences were observed among women with primary (no full term pregnancy) or secondary abortions (some full term pregnancies) with regard to common HLA antigens, with both groups being homogeneous. CONCLUSIONS: The presence of cytotoxic antibodies against paternal lymphocytes in maternal serum detected by cross-match reaction was not related to the pertaining to an infertile (including any of the established subgroups) or fertile population. Neither were differences observed in the presence of these antibodies among women with primary or secondary abortions.

Müllerian abnormalities in fertile women and recurrent aborters.

Ninety-six women with recurrent first-trimester spontaneous abortions underwent hysterosalpingography to rule out müllerian abnormalities, both congenital and acquired. Results were compared with those in 96 women who had undergone hysterosalpingography before artificial insemination by donor and subsequently had a full-term, normal delivery. The patients with two recurrent, consecutive abortions had müllerian abnormalities similar to those in women with three consecutive abortions; however, they had different müllerian abnormalities than did the control group. Congenital and acquired malformations seen most often in patients with recurrent abortions were septate, arcuate and bicornuate uteri and incompetent cervical os. Pelvic examination did not discriminate between patients with recurrent abortions and the control group.

Clinical selection of infertile patients for laparoscopy.

For a period of time routine hysterosalpingography and laparoscopy were carried out in every patient complaining of more than 2 years of primary infertility. The records of 433 such patients were retrospectively evaluated according to their clinical aspects. Complete agreement between the two diagnostic methods was found in 70.9% of this unselected population. Almost 50% of the population had some abnormalities in either hysterosalpingography or laparoscopy. According to the patient's past history, pelvic examination, and the duration of infertility, the unselected infertile population was classified into a) high risk infertility and b) low risk infertility. High risk infertility patients had (P less than 0.01) greater abnormal findings at both hysterosalpingography and laparoscopy. In this high risk group we recommend early laparoscopy and the postponement of hysterosalpingographic investigation for patients with suspected cornual occlusion or destruction of ampullary rugae (valuable in assessing tubal damage). Low risk infertility patients had (P less than 0.01) low abnormal findings at both hysterosalpingography and laparoscopy, and in these patients hysterosalpingography does not discriminate the group of higher abnormal laparoscopic findings. Hysterosalpingography can be initially indicated as a less invasive investigation in the low risk group. We conclude that clinical data are very valuable in the selection of infertile patients for early or late laparoscopy.

Morphology of spermatozoa in infertile men with and without varicocele.

This study was carried out to evaluate the morphology of spermatozoa in infertile men with and without varicocele. A series of 285 ejaculates were fully evaluated for seminal volume, sperm count, motility, and morphology, and classified into fertile (165 subjects), infertile without varicocele (93 subjects) and infertile with varicocele (27 subjects). Sperm morphology was classified by multiple entry criteria and recorded as normal, abnormal with head, midpiece, or tail single anomaly or abnormal with simultaneous multiple abnormalities. Semen volume was almost identical in the three groups. Among the infertile men, sperm count was lower in those having a varicocele, but conversely those with varicocele had a higher percentage of motile spermatozoa, higher percentage of spermatozoa with forward movement and higher sperm velocity. There were higher proportions of spermatozoa with abnormal morphology, total number of anomalies, and multiple anomalies in infertile men, both with and without varicocele, than in fertile men. The percentage of abnormal spermatozoa was higher in infertile men with varicocele than in those without varicocele. The pattern of sperm morphology differed between the infertile and the fertile group, and with the presence or absence of varicocele. In the presence of varicocele, only the incidence of elongated (tapered) forms was significantly increased.

Early conception in patients with untreated mild endometriosis.

The purpose of this paper is to report the reproductive experience in 31 infertile patients with mild endometriosis who were not treated by surgery or medication. A series of 31 cases of laparoscopically diagnosed mild endometriosis were followed up without therapy for a period of 36 months. Ten patients received artificial insemination by donor (AID) because of male-related infertility; 21 patients had well-timed postcoital tests and monitored ovulation cycles. Life-table analysis of conceptions was used for presentation of the pregnancy rate. The group of patients whose husbands were azoospermic had a 90% pregnancy rate within 18 months, with a mean of 3.5 treatment cycles for pregnancy. The nonazoospermic couples had a 47.6% pregnancy rate within 18 months, with a mean of 7.2 monitored cycles for pregnancy. The calculated median delays for the series of patients who conceived were 1.9 cycles. The whole series (n = 31) of patients with mild endometriosis had an 8.3% monthly pregnancy rate within 18 months and a 61.2% cumulative pregnancy rate within 18 months. We have come to the conclusion that mild endometriosis does not interfere with female fertility, and patients with this extent of disease should not be treated for a trial period of at least 18 months as an alternative to more aggressive therapy.

Absence of ovulation stigma in the conception cycle.

The purpose of this paper is to show the incidence of ovulation stigmata (and the so-called luteinized unruptured follicle) in six patients who conceived during the laparoscopy cycle. Only two patients (33.3%) showed ovulation stigmata when their ovaries were visualized 2 to 7 days after the BBT dip, close to the estimated time of ovulation. Four patients (66.6%) whose ovaries were seen 10-12 days after the BBT dip failed to show any ovulation stigmata in spite of the fact that they conceived during that cycle and therefore the ovulation was proven. We have come to the conclusion that the laparoscopic picture of the luteinized unruptured follicle should no longer be considered to contain the trapped ovum and other diagnostic procedures should be used in the diagnosis of the ovum retention syndrome.

Peritoneal flushing and biopsy in laparoscopically diagnosed endometriosis.

A series of 74 patients with endoscopically proven endometriosis were selected for evaluation of usefulness of peritoneal flushing and aspiration in the early diagnosis of pelvic endometriosis. Forty-three patients had either an ovarian or a peritoneal biopsy performed after peritoneal lavage. The results indicate that 25% of the washings performed were successful in demonstrating endometrial glands or stroma. On the other hand, 72% of the patients on whom biopsies were performed showed endometrial tissue, and biopsy failures were mainly related to the technical difficulties of the ovarian biopsy. In 46% of the histologically proven cases of endometriosis, peritoneal lavage failed to demonstrate endometrial tissue. Conversely, in 4.6% of the negative biopsy cases, peritoneal lavage showed endometrial glands. We conclude that exfoliative cytology is not a useful tool in the diagnosis of endometriosis. On the other hand, we were able to make the diagnosis by biopsy in more than 70% of the patients on whom biopsies were performed.

Prognostic value of postcoital test in unexplained infertility.

A series of 70 couples with suspected unexplained infertility and who became pregnant after 262 monitored cycles, were reviewed. In each cycle, the postcoital test was scheduled near ovulation time as judged by prior basal body temperature shifts and by cycle length. Postcoital test was graded as excellent, good, fair, bad, and negative. A mean of 26.7% of pregnancy rate per cycle resulted and a mean of 3.74 cycles were needed to obtain a pregnancy. Pregnancy rate was higher (P less than 0.01) for cycles with excellent postcoital test and lower for cycles with bad test. There were no statistically significant differences (P greater than 0.05) in percentage of pregnancies between cycles with either excellent, good, or fair postcoital test. On the other hand, there was statistically significant decrease (P less than 0.05) in the percentage of pregnancies when cycles had bad postcoital test.

The corpus luteum in infertile patients found during laparoscopy.

A series of 407 infertile patients underwent luteal phase laparoscopy and endometrial biopsy as a part of their infertility workup. In 91% of the patients, a good correlation between the results of endometrial biopsy and those of laparoscopy was found. In 8% of the patients a secretory endometrium was found, but the laparoscopy did not show any luteal structures on the ovaries. Seventy-one percent of the patients had corpora lutea, but the stigma was only present in 17.5% of the series with secretory endometrium. Because of the stigma findings, only 326 patients with secretory endometrium were evaluated. The stigma was more frequently seen when laparoscopy was performed between day 17 and day 19 of the cycle. On the other hand, the stigma was also more frequently seen when laparoscopy was performed between 10 and 12 days before the actual onset of the next period. We conclude that the frequency of stigmata at the corpus luteum is a matter of the time in the cycle when laparoscopy is performed, and the particular cycle length of the patient should be considered.

Triple evaluation of tubal patency.

A series of 336 infertile patients were evaluated by tubal insufflation, hysterosalpingography, and laparoscopy. The treee procedures revealed patient tubes in 175 patients (52%) and occluded ones in 44 (13%) patients. Thus results with the three methods agreed in 219 patients (65%). False results of tubal insufflation were 18.5% (9.8% false negative and 8.6% false positive). False negative results of hysterosalpingography are 9.5% and false negative results of laparoscopy are 6.8%. Additional pelvic pathology detected by laparoscopy was seen 60 patients (17.8%). Pelvic adhesions (36 patients) and endometriosis (24 patients) were the pathologic processes most commonly missed by hysterosalpingography. Suspected pelvic pathology was corrected by laparocopy in nine cases (2.6%). Double evaluation, both by hysterosalpingography and laparoscopy was needed in 30% of the infertile patients, and therefore both methods should be considered supplementary. Provided that both hysterosalpingography and laparoscopy can be performed, tubal insufflation, since it gives no further information, should be abandoned or discrepant results rejected.

Ovulation recovery after hormonal contraception.

In an attempt to study the ovulation recovery after hormonal contraception, 20 patients who were on B. C. P. (birth control pills) during 12--36 months, were switched to I. U. D. contraception, and the ovarian changes occurred were assessed by laparoscopy and laparoscopic ovarian biopsy. Fresh corpus leuteum was found in 12 cases (60%), some follicular activity in 4 cases (20%) and no signs of activity in 4 cases (20%). Our results suggest that neither the length of hormonal contraception nor the patient's age have any particular influence upon the return of ovulation.

PIP: The ovulation recovery of 20 patients, aged 25-45, who had taken oral contraceptives for 6-30 months and then changed to Lippes Loop C IUDs, was studied on the 22nd and 23rd day of the 1st cycle following the change in the contraceptive method. The age of the patient was apparently not a determinant in ovulation recovery as 62% of those aged 25-35 years and 58% of those aged 35-45, had a successful recovery. Similarly, duration of pill use appeared to have no effect on recovery. Tables show 1) the number and % of cases by macroscopic and histologic findings; and 2) the % of cases showing ovulation recovery and failure by duration of oral contraceptive use and by the age of the patient.

[Laparoscopic sterilization for medical indication (author's transl)]. / Esterilización laparoscópica por indicación médica.

PIP: 35 patients between 20-40 were sterilized for strictly medical reasons, mostly cardiopathies and nephropathies. Patients with cardiac problems had parity over 2-3; patients with nephritic problems had parity over 1; nulliparous patients were sterilized to prevent hereditary diseases. The technique used was bilateral tubaric coagulation, followed by double tubal section. No complications were reported, except 1 tubal pregnancy 2 months after sterilization.^ieng