An axial pattern flap based on the dorsal perineal artery in a cat.

CASE REPORT: A 3-year-old male neutered Domestic Shorthair cat was evaluated for a skin mass of approximately 2 × 3 cm arising from the right dorsolateral aspect of the tail at the junction between the proximal and middle one-thirds of the tail length. Incisional biopsy sample was consistent with granulomatous inflammation. The granuloma was surgically excised with 5 mm margins of normal skin. The resulting defect was closed using an axial pattern flap based on a cutaneous branch of the dorsal perineal artery and augmented by a local subdermal plexus transposition flap. There was 100% survival of the flaps at postoperative days 7, 15 and 21. CLINICAL SIGNIFICANCE: We describe an axial pattern flap based on a cutaneous branch of the dorsal perineal artery in a cat. This flap offers surgeons a viable option for closing skin defects situated on the proximal one-third of the tail and a practical alternative to tail amputation.

The effect of loco-regional anaesthesia on motor activity induced by direct stimulation of the sciatic nerve in dogs.

A prospective, randomised, blinded, case-controlled clinical study was designed using client-owned dogs undergoing unilateral pelvic limb orthopaedic surgery, to determine the effect on induced motor activity by electrical stimulation of the sciatic nerve distal to the site of local anaesthetic administration. Dogs were administered 0.5% bupivacaine either extradurally or via a femoral and transgluteal sciatic electrolocation-guided nerve block prior to pelvic limb surgery. Motor response to electrical stimulation of branches of the sciatic nerve was tested and the minimum current required to induce muscle twitch was recorded prior to bupivacaine administration. Provided sensory blockade had been deemed successful intraoperatively, testing was repeated postoperatively, with each dog acting as its own control. Paired t-tests were performed to compare pre- and postoperative minimum currents. Eleven dogs administered extradural and 11 dogs administered femoral and sciatic perineural bupivacaine were eligible for post-operative testing. All dogs displayed normal motor response to electrical stimulation of the sciatic nerve at both sites tested before and after bupivacaine administration. There was no significant difference in the minimum current required to induce muscle twitch between pre- and post-operative testing (P = 0.31 sciatic site, P = 0.36 peroneal site), nor between the two groups using different loco-regional anaesthetic techniques (minimum P = 0.13). This study shows that stimulation of the sciatic nerve distal to the site of bupivacaine administration induces motor activity, despite adequate sensory blockade. This is relevant in surgical cases where mechanical stimulation of the sciatic nerve might be expected and needs to be recognised to avoid postoperative neurapraxia.

NHS-funded IVF: consequences of NICE implementation.

The UK National Institute for Health and Clinical Excellence (NICE) recommends that all subfertile women of < 40 years should be entitled to up to three IVF treatment cycles funded by the NHS. The full criteria have been implemented at The Newcastle Fertility Centre at Life since August 2009. The aim of this study was to evaluate the clinical outcome in terms of analysing the cumulative pregnancy rates. A retrospective analysis of data from 812 couples who started their first NHS-funded treatment after August 2009 was undertaken until there were 100 couples who had completed the three treatments. Cumulative pregnancy rates were calculated using life table analysis, and time intervals between treatments were recorded. The number of couples having first, second and third treatment cycles was 812, 298 and 100, respectively. The cumulative clinical pregnancy rates per each fresh cycle were 30.1%, 50.2% and 60.2%, and when frozen embryo transfers were included, they were 33.5%, 53.4% and 62.7%. The median + 2SD time interval between treatments was 11 and 10 months; 90.2% of the women were likely to complete up to three NHS-funded treatment cycles until they achieved a pregnancy. The NICE criteria offer most couples a chance of pregnancy, and the majority will take up the opportunity of undergoing three treatment cycles if required. The time interval between treatments indicated that it will take < 2 years for couples to complete the full course of NHS-funded treatment.

Estimating the risks of ovarian hyperstimulation syndrome (OHSS): implications for egg donation for research.

This study aims to provide an estimate of women's risk of ovarian hyperstimulation syndrome (OHSS) when undergoing superovulation to donate eggs for research. This is an essential prerequisite for appropriate informed consent. In the absence of sufficiently large numbers of egg donors to assess the risk, comparative data was obtained from women undergoing the same superovulation protocol for in vitro fertilization (IVF) treatment. In this prospective study 339 women, who developed >/=20 follicles after superovulation in their first treatment cycle (total number of treatment cycles during the same period - 2417), were intensively monitored on five occasions, between human chorionic gonadotrophin and pregnancy test, according to our routine clinical protocol. Hospital admission was needed for 49 (14.5%) women, 13 (3.8%) needed intravenous fluids and 9 (2.7%) needed paracentesis. The admission rates were similar in pregnant and non-pregnant women (13.5% vs. 15%); the need for intravenous fluids and paracentesis were 3.2% vs. 2.3% and 6.3% vs. 2.3%, respectively. The peak increase in haematocrit occurred on Day 4 after hCG, and the mean day of hospital admission was Day 5. If an egg donor develops <20 follicles, she can be reassured that the risk of OHSS is very small (<0.1%). If >/=20 follicles develop, her risk of hospital admission due to OHSS is <15%. The absence of pregnancy in egg donors does not eliminate the risk of OHSS. Given the timescale of development of the haematological and biochemical abnormalities, egg donors who develop >/=20 follicles should be actively monitored for the first week after egg collection.

Demographic, medical and treatment characteristics associated with couples' decisions to donate fresh spare embryos for research.

BACKGROUND: Isolation of human embryonic stem cell lines has opened a promising and pioneering area of basic and applied medical research. The issues in relation to a couples' decision in donating their supernumerary embryos for research need to be investigated further. METHODS: We carried out a prospective study of 300 couples who underwent IVF/ICSI treatment cycles in our unit. We analysed various factors contributing to their decision to consent to donate spare embryos for stem cell or preimplantation genetic diagnosis research. RESULTS: The majority of couples (54%) consented to donate their surplus embryos for research. Couples of ethnic minority origin were less willing to consent for research compared to Caucasian couples. The number of ovarian follicles at pre-hCG scan and the number of embryos obtained were significantly higher in couples consenting for research. The funding source of treatment did not appear to influence the decision to donate. Couples with previous failed fertilization were less likely to consent to embryo research. CONCLUSIONS: Physical characteristics based on ovarian response during a treatment cycle may positively influence a couple's decision to donate embryos. Further studies are needed to identify those couples who are likely to agree to research so that counselling for research can be directed efficiently.

Time from insemination to first cleavage predicts developmental competence of human preimplantation embryos in vitro.

BACKGROUND: The absence of reliable markers for the identification of viable embryos for transfer at the early cleavage stage is likely to contribute to the generally low implantation rates and high incidence of multiple gestation in IVF treatment. In this study, we investigate the relationship between timing of first cleavage and the incidence of blastocyst formation in vitro. METHODS: Couples (n = 70) with at least one embryo remaining after transfer were included in the analyses. All embryos (n = 579) were examined for early cleavage at 25 h after insemination. Following embryo transfer, the remaining embryos (n = 426) were cultured until day 7 of development, and assessed for blastocyst formation. RESULTS: Eighty-five embryos (14.7%) cleaved to the 2-cell stage within 25 h of insemination; 26 of these were selected for transfer on day 2. Of the 59 embryos remaining in culture, 19 (32.2%) developed to the blastocyst stage; this was a significantly higher number than was observed in embryos (61/367; 16.6%) that failed to cleave within 25 h of insemination (P < 0.01). Within these two groups of embryos the proportion of hatched blastocysts was 11/59 (18.6%) and 26/367 (7.1%) respectively (P < 0.005). CONCLUSIONS: These findings indicate that early cleavage is indicative of increased developmental potential in human embryos and may be useful as an additional criterion in the selection of embryos for transfer.

Tissue insulin sensitivity and body weight in polycystic ovary syndrome.

OBJECTIVE: Polycystic ovarian syndrome (PCOS) and obesity both affect insulin sensitivity. This study was designed to investigate the biochemical indices of PCOS and tissue insulin sensitivity in groups of lean and obese women with clinically equivalent degrees of the syndrome, relative to control subjects. DESIGN: A prospective study of in vivo parameters and in vitro study of adipocytes to assess insulin sensitivity. PATIENTS: Six lean and 14 overweight patients fulfilling formal diagnostic criteria for PCOS were studied. The degree of hirsutism and amenorrhoea was similar in each group. Eight control subjects were also studied. MEASUREMENTS: Endocrine and metabolic parameters were measured in lean and overweight patients with PCOS and control subjects. In vitro studies of adipocyte insulin receptor binding and adipocyte insulin action were performed. RESULTS: The mean plasma LH level was elevated in both groups of PCOS but was significantly higher in the lean group (LH levels were 25.1 +/- 3.1 and 14.5 +/- 1.6 iu/l in lean PCOS and obese PCOS, respectively (P = 0.01)). There was a strong inverse correlation between BMI and LH levels (R = - 0.70, P = 0.001). Fasting insulin levels were elevated in both lean and obese groups (11.5 +/- 2.8 and 26.8 +/- 8.1 mU/l, respectively; P = 0.068). Mean serum testosterone and serum androstenedione levels were also elevated in PCOS compared to control subjects but there was no difference between the two groups of PCOS subjects. Insulin receptor binding in amenorrhoeic subjects with PCOS was low in both lean and obese patients with PCOS but was not significantly different between the two groups (0.79 +/- 0.17% and 0.66 +/- 0.07% per 10 cm2 cell membrane, respectively). Maximally insulin-stimulated rates of 3-O-methylglucose transport were low in both groups compared to previously studied normal subjects (0.96 +/- 0.21 and 0.64 +/- 0.07 pmol per 10 cm2 membrane in lean and obese PCOS subjects, respectively; P = NS). CONCLUSIONS: Lean subjects with a given phenotypic expression of PCOS have an equivalent degree of tissue insulin resistance compared to obese PCOS subjects. This implies that the insulin resistance may be a primary feature of PCOS. If this is so, a similar clinical degree of the syndrome may be brought about by genetically determined insulin resistance in lean subjects or by insulin resistance which is secondary to obesity.

Altered osmotic thresholds for arginine vasopressin secretion and thirst during superovulation and in the ovarian hyperstimulation syndrome (OHSS): relevance to the pathophysiology of OHSS.

OBJECTIVE: To test the hypothesis that decreases in and maintenance of a new steady state in plasma osmolality and sodium level in ovarian hyperstimulation syndrome (OHSS) are due to altered osmoregulation of arginine vasopressin secretion and thirst. DESIGN: Prospective study. SETTING: IVF-ET program in a university-based assisted reproductive treatment center. PATIENT(S): Eight women undergoing superovulation for IVF-ET and five women with normal menstrual cycles. INTERVENTION(S): Two-hour infusion of 5% saline on day 3 or 4 after hCG administration in patients undergoing IVF or in the early luteal phase in controls. A 5% saline infusion test was done on day 10 after hCG administration in one patient with OHSS and one patient without OHSS, both of whom were undergoing IVF. MAIN OUTCOME MEASURE(S): Comparison of changes in thresholds for thirst and plasma vasopressin to plasma osmolality. Changes in urine osmolality, plasma electrolytes, hemoglobin level, and hematocrit were assessed at baseline and during infusion of 5% saline. RESULT(S): The sensitivity of the changes in arginine vasopressin secretion and thirst after 5% saline infusion was similar in IVF patients on day 3 or 4 after hCG and controls. However, the osmotic threshold was significantly lower by 6 mOsm/kg in IVF patients. By day 10 after hCG, the lower osmotic thresholds for arginine vasopressin secretion and thirst persisted in OHSS, although the sensitivity to arginine vasopressin secretion was markedly reduced. CONCLUSION(S): The osmotic thresholds for arginine vasopressin secretion and thirst are reset to lower plasma osmolality during superovulation for IVF-ET. This new lower body tonicity is maintained until at least day 10 after hCG in OHSS. Decreases in plasma osmolality and plasma sodium levels in OHSS are due to altered osmoregulation rather than electrolyte losses; correction of apparent "electrolyte imbalance" in OHSS is therefore inappropriate.

Adipocyte insulin action in hypogonadotrophic hypogonadism.

In-vitro studies of adipose tissue have shown that patients with polycystic ovarian syndrome (PCOS) have marked insulin resistance, the abnormalities being more pronounced during amenorrhoea compared to following an ovulatory cycle. If the insulin resistance in PCOS is a reflection of anovulation then patients with hypogonadotrophic hypogonadism (HH) should also have a reduction in insulin sensitivity. This study was designed to investigate insulin sensitivity in patients with HH. Seven patients with HH were studied and compared with eight age and body mass index matched female controls. Adipocyte insulin receptor binding was measured and adipocyte insulin action was assessed by measuring initial rates of 3-O-methylglucose uptake and inhibition of lipolysis. The specific insulin receptor binding per 10 cm(2) cell surface was 0.95 +/- 0. 25% in HH and 1.85 +/- 0.14% in control patients (P < 0.01). Maximum rates of glucose uptake were also impaired in HH compared with controls (3-O-methylglucose transport 0.81 +/- 0.22 versus 1.83 +/- 0.2 pmol/10 cm(2)/5 s)(P < 0.01). Hence, patients with HH have impaired insulin sensitivity to a degree similar to that seen in PCOS, suggesting a direct effect of anovulation on insulin sensitivity.

Coexistent hemoconcentration and hypoosmolality during superovulation and in severe ovarian hyperstimulation syndrome: a volume homeostasis paradox.

OBJECTIVE: To investigate the concomitant time courses of the changes in osmolality and calculated blood volume during the genesis of ovarian hyperstimulation syndrome (OHSS). DESIGN: Prospective longitudinal study. SETTING: IVF-ET program in a university-based assisted reproductive technology center. PATIENT(S): Thirty women undergoing superovulation for IVF-ET. INTERVENTION(S): Blood and urine samples were obtained on seven occasions from the start of FSH stimulation until a pregnancy test. Five women with severe OHSS had daily blood and urine tests during hospitalization. MAIN OUTCOME MEASURE(S): Changes in serum and urine osmolality, serum electrolytes, albumin, hemoglobin, and hematocrit. RESULT(S): Blood volume in women with OHSS decreased significantly by 20% from days hCG +2 to +4, followed by a sustained increase of 30% above baseline from days hCG +8 to +12. There was no statistically significant change in blood volume in women without OHSS. There was a sharp decrease in serum osmolality in women without OHSS between days 0 and hCG +2, which recovered toward baseline from day 4 after hCG. In women with OHSS, there was an unexpected increase in osmolality of 6 mOsm/kg between days hCG -2 and 0, followed by a decrease of 8 mOsm/kg by day hCG +2; this was sustained until day hCG +12. Patients with OHSS demonstrated a concentration and dilution of their urine during the acute and recovery phases of the syndrome, respectively, despite persistence of the hypoosmolar state. CONCLUSION(S): Decreased osmolality in severe OHSS is maintained despite significant decreases and increases in blood volume, suggestive of fundamental alterations in osmoregulation.

Embryonic development in vitro is compromised by the ICSI procedure.

The implantation rates achieved with intracytoplasmic sperm injection (ICSI) are equivalent to those with conventional in-vitro fertilization (IVF) but information on embryonic development in vitro after ICSI is scant. In this paper we compare blastocyst formation after IVF and ICSI; we have also investigated the effect of the ICSI procedure with internal control of extrinsic (including paternal) factors. The first series comprised cases of IVF treatment (n = 101) for tubal infertility and ICSI (n = 96) for male infertility. The proportions of embryos developing to the blastocyst stage was significantly lower after ICSI (8.9%, P < 0.001) than after conventional IVF (23.5%). In order to investigate the effect of the ICSI procedure in isolation, blastocyst formation was analysed in a second series of eight cases, in which sibling oocytes were non-selectively subjected to ICSI (n = 78) or IVF (n = 67) with spermatozoa from the same semen sample. It was found that 20% of ICSI embryos and 50% of IVF embryos formed blastocysts (P < 0.01), demonstrating that the ICSI procedure contributes to a reduced capacity for blastocyst formation in vitro.

Adipocyte insulin action following ovulation in polycystic ovarian syndrome.

The role of anovulation and insulin resistance in the pathogenesis of polycystic ovarian syndrome (PCOS) remains to be determined. The aim of this study was to investigate whether the metabolic abnormality of insulin resistance in PCOS reflects, rather than causes, the ovarian dysfunction. Eight subjects with classical PCOS were studied on two occasions. Adipocyte insulin sensitivity together with hormonal and metabolic changes were investigated in patients with PCOS following prolonged amenorrhoea and then again in the early follicular phase after ovulation. Insulin receptor binding in amenorrhoeic subjects with PCOS was low at 0.78 +/- 0.08% and this increased to 1.18 +/- 0.19% after an ovulatory cycle (P < 0.05). Maximal insulin stimulated 3-O-methylglucose uptake was 0.70 +/- 0. 14 during amenorrhoea and increased to 1.08 +/- 0.25 pmol/10 cm(2) cell membrane (P < 0.05). Plasma testosterone fell (4.0 +/- 0.4 to 2. 3 +/- 0.2 nmol/l; P < 0.001), luteinizing hormone fell (17.6 +/- 2.3 to 6.7 +/- 0.8 IU/l; P < 0.001) but plasma insulin concentrations remained unchanged following ovulation (14.6 +/- 1.9 and 15.7 +/- 3. 8 pmol/l during amenorrhoea and after ovulation respectively). The results of this study suggest that chronic anovulation per se appears to modify the factors contributing to cellular insulin resistance seen in PCOS.

Severe ovarian hyperstimulation syndrome following salvage of empty follicle syndrome.

We report a case of severe ovarian hyperstimulation syndrome (OHSS) following a rescue of empty follicle syndrome (EFS). This suggests that the risk of developing OHSS remains unaltered even in the presence of EFS. The case supports the possibility of obtaining oocytes that fertilize and cleave normally after a second dose of human chorionic gonadotrophin (HCG) and a repeat oocyte retrieval. It supports the suggestion that the follicles are not necessarily empty in EFS. It demonstrates further that OHSS cannot be prevented by aspiration of follicular fluid and patients with large numbers of follicles and EFS must be warned of this potential complication.

Endometrial leucocytes: expression of steroid hormone receptors.

BACKGROUND: Stromal leucocyte populations in human endometrium comprise T cells, macrophages, and phenotypically unusual endometrial granulated lymphocytes. Their proportions vary during the menstrual cycle and, in particular, endometrial granulated lymphocytes increase in number in the late secretory phase. The stimulus responsible for these cyclical changes is unknown but it is likely that the steroid hormones oestrogen and progesterone play a role. AIMS: To define further the expression of steroid hormone receptors by leucocytes in non-pregnant and pregnant human endometrium. METHODS: Frozen and paraffin wax embedded sections of endometrium from non-pregnant women and early pregnancy decidua were labelled using single and double immunohistochemical techniques with monoclonal antibodies directed against oestrogen and progesterone receptors and various leucocyte subpopulations. RESULTS: Despite the prominence of CD56 positive endometrial granulated lymphocytes in late secretory phase endometrium and early pregnancy decidua, double immunohistochemical labelling showed no evidence of expression of either progesterone or oestrogen receptors by these cells or other endometrial leucocyte populations. CONCLUSIONS: Rather than acting directly, steroid hormones are likely to influence endometrial leucocyte populations indirectly via products of endometrial stromal or epithelial cells that express steroid hormone receptors.

Thromboembolic disease associated with ovarian stimulation and assisted conception techniques.

Thromboembolic disease, as a complication of ovarian stimulation and assisted conception techniques, is generally considered to be a rare complication of ovarian hyperstimulation syndrome and, by implication, lower limb in origin. Sporadic cases of unusually sited thromboses, both venous and arterial, have been reported. This paper aims to draw attention to the relatively large number of such thromboses reported in the world literature compared with those cited in previous commentaries, and to emphasize how little is known about their pathogenesis. It is believed that this is an issue which requires to be addressed in order to understand the background pathology to such incidents and if possible to identify women at greatest risk from such potentially debilitating or fatal complications, such that appropriate prophylactic measures can be taken.

Upper limb thrombosis associated with assisted conception treatment.

Three cases of upper limb deep venous thrombosis occurring in association with assisted conception treatment are presented. The accepted argument that lower limb thrombosis occurring in cases of complicated or severe hyperstimulation syndrome represents the likeliest thrombo-embolic disorder in this situation is questioned.

Development of calcium signalling mechanisms during maturation of human oocytes.

Sperm-induced Ca2+ signals mediate the events of oocyte activation at fertilization. In this study, the development of mechanisms involved in the generation of Ca2+ signals in human oocytes was investigated. The thiol reagent, thimerosal, which induces oscillations of intracellular Ca2+ ([Ca2+]i) similar to those seen during fertilization, was used to mobilize Ca2+ in in-vivo matured, immature and in-vitro matured human oocytes. There was an increase in the sensitivity to thimerosal during maturation of human oocytes, with oocytes from small antral follicles being relatively insensitive, compared with those from luteinized follicles, which displayed a large spike followed by sustained oscillations in [Ca2+]i. These oscillations were inhibited by caffeine which suggests that they were mediated by the inositol trisphosphate receptor Ca2+ release system. When immature oocytes were cultured in vitro they acquired the capacity to undergo a single large spike in [Ca2+]i, however, subsequent sustained oscillations were not observed, indicating that these oocytes failed to develop fully competent Ca2+ signalling mechanisms during culture in vitro. This finding may be a key factor in the poor developmental competence of in-vitro matured human oocytes.