Hormonal and lipid profile in infertility women with polycystic ovary syndrome / Монголын Анагаах Ухаан

Introduction@#PCOS prevalence is 5-10 percent among reproductive age women in worldwide. It is caused by imbalance of sex hormones which ultimately leads to menstrual irregularities, infertility, anovulation and other metabolic disturbances. Most women with chronic anovulation is caused by polycystic ovary syndrome [PCOS] The Rotterdam criteria is useful diagnostic tool for PCOS. In Mongolia there is almost no study on PCOS related infertility and there are increasing trend infertility among reproductive aged women with PCOS, lead us to conduct the study. @*Objective@#The aim of this study was to estimate incidence of PCOS and to study clinical and biochemical characteristics of PCOS among infertility women.@*Material and Methods@#We used the cross-sectional and case control study designs. Total 1334 infertility women enrolled in this study. The study was conducted after approval from the Ethical and research review board of the hospital, and written informed consent was taken from all the women. Among 114 women with PCOS were found by Rotterdam’s criteria at the Infertility and reproductive department, National Center for Maternal and Child Health, between December, 2018 - 2019. Total of 43 females with PCOS were screened among 1334 infertile women. All parameters were assessed either with ELISA in 43 infertile PCOS women and 17 age matched apparently healthy controls diagnosed according to Rotterdam consensus. IDF diagnostic criteria for MS was used. The PCOS patients divided into following groups: (1) with MS ( n=42) and (2) without MS (n=72).@*Results@#The main age, body mass index (BMI), and duration of infertility were 28.7±4.1 years, 27.3±5.2 kg/ m² and 4.4±3.1y, respectively. Among patients 57.9% of them have oligomenorrhea, 22.8% with amenorrhea, primary infertility 57.0% and 51.9% with hirsutism and acne 50.8%. As a result of hormone assays were LH 9.3±3.5mIU/ml, LH/FSH 1.6 ±0.83 [0.1-3.6], AMH 6.1ng/ml ±3.6 /2.9-21.0/. The prevalence of MS was 36.8%. The variables including age (30.9±4.9), body mass (75.9±11.6kg) and also some metabolic parameters which is hypertension (133.6/88.4±13.6 mm Hg), WC (94.1±8.6 cm) and high triglyceride (1.8±1.0 mmol/l) were observed in MS group compared to without MS group.@*Conclusion@#Among 1334 women with infertility, the incidence of PCOS 8.7% (116), close to the prevalence in other countries. Considering the diagnose was confirmed of three criteria by the Rotterdam criteria. We found out that the prevalence of metabolic syndrome was 35.3% among infertility women with PCOS. Age, BMI, WC, amenorrhea, acne and acanthosis nigricans, were highly related to metabolic syndrome.

IDENTIFING SOME RISK FACTORS OF FEMALE INFERTILITY / Шинэ санаа Шинэ нээлт

@#BACKGROUND: Infertility rate among Mongolian couples was about 8.7% in 2003. According to researchers in Mongolia, the causes of infertility in male is about 25.6%, in female is about 45.8%, in both couples is 18.8% and unexplained infertility is about 9.8%. Women’s previous disease such as abdominal inflammatory diseases, disorders of pregnancy and surgical diseases of reproductive system can lead to infertility. Infertility has been setting 5th rank on list of human disability as shown as problem about quality of human life. METHODS: We surveyd about secondary infertile women, who has approved by inclusion criteria and determined infertility risks. We designed case-control study. We collected 52 data at “Post partum department” of “First Maternity Hospital” for control group, and 22 data at “Women stationary” of “First Maternity Hospital” for case group (ratio 2:1). Data analyzed by STATA for OR (logistic regression tests) and Microsoft Excel. RESULT: The most common previous disease is pelvic inflammatory disease (OR=2.2) р<0.001 before infertility situation. There was statistical reliability diseases. Including: female reproductive system surgery (OR=2.1), pelvic surgical diseases (OR=1.9) and complication of previous pregnancy (1.2). CONCLUSION: Pelvic inflammatory disease, surgical diseases of female reproductive system, complication of previous pregnancy and pelvic surgical diseases are the risk factors of female secondary infertility.

Relationship Between Endometrial Integrin-?_v?_3 Expression and Steroid Hormone Level in Patients with Infertility Induced by Chronic Pelvic Inflammatory Disease / 广州中医药大学学报

0.05),while that of serum P was significant(P

Experience with gynaecological laparoscopies in Wad Medani Hospital, Sudan.

OBJECTIVE: To assess the value and safety of laparoscopy in gynaecological practice in a tertiary care centre in Sudan to determine the magnitude of tubal disease as an aetiological factor in female infertility. DESIGN: A prospective case series study. SETTING: Department of Obstetrics and Gynaecology in a tertiary care Teaching Hospital in Sudan. SUBJECTS: Seven hundred and three women selected for laparoscopy for various reasons. MAIN OUTCOME MEASURES: Indications for laparoscopy findings and complications. RESULTS: Infertility was the main indication (94.32%). Tubal disease was diagnosed in 46.6% of all infertile women studied. The overall complication rate was 22.76 per 1000; two major complications and no death. CONCLUSION: Laparoscopy is a valuable and safe procedure and and is useful in solving patients' problems, especially infertility. Tubal disease is a major aetiological factor in female infertility.

PIP: This prospective case series study determined the main indications and complications of laparoscopy, evaluated the role of laparoscopy in infertility management at Medani Hospital in Sudan, and examined the magnitude of tubal diseases as an etiological factor in infertility. A total of 703 women selected for laparoscopy for different reasons were enrolled in the study. Infertility, both primary and secondary, was the main indication for laparoscopy, accounting for 94.32% of cases. Of all infertile women studied, 46.6% were diagnosed as having tubal disease. The overall complication rate was 22.76/1000, with two major complications and no death. The rest were minor complications, which required only 24-hour monitoring with no further management. In conclusion, the study results suggest that laparoscopy is a valuable and safe procedure in the management of various gynecological problems, especially infertility.

The Study of Loneliness in Infertile Women / 간호학회지

The purpose of this study was to investigate loneliness in infertile women and determine how loneliness related to personal characteristics, cause of infertility, family composition, and family conflicts. It also provides basic data for nursing strategies concerning infertile women. A total of 182 subjects were selected at an infertile clinic in Seoul, Korea. Data were collected from May 2 to June 21, 1997 by questionaire. It consisted of questions concerning general characteristics, items relating to infertility, and the Loneliness Scale. The UCLA Loneliness scale was used(more specifically, the Korean version of the Revised UCLA Scale by Kim Ok Soo.). The data were analyzed by using SPSS/PC computer program. The result are as follows: 1. The mean age of infertile women was 32.4 years old, and the mean age of souses was 34.8 yerars old. 30.2% of women had a marital duration of 3-5 years, and 25.8% had a marital duration of 5-10 years. 23.1% reported the main etiology of infertility as unexplained, 18.1% reported ovulation disturbances, and 26.4% reported complex causes. 3.8% of the couples had sexual relationship difficulty 83% lived in nuclear families, while 17% lived in large families. 2. The mean loneliness scores of infertile women was 35.53(SD=8.66). The total loneliness score of this study was 80. 3. There were significant differences in loneliness scores according to ages(F=6.893, p=.001), education background(t=4.418, p=.000), and the educational background of husband(t=2.339, p=.020). 4. Loneliness scores related to family situations were significantly different according to several male nephews in husbands' family(F=2.822, p=.027). 5. Loneliness scores related to conflicts were significantly different according to husbands and their family(F=11.465, p=.000). Nurses should acknowlege the fact that some infertile women may experience loneliness. In conclusion, nurses can provide infertile women with information about ways to decrease loneliness and create support groups for themselves, assisting infertile women to adjust to the experience of infertility through positive methods.

Reproductive tract infections, gynaecological morbidity and HIV seroprevalence among women in Mumbai, India.

Reported are the prevalence of reproductive tract infections and their contribution to pelvic inflammatory disease (PID), as well as the seroprevalence of human immunodeficiency virus (HIV), among women living in three inner city wards of Mumbai, India. Women aged < or = 35 years were recruited and screened as cases if they had been admitted to hospital for gynaecological investigation for suspected PID (n = 151) or infertility (n = 295); controls were healthy fertile women attending for laparoscopic tubal ligation (n = 2433). The women were mainly of low socioeconomic status. A total of 59.4% were migrants and 14.9% of these came to Mumbai to seek treatment. Cases reported a history of adverse pregnancy outcomes significantly more often than controls, and 30.5% of suspected PID cases had previously undergone laparoscopic tubal ligation. At examination 24.2% of cases and 8.4% of controls had a vaginal discharge. Pelvic infection was confirmed in 42.0% of suspected PID cases and 14.6% of infertile cases for whom diagnostic laparoscopy was performed. The prevalence of sexually transmitted diseases was low: Chlamydia trachomatis was found in 0.2%; and Neisseria gonorrhoeae was cultured from the cervix in only four cases. Neither of these infections was detected in laparoscopic aspirates. The prevalence of HIV1/2 infections in unlinked samples was 1.9%. Sexually transmitted diseases were not major factors leading to gynaecological morbidity. Heterosexual spread of HIV infection to this population of married women is still relatively low but needs to be carefully monitored. The gynaecological morbidity detected may be a consequence of widespread use of invasive methods of fertility regulation.

PIP: A case-control study conducted in 1993-95 among women 35 years of age and younger living in three inner-city wards of Mumbai, India, investigated the prevalence of reproductive tract infections and their contribution to pelvic infection. Enrolled as cases were 151 women admitted to the hospital with suspected pelvic inflammatory disease (PID) and 295 infertile women; 2433 healthy fertile women undergoing laparoscopic tubal ligation served as controls. Adverse pregnancy outcomes were reported significantly more often by cases than controls. 31.8% of suspected PID cases, 9.1% of infertile women, and 53.1% of tubal ligation patients reported ever-use of a contraceptive method, primarily a copper IUD. At examination, 24.2% of cases and 8.4% of controls had a vaginal discharge. Pelvic infection was confirmed in 42.0% of suspected PID cases and in 14.6% of infertile women in whom diagnostic laparoscopy was performed. HIV prevalence was 1.9% in unlinked samples. The prevalence of other sexually transmitted diseases (STDs) was under 1%. The gynecologic morbidity recorded in this study is presumed to be a result of widespread use of invasive methods of fertility regulation, not STDs.

Estimation of the prevalence and causes of infertility in western Siberia.

The study examined the epidemiology and causes of infertility in Tomsk, Western Siberia, using methodological approaches recommended by WHO and was based on the findings for a randomly selected sample of 2000 married women aged 18-45 years. Among the respondents, 333 couples were considered infertile since they had not conceived after 12 months or more of unprotected intercourse. This group of infertile couples was offered comprehensive clinical investigations but only 186 couples completed them. The infertility rate in Tomsk was 16.7%, being caused by diseases of the female reproduction system in 52.7% of the couples and by male reproductive diseases in 6.4%. In 38.7% of couples, both spouses suffered from infertility, while in 2.2% of cases the cause of infertility was not determined. Among the causes of female infertility, secondary infertility dominated (12.9% of all the women questioned), while primary infertility affected 3.8% of the women. The most frequent causes of female infertility were disturbances to tubal patency (36.5%) and pelvic adhesions (23.6%). Endocrine pathology was found in 32.8% of cases. The most frequent cause of male infertility was inflammatory disease of male accessory glands (12.9%). In 8.6% of cases infection resulted in obstructive azoospermia. Varicocele was registered in 11.3% of cases, and idiopathic pathospermia in 20.9%. Inflammatory complications among females were 4.2 times more frequent than among males.

PIP: In the first study to investigate the reproductive function of the couple at the population level in the Russian Federation, methodological approaches recommended by the World Health Organization (WHO) were used to analyze the causes of infertility in Western Siberia. In the first stage, interviews were conducted with 2000 randomly selected married women from the city of Tomsk. A total of 333 couples (16.7%) were considered infertile since they had not conceived after 12 months or more of unprotected intercourse. 3.8% of couples suffered from primary infertility and 12.9% from secondary infertility; 24.1% of women in the latter group had experienced complications associated with birth or abortion. Rigorous clinical investigation of 168 couples identified causes of infertility in both partners in 38.7%, in the female partner only in 52.7%, and in the male partner only in 6.4%. More than one cause was present in 80 women (43%). The most frequent causes of female infertility were disturbances to tubal patency (36.5%) and pelvic adhesions (23.6%). Endocrine pathology was found in 32.8% of cases. In men, the most frequent causes were idiopathic infertility or pathospermia (20.9%) and varicocele (11.3%). Inflammatory complications were 4.2 times more frequent among women than men. The 16.7% frequency of infertility in Western Siberia exceeds the 15% critical level defined by WHO.

Age-related decline in fertility: a link to degenerative oocytes?

OBJECTIVE: To determine whether the age-related decline in fertility is due to degenerative oocytes or to aneuploidy. DESIGN: Retrospective. SETTING: Fertility center of a public and tertiary institution. PATIENT(S): One hundred fifty-one women (ages 24 to 44 years) undergoing 158 cycles of conventional IVF or IVF with intracytoplasmic sperm injection (ICSI) between January 1993 and December 1995 were divided into three age groups (group 1, < or = 34 years; group 2, between 35 and 39 years; and group 3, > or = 40 years). They were selected on the basis of available oocytes that remained unfertilized after IVF and that had analyzable chromosomes. INTERVENTION(S): Standard pituitary down-regulation and ovarian stimulation with FSH and hMG were done for both IVF and ICSI patients. In addition, all patients were given luteal phase support with P, administered orally, via pessaries, or by IM injections from the day of transfer. MAIN OUTCOME MEASURE(S): Fertilization rates and pregnancy rates (PRs), and cytogenetic analyses of unfertilized oocytes. RESULT(S): Although fertilization rates were not different among women in groups 1, 2, and 3 (50.9%, 49.3%, and 37.9%, respectively), PRs were significantly lower between groups 1 and 3 (43.2% versus 14.3%). A total of 383 oocytes were examined, of which 287 (75%) could be karyotyped. Of these, 201 oocytes showed a normal 23,X karyotype (70%), 40 (13.9%) were aneuploid, 24 (8.4%) were diploid, 12 (4.2%) had structural aberrations, and 13 (4.5%) had single chromatids only. No increase in the aneuploidy rate was detected between groups 1 and 2 (14.8% versus 12.4%). However, highly significant differences in the rate of oocyte chromosome degeneration, characterized by chromosomes splitting into unassociated chromatids, were observed with increasing age (group 1, 23.7%; group 2, 52.0%; and group 3, 95.8%). CONCLUSION(S): It seems that the age-related decline in fertility may be due more to degenerative oocytes than to aneuploidy. A decline in the number of oocytes retrieved with age may be of less importance than the decline in oocyte quality. Women in the older age group have a higher chance of achieving pregnancy from ovum-donation programs than by persisting in using their own aged oocytes, which have a very poor prognosis for success.

PIP: The hypothesis that the fertility decline observed in women over 40 years old is linked more to degenerative oocytes than to age-associated aneuploidy was investigated in 151 women 24-44 years old who underwent a total of 158 in vitro fertilization (IVF) cycles at Singapore General Hospital during 1993-95. Fertilization rates were 50.9% in women 34 years or younger, 49.3% in those 35-39 years old, and 37.9% in women 40 years or older. The pregnancy rates were 43.2%, 32.7%, and 14.3%, respectively. 287 (74.9%) of the 383 unfertilized oocytes could be karyotyped fully. The total chromosome abnormality rate was 30.3%; this included aneuploidy (13.9%), diploidy (8.4%), structural aberrations (4.2%), and single chromatids only (4.5%). A relationship between increased maternal age and an increase in the aneuploidy rate could not be assessed because of the small sample size in the oldest age group. The rate of chromatid separation increased significantly from 23.8% in the youngest age group to 95.8% in the oldest age group. This rate did not differ between in vitro fertilization and intracytoplasmic sperm injection. The degeneration evident in the majority of oocytes of older women presumably reflects decades of metabolic arrest at the dictyate stage. These findings suggest that the decline in the number of oocytes retrieved with age may be of less importance than the decline in oocyte quality. Women in the older age group have a greater likelihood of achieving pregnancy from ovum donation programs.

Oral contraceptives and ovulatory causes of delayed fertility.

The return of fertility for women who discontinue oral contraceptives takes longer as compared with women who discontinue other methods of contraception. It remains unclear, however, whether subsequent fertility differs according to duration or age at first use. The authors performed a nested case-control study within a cohort of 116,686 female registered nurses residing in 14 US states. Baseline information was reported on mailed questionnaires in 1989. Cases comprised 1,917 married nurses without previous pregnancy who were unable to become pregnant for at least 1 year and were subsequently diagnosed with primary ovulatory infertility. Controls comprised 44,521 married parous nurses with no history of infertility and no pregnancies lasting less than 6 months. After allowing for 2 years of suppressed fertility following discontinuation of oral contraceptive use and excluding women with signs of menstrual or hormonal disorder, the authors found that the multivariate relative risk for ovulatory causes of delayed fertility was 1.2 (95% confidence interval 0.7-1.9) for ever users. There was no statistically significant trend of increasing risk with increasing duration of use and younger age at first use. The fact that 88 percent of cases reported an eventual pregnancy by 1993 suggests that absolute fertility was not impaired.

HIV infection and sexual behaviour among women with infertility in Tanzania: a hospital-based study.

BACKGROUND: Infertility is common in Africa, but virtually no data exist on HIV prevalence among infertile women. Mainly anthropological studies in Africa have shown that infertile women have higher risks of marital instability and possibly also have more sexual partners than fertile women. METHOD: This study was conducted in a hospital in northwest Tanzania during 1994 and 1995. Women presenting themselves with infertility problems to the outpatient clinic were interviewed, examined and blood was drawn. Women who came to deliver in the hospital, excluding primiparae, were taken as a control group. The analysis was limited to women > or = 24 years. In total 154 infertile and 259 fertile women were included in the study. RESULTS: HIV prevalence was markedly higher among infertile women than among fertile women: 18.2% and 6.6% respectively (adjusted odds ratio [OR] for age, residence and occupation 2.7; 95%-confidence interval [CI]: 1.4-5.3). Data on past sexual behaviour showed that infertile women had more marital breakdowns, more lifetime sexual partners and a higher level of exposure to sexually transmitted diseases (STD). CONCLUSION: Women with fertility problems appear to have higher HIV prevalence, which justifies more attention for such women in the context of AIDS programmes. In addition, caution is needed when using sentinel surveillance data from antenatal clinics to monitor HIV prevalence.

PIP: Infertility is common in Africa. Anthropological studies conducted on the continent have found infertile women to have higher risks of marital instability and possibly more sex partners than fertile women. Findings are reported from a study conducted during 1994 and 1995 in a hospital in northwest Tanzania to determine the prevalence of HIV infection among infertile women. Women presenting with infertility problems to the outpatient clinic were interviewed, examined, and blood was drawn. Women who came to deliver in the hospital, excluding primiparae, comprised the control group. A total of 154 infertile and 259 fertile women were included in the study, all age 24 years and older. 18.2% of infertile women and 6.6% of fertile women were infected with HIV. Data on past sex behavior indicated that infertile women had more marital breakdowns, more lifetime sex partners, and a higher level of exposure to sexually transmitted diseases.

Ethnographic results of a community STD study in the Eastern Highlands Province.

This paper reports on women's understanding of diseases believed to be sexually transmitted in the Asaro Valley of the Eastern Highlands Province. Sexually transmitted diseases (STDs) seemed to be a new category of disease as there were no local language terms for them. Women did not associate STDs with infertility. Although some symptoms were recognized and known to be sexually transmitted, STDs sometimes went untreated for years. STDs were thought of as milder than AIDS because they could be treated. Those informants who had good knowledge of AIDS claimed to have known an AIDS patient. It was interesting that those who knew an AIDS patient reported a change in sexual behaviour among people who saw the deteriorating state of their relative who was dying of AIDS.

PIP: Women's perception of STDs in the Asaro Valley of the Eastern Highlands Province of Papua New Guinea was studied along with the local language terms for reproductive tract infections. Considering that there are no known specific local language terms for diseases that are sexually transmitted, women tend to view STDs as a new category of disease. The study emphasizes the women's understanding of the risk factors, as well as signs and symptoms, causes and measures taken, behavior towards treatment, and suggestions concerning treatment and protection. Interviews were conducted with 30 women aged 17-50 years. 14 of those participated in the clinical side of a community- based STD study, while the rest provided information independently. Particular emphasis was given to sources of information on STDs, understanding of risk factors, signs and symptoms, causes and measures taken, attitude towards treatment, and suggestions for treatment and protection. Since the local language does not have a term to refer to any diseases thought to be passed on through sexual intercourse, three terms were used: "sik nogut" (bad sickness), gonorrhea, and syphilis; additionally, signs and symptoms were described rather than named. It was found that rumors and educated relatives were the primary sources of information about "sik nogut." One of the major findings was that women did not link infertility with STDs, even if symptoms were felt in and around the reproductive tract. The paper concludes that sexual intercourse, as identified by women, is the dominant mode of disease transmission in the Valley. Condoms are becoming acceptable but are not used because of their unavailability. An interesting finding in this study is the reported change in sexual behavior among people who have seen their relatives die of AIDS.

Tuberculosis of the female reproductive tract: effect on function.

OBJECTIVE: To discuss the clinical presentation and consequences of genital tuberculosis (GTB), a known cause of infertility. Although it appears to be a rare entity, usually secondary to a primary site of infection by Mycobacterium tuberculosis, its true incidence is not known owing, in part, to inadequate diagnostic procedures, particularly in less developed areas of the world. PATIENTS AND METHODS: We present our experience with 25 cases of genital TB. Of these woman, 21 were seen for infertility; 3 were postmenopausal with uterine hemorrhage, and 1 was admitted with an acute abdomen. All women were treated medically and/or surgically. RESULTS: Only five women were found to be suitable for artificial insemination. Two of the women became pregnant but aborted. CONCLUSIONS: The incidence of genital TB may be higher than one might imagine, based on the lack of reports in the literature, and may account for a significant amount of female infertility.

PIP: During 1988-93, in Mexico City, the National Institute of Perinatology diagnosed 25 cases of female genital tuberculosis. Their age ranged from 21 to 42 years. The diagnostic procedures used to detect these cases included laparoscopy, PPD skin test reaction, hysterosalpingography (HSG), culture of tissue and fluid samples, and histopathological examination of tissue biopsies. 16% had a history of tuberculosis. 39.1% had a history of contact with a relative with tuberculosis. Three women were postmenopausal and suffered from uterine bleeding; they underwent a hysterectomy. 17 of 21 women who went on to infertility studies had suffered infertility for 2-14 years. HSG revealed abnormalities in 95.2%, especially bilateral tubal occlusion (57.1%) and deformity of the uterine cavity (54.5%). Mycobacterium tuberculosis was isolated in 4 women, all of whom had fluid in the pelvic cavity. 14 of the 16 patients who underwent the PPD skin test had an induration larger than 10 mm in diameter. 68% of the 19 patients who underwent endometrial biopsy had granulomas consistent with tuberculosis. All the women received antibiotics to treat female genital tuberculosis. Five of the 17 patients referred for infertility evaluation underwent in vitro fertilization and embryo transfer. Two of these women became pregnant but later suffered a spontaneous abortion. The other 3 women never conceived. These findings indicate that the incidence of female genital tuberculosis may be higher than expected and may be responsible for a substantial amount of female infertility. Pregnancy occurs when female genital tuberculosis is detected at an early stage and when no irreversible anatomical pathology is evident. Thus, it is important to determine the existence of tuberculosis early in cases of infertility and to begin therapy immediately.

Results of in vitro fertilization and embryo transfer in women with infertility due to genital tuberculosis.

OBJECTIVE: To determine the results of IVF-ET in women with infertility due to genital tuberculosis. DESIGN: Retrospective case-control study. SETTING: In vitro fertilization and ET unit of a university hospital. PATIENTS: Forty-four cycles of IVF-ET were undertaken in 24 women with genital tuberculosis and the results were compared with 366 cycles in 274 nontuberculous tubal factor couples. INTERVENTIONS: All women with genital tuberculosis were evaluated with hysteroscopy, endometrial biopsy, and acid fast bacilli stain before treatment with IVF-ET. RESULTS: Subjects with genital tuberculosis had higher basal FSH levels, required more exogenous gonadotropins for controlled ovarian hyperstimulation, reached lower peak E2 levels, and yielded fewer oocytes and embryos when compared with tubal factor patients. Furthermore, in women with genital tuberculosis, clinical pregnancy rate per cycle was lower and spontaneous abortion rate was higher. CONCLUSIONS: Women with genital tuberculosis appear to represent a less favorable subset within other tubal factor patients when treated with IVF-ET.

PIP: At Hacettepe University Hospital in Ankara, Turkey, 24 women with genital tuberculosis had undergone 44 cycles of in vitro fertilization-embryo transfer (IVF-ET) and 274 women with tubal infertility not related to genital tuberculosis (controls) had undergone IVF-ET. Physicians compared the results of IVF-ET in these two sets of women. Women with genital tuberculosis had significantly higher day-3 follicle stimulating hormone (FSH) levels than the controls (11.6 vs. 7.7 mIU/ml; p 0.001). Thus, they had a higher number of ampules of hMG than the controls (27.3 vs. 18.4; p 0.05) to achieve peak estradiol levels on the day of human chorionic gonadotropin (hCG) and the number of days of follicle stimulation. Peak estradiol levels were lower among cases than controls (852 vs. 1141 pg/ml; p 0.05), while the number of days of follicle stimulation was higher among cases than controls (10.3 vs. 7.5; p 0.01). Women with genital tuberculosis also had a significantly lower number of aspirated oocytes and of transferred embryos than controls (5.8 vs. 7.7 and 2 vs. 2.9, respectively; p 0.01 for both). They also had a much lower clinical pregnancy rate than controls (9.1% vs. 21.3%; p 0.001). Women with genital tuberculosis also had a significantly higher spontaneous abortion rate than controls (75% vs. 19.2%; p 0.05). The only woman with genital tuberculosis who delivered a live infant had undergone hysteroscopic lysis of dense intrauterine synechia. The lower pregnancy rate was largely due to the fewer embryos available for transfer among the women with genital tuberculosis. The implantation rates per transferred embryo were not significantly different between the two groups (5.85% for cases vs. 8.6% for controls). These findings suggest that women with genital tuberculosis are a less favorable subset among tubal factor patients when treated with IVF-ET. Physicians should anticipate these women to have a reduced ovarian reserve, lower intrauterine pregnancy, and higher miscarriage rates.

Chlamydia and its effect on reproduction.

PIP: Epididymitis in the male and salpingitis in the female may cause permanent functional damage to the reproductive tract, resulting in infertility. Agents with proven connection to post-infection infertility are Neisseria gonorrhoeae and Chlamydia trachomatis. In men, infertility after chlamydia-associated epididymitis is uncommon, whereas in women sequelae after salpingitis--including chlamydia-associated disease--are the most common cause of acquired infertility. In a prospectively followed cohort of women who all sought pregnancy after one episode of laparoscopically verified acute salpingitis, 79/1025 (7.8%) were infertile because of post-salpingitic tubal occlusion, compared with 4/448 control women (0.9%). Important factors in post-salpingitic infertility were: number of episodes [relative risk (RR) after none, 1, 2, and 3 or more episodes were 1.0, 5.2, 11.3, and 19.8, respectively, amounting to a total infertility rate after salpingitis of 15%]; in women with only one episode, the severity of infection (mild, moderate, and severe; RR, 1.0, 1.8, and 5.6, respectively) and delayed care (less than 3 days and 3 or more days; RR, 1.0 and 3.0, respectively); use of contraceptives (non-contraceptors, pill users, IUD users, and 'other'; RR, 1.0, 0.3, 0.5, and 0.8, respectively); and non-chlamydial and chlamydial infection (RR, 1.0 and 1.7, respectively). Observations in infertile women suggest that an equally large number of women may have post-infectious tubal infertility also after asymptomatic salpingitis; in the majority of cases with serologic evidence of a passed genital chlamydial infection. Recently, a hypothesis has been presented that antigen-antibody reactions to chlamydial heat-shock proteins might be an important factor for the morphological tissue damage and scarring leading to impaired fertility. Post-pelvic inflammatory disease associated with sexually transmitted disease infertility is acquired and, hence, preventable.^ieng

Effect of pelvic inflammatory disease on fertility.

Genital infections, in both men and women, may cause permanent functional damage to the reproductive tract resulting in infertility. In men, post-infection infertility is uncommon, whereas in women sequelae after pelvic inflammatory disease (PID) are the most common cause of acquired infertility. In a prospective cohort study of women who all sought pregnancy after laparoscopically verified acute (non-tuberculous) salpingitis, 141/1309 (10.8%) were infertile because of proven post-PID tubal occlusion. In 448 control women, the corresponding figures were 4/448 (0.9%). Of independent and significant importance for post-PID infertility were the numbers of PID episodes (0/1/2 or= 3: RRs 1.0/7.0/16.2/28.3), and in women with only one PID episode, the severity of infection (mild/moderate/severe; RRs 1/1.8/5.6), delayed care (3 days/3 or more days; RR 1/2.8), use of contraceptives (none/pills/IUDs/other; RRs 1/0.3/0.5/0.8). Similar influences of the same variables were also demonstrated for subfertility, i.e. ectopic pregnancy, and time between index laparoscopy and pregnancy in those women who conceived after PID.

Intrauterine adhesions.

Anticipation and suspicion are critical aspects to any discussion of intrauterine adhesions. Curettage between the second and fourth week postpartum is more likely to cause adhesions than is any other endometrial trauma. Infertility, recurrent abortion, or menstrual aberrations after any uterine trauma should cause the physician to suspect the presence of intrauterine adhesions. Hysterosalpingography and hysteroscopy are the ideal methods to make the diagnosis of IUA, and the latter is the safest, least traumatic, and most precise method of treating adhesions. The addition of an intrauterine splint and high-dose estrogen therapy completes the therapeutic approach. Before attempting conception the cavity should be inspected to verify its normality.

PIP: This paper reviews what has been reported about intrauterine adhesions (IUAs) from their earliest description. Endometrial trauma, most often caused by curettage associated with pregnancy, must occur before IUAs will develop. Postpartum curettage will most likely cause IUAs if it is performed between the second and fourth week postpartum. The symptoms of IUAs are amenorrhea/hypomenorrhea, infertility, recurrent abortion, and/or adherent placenta. The menstrual pattern is usually predictive of the extent of intrauterine scarring, with amenorrhea being associated with the most extensive damage. Diagnosis can be confirmed and classified by hysteroscopy. The safest, least traumatic, and most precise method of operative treatment involves adhesiolysis, using hysteroscopy with the use of a postoperative intrauterine splint and administration of postoperative high-dose estrogen therapy. Before conception is allowed, the uterus should be examined to verify its normality. This treatment results in a pregnancy rate of 60-75%, regardless of the pretreatment extent of disease in an otherwise normal uterus. Preconception examination and verification of normality insures against the occurrence of an adherent placenta during subsequent pregnancy.

Age and infertility in a micronesian atoll population.

The relationship between female age and infertility is examined using a single-island Micronesian population case. Demographic data, derived primarily from reproductive history interviews, show that a significant age-associated decline in marital reproductive performance is absent before women reach their late thirties in this population but a substantial decline is present once women reach their forties. Ethnographic data support the demographic inference that couples are maintaining relatively high levels of conjugal coital activity with both advancing female age and increasing marital duration. Thus coital activity levels appear to be an important factor in the maintenance of fertility in this group before the mid-thirties but decreases in fecundability after this age are due primarily to reductions in fecundity, not to declines in coital activity. The description of the Butaritari case lends support to Underwood's (1990) suggestion that a "Micronesian pattern" of reproductive performance may exist for the region's atoll-based populations and underscores the promise of further investigations of these special cases in the fields of demography and reproductive ecology.

PIP: The aim of this study of infertility was to describe demographic patterns of infertility by age and their link with age-associated behavior changes, such as coital activity, on the Butaritari Atoll north of Tungaru in the Republic of Kiribati. The population is relatively circumscribed on this high-population-density island; there were high rates of nuptiality, minimal premarital exposure to pregnancy risk, low contraceptive usage, and an absence of sexually transmitted diseases that cause infertility. The population in 1990 was 3800, of which almost 50% were aged 15 years. Fertility was high, at a mean of 4.5 births for ever married women (N=791) and a completed fertility of 7.14 for ever married postmenopausal women. Almost all men and women marry. Primary infertility levels were only 1.29% of ever married postmenopausal women (N=231). Data on reproductive histories were collected from 87.1% (N=203) of all women aged 15 years in the village in 1990/91 and supplemented with other archival records. A subsample of 34 women were interviewed for a detailed analysis of life course changes in reproductive and sexual behavior. Census data from 1990 were also collected and checked against vital registration records. The following measures were examined: infertility in relation to marriage duration, current reproductive status of women in relation to age, infertility in relation to parity, infertility in relation to age, pregnancy failure in relation to age, and ethnographic factors. The findings indicated that infertility rarely occurred before the late 30s because of the low levels of subfecundity, no age variation in breast feeding patterns, no significant increase in reported fetal death rates before the 40s, and sustained coital frequency with increasing marriage duration. Coital frequency declined after the age of 40 years, as did fecundity. The coital patterns were found to be similar to the Micronesian region; women produce as many children at later ages as they do at earlier ages.

Perihepatic adhesions: not necessarily pathognomonic of pelvic infection.

Perihepatic adhesions are often considered to be associated with pelvic inflammatory disease and subsequent infertility. Seventeen patients out of 100 undergoing elective laparoscopic sterilization had evidence of perihepatic adhesions. Four of the 17 showed evidence of old pelvic inflammatory disease, but only two gave a history of sexually transmitted disease. All patients had a negative gonorrhea culture and 50 also had a negative chlamydia culture before the procedure. These data suggest that perihepatic adhesions may be observed in otherwise normal fertile women, and its presence does not necessarily imply pelvic inflammatory disease or poor fertility.

PIP: 100 consecutive patients undergoing elective laparoscopic tubal ligation were enrolled in a study aimed at investigating the association between perihepatic adhesions and pelvic inflammatory disease (PID). Perihepatic adhesions were identified in 17 of these patients on the basis of evaluation of the liver capsule and anterior abdominal wall. 2 patients (12%) in the adhesions group and 12 (15%) in the no-adhesions group reported a history of sexually transmitted diseases (STDs). No patient with adhesions had a documented PID episode in her history compared with 2 (2%) in the no-adhesions group. 4 patients with adhesions (24%) and 5 (6%) of those with no adhesions had clinical evidence of old pelvic infection. 2 women with a history of STD and adhesions had evidence of chronic pelvic infection. All patients had a negative gonorrhea culture, and all were clinically asymptomatic. The finding that 13 of the 17 patients with perihepatic adhesions had no evidence of prior infection of the pelvis was unexpected and suggests a need for a larger study to define the causes of these adhesions. Also suggested by these findings is the lack of association between perihepatic adhesions and infertility, since all patients were fertile women undergoing interval sterilization.

The other epidemic.

PIP: Sexually transmitted diseases cause more problems for women, than AIDS causes for men, children, and women combined. Yet, the cure for this problem is simple contraceptive prevention. In developing countries women can be abandoned, abused, and even murdered for being infertile, yet 70% if female infertility is caused by the STDs they contracted from their husbands. Men are the agents that transmit STDs, not wives, not prostitutes. Men seeking commercial sex can infect a prostitute who then goes on to infect many other men who then infect their wives. In overview, STD rates are that same for men and women. STDs cause 750,000 deaths annually and 75 million illnesses among women yearly. By 2000, estimates are double.^ieng

Sensitivity of hysterosalpingography after tubal surgery.

Hysterosalpingography (HSG) to assess tubal patency in the postoperative evaluation of the infertile patient has been well described. However, the sensitivity and specificity of HSG after tubal surgery has not been reported. We correlated HSG and laparoscopic findings in 25 patients who had tubal surgery (microsurgical tubal reanastomoses [11] and distal salpingostomies [14]). HSG provided a more reliable means of assessing tubal patency (sensitivity and specificity of 96% and 61% respectively) than in detecting pelvic adhesive disease (PAD) (sensitivity and specificity of 12% and 75% respectively) regardless of tubal surgical procedure. HSG was associated with a high false negative rate (60%) due primarily to the inability to detect PAD. Complete agreement between HSG and laparoscopy was noted in only 15% of cases. These data suggest that HSG is a sensitive means to determine tubal patency, but was not sufficiently sensitive or specific to detect PAD after tubal surgery. These limitations should be noted in the interpretation of HSG in any infertile patient with a history of tubal surgery, and severely limits the application of HSG to the management of the post-operative infertile patient.

PIP: Researchers analyzed data on 25 women who underwent either tubal reanastomosis or distal salpingostomy at least 12 months earlier and came to the Tripler Army Medical Center in Honolulu, Hawaii, for hysterosalpingography (HSG) to compare HSD findings with those of laparoscopy, thereby determining HSG's sensitivity and specificity after tubal repair. They were only able to evaluate 42 tubes, since 2 patients had severe pelvic adhesive disease. HSG was more reliable in determining tubal patency (sensitivity of 96% and specificity of 61%) than in detecting pelvic adhesive disease (12% and 75%, respectively). HSG and laparoscopy findings agreed in just 15% of cases. HSG's inability to detect pelvic adhesions was responsible for this low agreement rate. Specifically, HSG found adhesions in only 6% of patients compared to 65% for laparoscopy (false negative rate = 60%). The adhesions completely covered all pelvic structures in 8% of cases at the same frequency for both reanastomosis and salpingostomy, thereby making it impossible to evaluate the anatomy. Further, HSG did not detect other pelvic pathologies (mild endometriosis, uterine fibroids, and ampullary fistulae) in 10% of cases. These findings suggest that HSG is sensitive and specific enough to assess tubal patency following reanastomosis, but is basically not specific enough to do so after distal salpingostomy. Therefore, clinicians should be aware of HSG's limitations when interpreting any HSG findings in infertile patients who had tubal surgery. Further, it limits their ability to manage postoperative infertile patients.