Absence of uterine arteries discovered at fibroid embolisation

Uterine artery embolisation is an increasingly used modality for the treatment of uterine leiomyomata. A 45-year-old woman with menorrhagia due to fibroids was discovered at uterine artery embolisation to have absent uterine arteries. Knowledge of the potential anatomical variants is important for those carrying out uterine artery embolisation, and further investigation of alternative treatment methods is required.

Retroperitoneal solitary fibrous tumour arising from the pelvis in women – A case report and review of literature

A solitary fibrous tumour is an unusual spindle cell neoplasm that most frequently occurs in the pleura based intrathoracic region. In recent years attention has been drawn towards solitary fibrous tumours arising in extrathoracic sites. They are usually benign but malignant solitary fibrous tumours have also been reported (Nielson et al. 1997). There is far less information about the clinical behaviour of an extra thoracic solitary fibrous tumour unlike intrathoracic tumours which is well reported in many case series (England et al. 1989). Although solitary fibrous tumours are well described lesions, the occurrence of similar tumours in the pelvic retroperitoneum of women and presenting as pelvic mass have been reported only sporadically. Because of the rarity, unpredictable behaviour; lack of information available about the clinical behaviour (recurrence and metastasis) and lack of follow up protocol, we are reporting this case which we encountered along with the review of previously reported cases.

Fatal pulmonary embolus after uterine artery fibroid embolisation

We report a 44-year-old woman who developed a fatal pulmonary embolus after uterine artery fibroid embolisation (UAE). Bilateral UAE was carried out through a single right-femoral artery puncture. The largest fibroid in the anterior fundal wall measured 4.5 cm, and the largest fibroid in the posterior fundal wall measured 6 cm. The appearances after UAE were satisfactory, and the procedure was apparently uneventful. No immediate complications were noted. The patient developed sudden-onset shortness of breath and went into cardiac arrest 19 h after the procedure. Postmortem autopsy confirmed that the cause of a death was a pulmonary embolism. To our knowledge this is the first reported case in the United Kingdom in which death occurred from a pulmonary embolus after UAE.

A randomized controlled trial of a cognitive-behavioural group intervention versus waiting-list control for women with uterovaginal agenesis (Mayer–Rokitansky–Küster–Hauser syndrome: MRKH)

BACKGROUND

Uterovaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome: MRKH) is a congenital abnormality of the female genital tract, characterized by the non-formation of the vagina and uterus. There is a widespread agreement that MRKH has a lasting negative psychological impact on women with this condition, but as yet little is known about how to conceptualize and manage this. We developed a cognitive-behavioural group treatment (CBT) of MRKH. The aim of the present study was to determine whether this intervention, compared to waiting-list control, improves psychosocial outcomes in women with MRKH.

METHODS

After stratifying for age and type of MRKH (simple or complex), 39 women with MRKH were randomized to group CBT (n = 19) or waiting list (n = 20). Outcomes were assessed at pre-treatment, post-treatment (7 weeks) and at 3 months follow-up. The main outcome measure was the Symptom Check-List (SCL-90-R). Other outcomes included impact of event, self-esteem and interpersonal functioning.

RESULTS

Participants allocated to group CBT showed significantly reduced psychological symptoms on the SCL-90-R and non-significant improvements on all secondary outcomes at the end of treatment and follow-up, whereas those on the waiting list remained unchanged.

CONCLUSIONS

A group CBT intervention improves psychological outcomes in MRKH. This treatment may also be applicable to other gynaecological conditions.

Congenital abnormalities of the genital tract: management or mismanagement?

Congenital malformations of the genital tract are uncommon and their management requires skill that is only available in a very few centres worldwide. The management requires sensitivity both in terms of the psychological welfare of the patient and the physical welfare and these must be combined together to provide such support. Management of patients outside of these environments is less than optimal and this article seeks to exemplify a principle of management excellence.

The elective use of oxytocin infusion during labour in nulliparous women using epidural analgesia: a randomised double-blind placebo-controlled trial

The obstetric outcome following the elective use of oxytocin infusion was determined in a randomised, double-blind placebo-controlled trial. 93 nulliparous women in a London hospital, who had requested epidural analgesia in labour (</= 6 cm.), were given an infusion of oxytocin (n = 46) or placebo (n = 47). The initial epidural dose was 15 ml of 0.125% bupivacaine, followed by an infusion at 10 ml per h, with 15 ml top-ups if required. When oxytocin was used electively there was a reduction in the length of the first stage of labour from 696 min to 578 min, (P < 0.05) even though more than half of the control group (53%) required oxytocin augmentation. There was no significant difference between the number of operative deliveries (34 [74%] vs 35 [74%]). The rotational delivery rate was less in the study group (2 [4%] vs 5 [11%]), though this did not reach significance. There were no adverse effects on the fetus, as judged by cord pH measurement, Apgar score, admission to the special care baby unit and neonatal jaundice. The prophylactic use of oxytocin in nulliparous women with epidurals reduces the length of the first stage of labour and appears to be safe. It does not reduce the operative delivery rate.

Sexual function in women treated with dilators for vaginal agenesis

OBJECTIVE

To discover the sexual satisfaction of young women treated with vaginal dilators for vaginal agenesis.

DESIGN

Anonymous questionnaire study.

MAIN OUTCOME MEASURES

Comparison of sexual desire arousal lubrication, orgasm satisfaction and pain with a normal population.

RESULTS

There was no significant difference between the study population and controls for the domains of sexual desire, sexual arousal, and satisfaction with a sexual relationship. There was, however, a significant difference for vaginal lubrication and orgasm where the Rokitansky patients scored lower. 22.3% of patients reported some degree of dyspareunia following vaginal penetration. However, this did not affect their enjoyment of the sexual act.

CONCLUSION

The use of graduated vaginal dilators for patients with Mullerian agenesis is highly successful in creating a neovagina. Although the lack of adequate lubrication, pain and difficulty in reaching orgasm is significantly higher in this group, the patients subsequently enjoy sexual satisfaction that is comparable to a normal population.

Vaginal and uterine anomalies in the paediatric and adolescent patient

The past year has brought a number of interesting developments in the world of paediatric and adolescent gynaecology. These primarily relate to the genetics of the biology of sexual differentiation, which is now beginning to gain considerable understanding. A number of case reports and surgical procedures have also been described, although they have contributed only minimally to our existing understanding. Data on prevalence has always been difficult in congenital abnormalities, and some data are also now emerging to support the figures quoted in the literature.

Congenital malformations of the genital tract

Congenital abnormalities of the genital tract are a source of major morbidity for teenage girls. Careful counseling is as important as the surgical approach to management. It is imperative that specialist centers are established worldwide to deal with these problems. Centralization of services will ensure these girls receive the highest quality care.

Dysfunctional uterine bleeding in adolescence

Dysfunctional uterine bleeding in adolescence is usually not a pathological process but a physiological adjustment in the achievement of normal reproductive status. The source of the problem in the vast majority of patients lies in the development of an intact hypothalamo-pituitary ovarian axis which exhibits normal pulsatile gonadotrophin release. The achievement of this in point usually resolves the dysfunctional bleeding problem. Management of these problems is dependent on the clinical impact of blood loss and only requires medication when menstrual loss needs to be controlled. Special circumstances, such as mentally retarded children, require special attention in order to fulfil a number of clinical difficulties and almost always require medical intervention.

Elevated serum lipoprotein(a) levels in young women with endometriosis

Elevated serum lipoprotein(a) [Lp(a)] levels increase the risk of cardiovascular disease if levels of low-density lipoproteins (LDLs) are also high. The biological function of Lp(a) is unknown, but plasma levels may be elevated in inflammatory disease. Endometriosis is a common gynecologic disorder in which endometrial tissue is found outside of the lining of the uterine cavity. There is an immune component to this condition whereby the number of peritoneal macrophages is increased and the level of prostanoids and cytokines in peritoneal fluid is elevated. In the present study, we measured serum lipid, lipoprotein, and apolipoprotein levels in 29 women with endometriosis and in 29 matched healthy controls. Fasting serum triglyceride and apolipoprotein (apo) Al levels were higher in women with endometriosis (+28.1%, P < .001, and +12.3%, P < .01, respectively), but there were no significant differences in LDL or high-density lipoprotein (HDL) cholesterol levels. Serum Lp(a) levels were fivefold higher (P < .01) in the patients (median, 15.0 mg/dL; range, 0.05 to 60.0) than in controls (median, 3.1 mg/dL; range, 0.05 to 57.2). The distribution of apo(a) isoforms was similar in the two groups, but in women with endometriosis the individual apo(a) isoforms tended to be associated with higher serum Lp(a) levels. Endometriosis may represent a relatively common condition in which to investigate the role of Lp(a) in human metabolism.

External cephalic version at term: a survey of consultant obstetric practice in the United Kingdom and Republic of Ireland

OBJECTIVE

To undertake a survey of external cephalic version (ECV) in the United Kingdom and Republic of Ireland.

DESIGN

In June 1995 every consultant obstetrician and gynaecologist in the United Kingdom and Republic of Ireland was sent a postal questionnaire which asked whether ECV was routinely performed for breech presentation after 37 weeks of gestation, assuming no contraindications. If consultants did not perform ECV, a supplementary question inquired whether they referred patients to a colleague who would perform ECV. The questionnaires were colour coded for country and dispatched from the Postgraduate Education Department of the Royal College of Obstetricians and Gynaecologists (RCOG).

RESULTS

Overall, 78% of questionnaires were returned. The percentage of consultants routinely practising ECV in each country was as follows: Northern Ireland 82%; Scotland 64%; Republic of Ireland 64%; England 43%; and Wales 41%. When these figures were compared with the latest RCOG Annual Statistical Returns for breech delivery and caesarean section for breech delivery, there was an inverse correlation between the percentage of obstetricians performing ECV in any one country and the incidence of breech delivery (P < 0.001). There was a similar inverse correlation for the percentage of obstetricians performing ECV and the caesarean section rate for breech delivery (P < 0.001).

CONCLUSION

Although postal survey results are not necessarily an accurate reflection of what happens in clinical practice, these data are supported by evidence from the Cochrane Database of Systematic Reviews indicating that ECV after 37 weeks reduces the incidence of both breech delivery and caesarean section for breech delivery.

Booking ultrasound examinations performed by obstetric senior house officers--time to reevaluate?

We evaluated the proficiency of obstetrics senior house officers, not formally trained in ultrasonography, in assessing fetal viability, the number of fetuses and gestational age. Of 366 women who had an ultrasound examination at the first antenatal visit, 7 (2.1%) had nonviable pregnancies and 7 pairs of twins were correctly identified. Of these women, 329 had a detailed anomaly scan at 18-20 weeks. No anomalies were detected at either scan. Of the booking scans performed by the senior house officers, 89.4% correctly assessed the gestational age of the pregnancy when compared to the anomaly scan (+/- 1 week). One in 10 of the scans performed by the senior house officers was inaccurate. This is important particularly when being used for risk assessment in serum screening for Down syndrome. At present the early ultrasound scan should be performed by more formally trained personnel.

Add-back therapy in the treatment of endometriosis: the European experience

Add-back hormone replacement therapy (HRT) can alleviate the undesirable hypo-oestrogenic effects of the gonadotrophin-releasing hormone (GnRH) agonists, including loss in bone mineral content. However, this approach presents a dilemma in patients with endometriosis as the re-introduction of oestrogen could re-stimulate the endometriotic process. There have been three recently published European studies investigating the combination of GnRH agonist plus add-back HRT in the treatment of endometriosis. The loss of bone mineral density was significantly diminished in a study using 25 micrograms oestradiol patches combined with continuous medroxyprogesterone acetate (5 mg). Neither this low oestrogen dose nor a full bone-sparing dose of oral oestradiol (2 mg daily) reduced the efficacy of Zoladex (goserelin acetate) in patients with endometriosis. Furthermore, in a small open study the gonadomimetic tibolone totally prevented the loss of bone structure during GnRH agonist therapy. If a GnRH agonist is considered the treatment of choice, then HRT should be used in combination.

Endocrine effects of GnRH analogue with low-dose hormone replacement therapy in women with endometriosis

OBJECTIVE

GnRH analogues are being used increasingly for a number of oestrogen dependent conditions in women. The resultant profound hypo-oestrogenism is a disadvantage, however, but the preservation of pituitary sensitivity to negative feedback by oestradiol is not well defined. We have determined the effect on gonadotrophins and inhibin of GnRH analogue plus low-dose continuous combined hormone replacement therapy in comparison with GnRH analogue therapy alone.

DESIGN

Randomized controlled trial.

PATIENTS

Fifty premenopausal women with endometriosis randomized to treatment with goserelin alone (Group 1) or goserelin plus 17 beta-oestradiol and medroxyprogesterone acetate (Group 2).

MEASUREMENTS

FSH, LH, oestradiol, oestrone, inhibin before and during treatment.

RESULTS

Oestradiol and oestrone were suppressed in both groups, but Group 2 had significantly higher oestradiol during the hormone replacement therapy period. LH was suppressed in both groups. In Group 1, FSH levels recovered during treatment but, in contrast, in Group 2, FSH levels remained suppressed throughout treatment. Inhibin was significantly lower in Group 2, but not in Group 1, during treatment compared to pretreatment.

CONCLUSIONS

Pituitary secretion of FSH appears to remain responsive to feedback control by oestradiol during GnRH analogue therapy and is incompletely suppressed, unlike LH which remains completely suppressed. The possible mechanisms for this are discussed.

Gonadotropin-releasing hormone analogue (goserelin) plus hormone replacement therapy for the treatment of endometriosis: a randomized controlled trial

OBJECTIVE

To determine whether treatment of endometriosis with a GnRH analogue (GnRH-a; goserelin) combined with continuous estrogen and progestogen hormone replacement therapy (HRT) would prevent the hypoestrogenic effects, including loss of bone density, while maintaining efficacy for treatment of endometriosis.

DESIGN

Randomized controlled trial.

PATIENTS

Fifty premenopausal women with laparoscopically diagnosed endometriosis (revised American Fertility Score for endometriosis implants equal to four or greater) and significant symptoms of dysmenorrhoea, dyspareunia, and other pelvic pain.

INTERVENTION

Patients were randomized to receive either goserelin alone, 3.6 mg SC depot every 4 weeks for 24 weeks, or goserelin, 3.6 mg SC depot every 4 weeks for 24 weeks, plus HRT (25 micrograms transdermal 17 beta E2 daily and 5 mg medroxyprogesterone acetate orally daily) for 20 weeks commencing with the second goserelin injection.

RESULTS

There was a significant reduction in the extent of pelvic endometriosis in both groups, with no difference between the groups. Both groups experienced an improvement in symptoms and signs, again with no difference between groups. Hypoestrogenic side effects of hot flushes and loss of libido were significantly less in the group that received HRT. The amount of bone mineral density loss was significantly less in the HRT group at the lumbar spine, although it was not prevented completely.

CONCLUSION

The addition of HRT to GnRH-a for the treatment of endometriosis did not reduce the efficacy of treatment, and adverse hypoestrogenic effects were decreased, although not abolished.

Asthenozoospermia and the human sperm mid-piece

This study provides a quantitative comparison between surface and ultrastructural features of motile spermatozoa in asthenozoospermic and fertile men. The study group consisted of 10 individuals with persistent asthenozoospermia and the controls were 10 fertile donors to a sperm bank. Scanning electron microscopy and image analysis were used to objectively measure sperm mid-piece and tail dimensions. Sperm mid-piece length was significantly shorter (P < 0.01) in asthenozoospermic subjects compared with the controls, with mid-piece width and tail length being comparable. Mid-piece ultrastructure was then examined with the transmission electron microscope and the number of mitochondrial gyres and their configuration recorded. At the ultrastructural level the asthenozoospermic subjects demonstrated significantly fewer mitochondrial gyres (P < 0.001) than their fertile counterparts. Energy for sperm movement is provided by mitochondria and a deficit in these organelles in the sub-fertile cohort provides an explanation for poor sperm function in these subjects.

Oestrogen and progesterone receptors in endometriosis: heterogeneity of different sites

The expression of receptors for the ovarian steroid hormones oestrogen and progesterone was studied immunohistochemically using monoclonal antibodies in samples of endometriosis and endometrium in 22 patients. In nine patients samples of endometriosis from more than one site were studied. There was marked heterogeneity in expression of receptors in endometriosis, both when comparing lesions with the corresponding endometrium and also between samples of endometriosis collected from different sites within the same patient. It was suggested that local environmental factors related to the site, depth and degree of fibrosis of the lesions determine the amount of steroid hormone stimulation reaching the lesions and account for the observed difference between endometriosis and endometrium and between endometriosis lesions of different sites.

Morphometric characteristics of motile spermatozoa in subfertile men with an excess of non-sperm cells in the ejaculate

A comparison has been made between the morphological dimensions of motile spermatozoa in subfertile men demonstrating a persistent excess of non-sperm cells in their semen and those found in spermatozoa from fertile controls. Scanning electron microscopy and image analysis were used to make a morphometric assessment of defined sperm parameters in the study and control subjects. Half of the study cohort had an excess (> 5 x 10(6)/ml) of seminal leukocytes and the remainder an excess of sperm precursors in the ejaculate. In subjects with a sperm precursor excess, the motile spermatozoa had several significantly larger head parameters than those from both the fertile controls and those men with a leukocyte excess. Mid-piece and tail measurements did not differ significantly between groups. These findings suggest that, where there are large numbers of immature germinal elements present in semen, there is aberrant morphological development of the motile, apparently mature, spermatozoa which may represent disordered spermatogenesis.

A quantitative study of sperm head ultrastructure in subfertile males with excess sperm precursors

OBJECTIVE

To make an objective comparison between sperm head ultrastructure in fertile subjects and a subfertile cohort with an excess of immature germinal elements in the ejaculate.

DESIGN

A quantitative analysis of ultrastructural features of the sperm head using transmission electron microscopy in the defined groups.

PATIENTS

Ten men of proven fertility as controls and 10 subfertile subjects with a persistent excess of sperm precursors in the ejaculate were investigated.

SETTING

The Infertility Clinic at Queen Charlotte's and Chelsea Hospital, London.

MAIN OUTCOME MEASURES

Each individual in the study achieved a score for a range of previously defined features of sperm head ultrastructure. These scores provided the basis for comparison between fertile and subfertile subjects.

RESULTS

Subfertile individuals were found to have motile sperm with significantly more hypoplastic, detached, and abnormally shaped acrosomes than fertile controls. Sperm nuclei in these subjects also contained significantly more intranuclear vacuoles and immature chromatin and were associated more commonly with cytoplasmic droplets than fertile controls.

CONCLUSION

Men with an excess of sperm precursors in the ejaculate have motile sperm with a range of abnormalities involving the nucleus and acrosome to account for reduced functional competence.

Preinduction cervical assessment by Bishop's score and transvaginal ultrasound

In this pilot study, 50 patients underwent preinduction cervical assessment by digital Bishop Score (BS) and transvaginal ultrasonography. The BS was lower in 7 patients requiring caesarean section than in 43 delivered vaginally (P = 0.017). Of seven ultrasound parameters examined, six (cervical length, width, dilatation, application and position and lower segment thickness) were similar in both groups. Cervical angle, however, was more acute in those delivered abdominally than vaginally (median = 60 degrees and 90 degrees, respectively, P = 0.002). Posterior cervical angle was more accurate than BS in predicting vaginal delivery (Kappa = 0.48 versus 0.21). Patient discomfort was significantly less with transvaginal ultrasound than digital examination. Combining posterior cervical angle greater than 70 degrees and BS greater than 5 yielded the best accuracy in predicting successful induction of labour (sensitivity = 88%, specificity = 100%, Kappa = 0.68).

The effect of danazol on pulsatile gonadotropin secretion in women with endometriosis

OBJECTIVE

To determine whether the effect of danazol on gonadotropin pulsatility was due to a direct effect of the drug or the suppression in the estradiol (E2) levels.

DESIGN

Prospective analysis of serial blood samples at 10-minute intervals for 5 hours on days 3, 4, or 5 of the control cycle and 2 months after the start of danazol treatment.

SETTING

Tertiary institutional outpatient care.

PATIENTS, PARTICIPANTS

Six eugonadal women with minimal endometriosis.

INTERVENTIONS

Oral administration of danazol, 200 mg three times daily.

MAIN OUTCOME MEASURES

Gonadotropin mean levels, pulse frequency, and amplitude.

RESULTS

The mean level of E2 was the same in the control cycle as that during danazol treatment (170 pmol/L). Danazol administration resulted in a 16% increase in the mean luteinizing hormone (LH) pulse amplitude (95% confidence interval [CI] 6% to 26%, P less than 0.01), associated with a 20% decrease in LH pulse frequency (95% CI -71% to +31%, P = 0.37). There was a nonsignificant increase in follicle-stimulating hormone (FSH) pulse amplitude (2%, 95% CI -9% to +14%, P = 0.68) and in FSH pulse frequency (27%, 95% CI -4% to +58%, P = 0.08). The 22% decrease in the mean LH level (95% CI -85% to +12%, P = 0.13) and the 20% decrease in the mean FSH level (95% CI -53% to +37%, P = 0.33) were also not significant.

CONCLUSIONS

The increase in LH pulse amplitude represents a direct effect of danazol on the hypothalamic-pituitary axis.

The effect of danazol and the LHRH agonist analogue goserelin (Zoladex) on the biological activity of luteinizing hormone in women with endometriosis

In an attempt to determine whether the suppression in oestradiol levels caused by danazol is due to an effect on the hypothalamic-pituitary axis, we compared the endocrine effects of danazol with those of the LHRH (GnRH) agonist analogue goserelin. Serum levels of immunoreactive LH (I-LH), FSH, 17 beta-oestradiol (E2) and bioactive LH (B-LH) (using a mouse Leydig cell bioassay), were measured in ten and 20 women with endometriosis treated with danazol and goserelin, respectively. I-LH was measured both by radioimmunoassay (RIA) and immunoradiometric assay (IRMA). During 6 months of treatment with 600 mg of danazol daily, mean serum E2 decreased (P less than 0.05) to levels near the upper limit of the post-menopausal range (to a mean (and 95% confidence interval of the mean) of 117 (65-169) pmol/l) whereas FSH, I-LH (both by RIA and IRMA) and B-LH levels were not significantly altered. During 6 months of treatment with monthly depot injections of 3.6 mg goserelin, mean serum E2 decreased (P less than 0.001) to well within the post-menopausal range (to 23 (18-28) pmol/l). The mean FSH, I-LH and B-LH levels also decreased (P less than 0.05) during therapy with goserelin (from 3.9 (3.1-4.7) to 2.0 (1.6-2.4) IU/l for FSH, from 5.3 (4.5-6.1) to 1.9 (1.7-2.1) IU/l for RIA-LH, from 2.9 (2.5-3.3) to less than 0.5 (less than 0.5) IU/l for IRMA-LH and from 9.1 (7.1-11.1) to 2.9 (2.6-3.2) IU/l for B-LH).(ABSTRACT TRUNCATED AT 250 WORDS)

Oxytocin infusion during second stage of labour in primiparous women using epidural analgesia: a randomised double blind placebo controlled trial

OBJECTIVE

To determine whether the high rate of forceps delivery associated with the use of epidural analgesia could be reduced through giving an intravenous infusion of oxytocin during the second stage of labour.

DESIGN

A randomised, double blind, placebo controlled trial.

SETTING

Delivery suites in three hospitals.

SUBJECTS

226 Primiparous women with adequate epidural analgesia in whom full dilatation of the cervix had been achieved without prior stimulation with oxytocin.

INTERVENTION

An infusion of oxytocin or placebo starting at the diagnosis of full cervical dilatation at an initial dose rate of 2 mU/min increasing to a maximum of 16 mU/min.

MAIN OUTCOME MEASURES

The outcome of labour was assessed in terms of the duration of the second stage, mode of delivery, fetal condition at birth, postpartum blood loss, and the incidence of perineal trauma.

RESULTS

Treatment with oxytocin was associated with a shorter second stage (p = 0.01), a reduction in the number of non-rotational forceps deliveries (p = 0.03), and less perineal trauma (p = 0.03) but was not associated with any reduction in the number of rotational forceps deliveries performed for malposition of the occiput. No adverse effects on fetal condition at birth or in the early puerperium were seen in association with the use of oxytocin.

CONCLUSIONS

The use of an oxytocin infusion may reduce the high rate of operative delivery associated with epidural analgesia provided that the fetal occiput is in an anterior position at the onset of the second stage of labour but within the dose range studied does not seem to correct malposition of the fetal occiput.

Human oocyte-cumulus complexes stimulate the human acrosome reaction

Oocyte-cumulus complexes were obtained, after induced ovulation, from infertile patients participating in an in-vitro fertilization programme. About 6 h after retrieval and depending on the expansion of the cumulus, 100,000 motile spermatozoa, prepared by a migration-centrifugation method, were added. After 14-18 h incubation at 37 degrees C, oocytes were examined for signs of fertilization (pronuclei and polar body formation) and then removed; spermatozoa remaining in the incubation medium were fixed for transmission electron microscopy. To provide an adequate number of cells for observation, spermatozoa from a minimum of 3-5 oocytes from the same patient were pooled. When sufficient spermatozoa were available after insemination, the remainder of the suspension was incubated at 37 degrees C and fixed along with the corresponding oocyte-incubated sample. In all, 32 sperm samples were assessed and fertilized oocytes were obtained with 29 of these. In the 24 samples in which greater than 100 spermatozoa (mean of 192) could be assessed, 32% of spermatozoa had initiated or completed the acrosome reaction. In the 15 of these 24 samples for which oocyte-free controls were available, 31% of cells were reacting or reacted, compared with 15% of cells (P less than 0.001) in the controls. In the remaining 8 samples, incubated with oocyte-cumulus complexes, less than 100 but greater than or equal to 20 spermatozoa (mean of 42) were assessed and again 32% of spermatozoa were reacted.(ABSTRACT TRUNCATED AT 250 WORDS)

Extended exposure to follicular fluid is required for significant stimulation of the acrosome reaction in human spermatozoa

The effect of human follicular fluid (FF) on the incidence of spontaneous acrosome reactions (AR) in human spermatozoa was examined over a 24-25 h period using electron microscopy. Suspensions of motile spermatozoa were prepared by a swim-up method in Earle's medium, known to support in-vitro fertilization. After adjusting the concentration to 10 x 10(6) cells/ml, suspensions were diluted 1:1 with medium (control) or FF, the latter giving a final concentration of 50% FF. In addition, at 5 h and 24 h an aliquant of the control suspension was removed, diluted 1:1 with FF and incubated for 1 h; the three suspensions were examined at 6 h and 25 h. Continuous exposure to 50% FF stimulated the AR, the effect being significant (P less than 0.001) at 25 h. However, the 1-h short exposure of spermatozoa to FF did not produce an increase in AR, even after 24 h preincubation. In a separate series of experiments, the effect of continuous incubation for 24 h in increasing concentrations of FF was investigated. A significant linear dose-dependent effect on the AR was observed with all concentrations assessed (P less than 0.01 for 12.5% FF and P less than 0.001 for 25, 50, 75 and 100% FF, compared with FF-free control). Therefore, human FF can stimulate the AR, but only after a continuous exposure to FF. A short exposure to FF, even after 24 h preincubation, does not trigger an increased AR response.

Retrograde ejaculation: successful treatment with artificial insemination

Between 1977 and 1987, 14 couples in whom the male partner had retrograde ejaculation were treated with artificial insemination using the husband's sperm (AIH). There were 6 pregnancies in 4 couples, giving a cumulative probability of pregnancy at 12 months of 72%. The success rate depended on a number of factors, including semen quality, methods of sperm extraction from the urine, timing of ovulation and other complicating fertility factors.

Programmed gamete intrafallopian transfer (GIFT)

Thirty-three patients with unexplained infertility underwent a total of 42 programmed superovulation cycles in a gamete intrafallopian transfer (GIFT) programme. The date of oocyte retrieval was decided in advance and the cycle preceding oocyte collection was modified with norethisterone from mid-cycle until 14 days before the scheduled laparoscopy. This was followed by a fixed schedule superovulation regimen. Serum oestradiol, progesterone and luteinizing hormone were monitored and the data analysed retrospectively. A single ultrasound scan was performed on the day of laparoscopy to exclude ovulation. Thirty-eight GIFT procedures were performed, resulting in 11 (29%) clinical pregnancies of which four twin and four singleton pregnancies are continuing. There was a significant correlation between the oestradiol response pattern and the maturity of oocytes retrieved, the fertilization rate of supernumerary oocytes and the pregnancy rate. Programmed cycles may be conveniently combined with GIFT, and basic endocrinological monitoring can be used to identify cycles with a poor prognosis before laparoscopy.

Uterine activity in the second stage of labour and the effect of epidural analgesia

Uterine activity was measured during the second stage of normal labour in 20 patients with and 31 patients without epidural analgesia. There was a significantly lower uterine activity integral (UAI) in patients having epidural analgesia, and it is suggested that this may contribute to the increased rate of instrumental delivery associated with epidural analgesia.

Cryopreservation of semen in men with testicular tumour or Hodgkin's disease: results of artificial insemination of their partners

After cryopreservation of semen from men with testicular tumours or Hodgkin's disease the success rate of artificial insemination of their partners was analysed. The cumulative probability of pregnancy at 6 months was 45%. The chance of pregnancy was greater when timing of ovulation was predicted with measurements of urinary luteinising hormone. Sperm density and sperm motility were also important in predicting the likelihood of pregnancy.

Early embryonic mortality in women

Measurements of human chorionic gonadotropin (hCG) have been used to assess early embryo loss in women. Urine samples obtained from a control group of sterilized women with normal ovulatory menstrual cycles enabled a concentration limit of 56 IU/l to be determined so that any nontrophoblastic hCG or other cross-reacting compounds could be accounted for. One hundred ninety-eight ovulatory cycles were collected from a normal population attempting to conceive. Fecundability was 22% to 27% for this population. The risk of pregnancy in exposed ovulatory cycles was 59.6%; however, 61.9% of conceptuses will be lost prior to 12 weeks. Most of these losses (91.7%) occur subclinically, without the knowledge of the mother.