Changes in Haematological Indices, Blood Viscosity and Inhibitors of Coagulation during Treatment of Endometriosis with Danazol

The effects of treatment with danazol (600 mg daily) on haemostatic and haematological function were investigated in 18 pre-menopausal women with endometriosis. Blood samples were taken at 2 pre-treatment visits, at 6, 12 and 24 weeks on treatment, and at 6 weeks after discontinuation of the drug. Haemoglobin, red cell count, haematocrit and platelet count all rose significantly during treatment with danazol (p <0.01 vs. baseline). Plasma fibrinogen levels fell significantly (p <0.01), while whole blood viscosity increased during treatment and remained significantly elevated at follow-up. The prothrombin time shortened, but remained within normal limits, and there were no significant changes in factor VII:C, Vila, or fibrinopeptide A. No significant changes were found in platelet function. Plasma B-beta 15-42 increased significantly. Functional levels of protein C, protein S, and antithrombin III, all rose significantly, above the normal range, while C4b-binding protein levels fell. We conclude that the observed changes in coagulation inhibitors and fibrinolytic activity may be considered beneficial in the context of venous thromboembolism. The rheological effects, however, indicate a degree of caution in the use of the drug in individuals considered to be at risk from arterial cardiovascular disease.

The changing nature of elective laparoscopic surgery: a review over a 7 year period in a reproductive surgery unit

There was a significant increase in the number of laparoscopic procedures performed in the Reproductive and Surgery Unit at the Jessop Hospital for Women over the 7 year period from 1991 to 1997. The three most common procedures were adhesiolysis/salpingo-ovariolysis, treatment of endometriosis and ovarian drilling, which together constituted over 80% of all cases. The duration of surgery and the complexity of the cases gradually increased with time. The determinants of patients staying overnight after laparoscopic surgery in decreasing order of importance were: (i) whether they had undergone surgery in the morning or in the afternoon; (ii) the operating time; and (iii) the number of entry ports used. Most (75%) of the laparoscopic procedures were performed or supervised directly by a consultant. In this study period the major complication rate was 0.7%.

Reversal of sterilisation vs. IVF: a cost-benefit analysis

A consecutive series of 132 cases of reversal of sterilisation carried out in a teaching hospital in England between 1982 and 1995 was analysed. Follow-up data was obtained on 112 patients. The overall cumulative conception rate was 47% at 12 months and 55% at 24 months. Among the 71 pregnancies there were seven miscarriages (9%) and 11 ectopic pregnancies (15%). Factors affecting the outcome of surgery were examined. The pregnancy rate achieved with microsurgical techniques was significantly higher than the conventional (macrosurgical) techniques (61% v. 40%, P = 0.05). The method of sterilisation also has a significant impact on the outcome; Filshie clips 69%; Fallope ring 46%; Pomeroy technique 31% (P < 0.05). Age, associated infertility factors and the interval between sterilisation and reversal operation did not appear to have a significant impact on the outcome. When compared with IVF, reversal of sterilisation is associated with a higher ectopic rate, lower multiple pregnancy rate and a lower miscarriage rate. We conclude that reversal of sterilisation carries a higher overall success rate than IVF and is more cost effective when the method of sterilisation is by the clip or ring and when the reversal operation is carried out with microsurgical techniques.

A prospective dose-finding study of the amount of thermal energy required for laparoscopic ovarian diathermy

BACKGROUND

This prospective dose-finding study was undertaken to determine the optimal amount of thermal energy required for laparoscopic ovarian diathermy (LOD) in women with polycystic ovary syndrome (PCOS).

METHODS

Thirty women with clomiphene-resistant PCOS were included in the study. All women underwent LOD. A modified Monte Carlo up-and-down design was utilized. Women were treated in groups of three (10 groups). The amount of energy applied was standardized at 150 J/puncture. The number of punctures in each group was decreased/increased according to the number of responders in the previous group. The main outcome was ovulation as defined by a serum progesterone concentration of > or =30 nmol/l.

RESULTS

Four groups (n=12) were treated with four punctures/ovary, three groups (n=9) with three punctures, two groups (n=6) with two punctures and one group (n=3) with one puncture. Ovulation occurred in 67, 44, 33 and 33% of women treated with four, three, two and one puncture/ovary respectively. The corresponding pregnancy rates were 67, 56, 17 and 0%. The reductions in the free androgen index and the serum concentrations of testosterone and androstenedione after LOD were observed only in women treated with three and four punctures/ovary.

CONCLUSION

The clinical response to LOD seems to be dose-dependent, with an increase in the frequency of ovulation and conception with an increasing dose of thermal energy up to 600 J/ovary.

Long-term follow-up of patients with polycystic ovary syndrome after laparoscopic ovarian drilling: endocrine and ultrasonographic outcomes

BACKGROUND

There is considerable controversy as to how long the beneficial effects of laparoscopic ovarian drilling (LOD) last. This follow-up study was undertaken to investigate the long-term effects of LOD.

METHODS

The study included 116 anovulatory women with polycystic ovary syndrome (PCOS) who underwent LOD between 1991 and 1999 (study group) and 34 anovulatory PCOS women diagnosed during the same period, who had not undergone LOD (comparison group). The hospital records were reviewed and most patients attended for a transvaginal ultrasound scan and blood sampling to measure the serum concentrations of LH, FSH, testosterone, androstenedione and sex hormone-binding globulin. The results before and at different intervals, short- (<1 year), medium- (1-3 years) and long-term (4-9 years), after LOD were compared.

RESULTS

The LH:FSH ratio, mean serum concentrations of LH and testosterone and free androgen index decreased significantly after LOD and remained low during the medium- and long-term follow-up periods. The mean ovarian volume decreased significantly (P < 0.05) from 11 ml before LOD to 8.5 ml at medium-term and remained low (8.4 ml) at long-term follow-up.

CONCLUSION

The beneficial endocrinological and morphological effects of LOD appear to be sustained for up to 9 years in most patients with PCOS.

Long term follow-up of patients with polycystic ovarian syndrome after laparoscopic ovarian drilling: clinical outcome

BACKGROUND

Currently, there is an uncertainty about the impact of laparoscopic ovarian drilling (LOD) on the natural history of polycystic ovarian syndrome (PCOS). This longitudinal follow-up study was undertaken to investigate the long-term effects of LOD.

METHODS

The study included 116 anovulatory PCOS women who underwent LOD between 1991 and 1999 (study group) and 34 anovulatory PCOS women diagnosed during the same period but who had not undergone LOD (comparison group). The hospital records were reviewed and questionnaires were sent to all the women. In addition, most women attended a follow-up interview. Clinical data recorded at different intervals of follow-up (short-term, <1 year; medium-term, 1-3 years; and long-term, 4-9 years) included: the menstrual pattern, symptoms relating to hyperandrogenaemia and reproductive history.

RESULTS

The proportion of women with regular menstrual cycles increased significantly [relative risk (RR) = 1.6, 95% confidence interval (CI) = 1.4-1.9, P < 0.05] from 8% before LOD to 67% post-operatively. The proportion dropped to 37% (RR = 2.6, 95% CI = 1.8-3.8, P < 0.01) at medium-term follow-up and then increased again to 55% (RR = 2.2, 95% CI = 1.7-2.8, P < 0.01) at long-term follow-up. After LOD, 54/110 women (49%) conceived spontaneously during the first year and 42 (38%) during medium- and long-term follow-up. Among women with hirsutism (n = 43) and acne (n = 25), 10 (23%) and 10 (40%) respectively experienced long-term improvement after LOD.

CONCLUSION

LOD produces long-term improvement in menstrual regularity and reproductive performance in about one-third of cases. A modest and sustained improvement in acne and hirsutism can be expected in approximately 40 and approximately 25% of patients respectively.

An evaluation of the inter-observer and intra-observer variability of the ultrasound diagnosis of polycystic ovaries

BACKGROUND

This prospective observational study was undertaken to evaluate the reliability and consistency of ultrasound diagnosis of polycystic ovarian syndrome (PCOS).

METHODS

Eighteen women with clinical and biochemical features suggestive of PCOS and nine normal control women underwent transvaginal ultrasound scan by a single ultrasonographer. The 27 ovarian scans were video-recorded and the recordings were later edited and arranged randomly so that each record appeared twice at random on the tape producing a total of 54 ovarian scans. Four experienced observers independently reviewed the recordings. The observers scored each case as follows: normal, possible polycystic ovary (PCO) and definite PCO.

RESULTS

The mean intra-observer agreement was 69.4% (kappa = 0.54) and the mean inter-observer agreement was 51% (kappa = 0.28).

CONCLUSION

The results suggest that the currently used ultrasonographic criteria for the diagnosis of polycystic ovaries do have significant intra-observer and inter-observer variability and as such must be considered subjective. Transvaginal ultrasonography alone may not therefore be a reliable method of diagnosing or excluding PCOS.

Laparoscopic ovarian diathermy in women with polycystic ovarian syndrome: a retrospective study on the influence of the amount of energy used on the outcome

BACKGROUND

Currently, there is an uncertainty about the optimum number of punctures to be applied at laparoscopic ovarian diathermy (LOD). This retrospective study was undertaken to investigate the dose-response relationship of LOD.

METHODS

The hospital records of 161 women with polycystic ovarian syndrome who underwent LOD were reviewed and the clinical data before and after LOD were documented. Subjects were divided into six groups according to the number of punctures made in their ovaries as follows: group 1, two punctures per ovary; group 2, three punctures; group 3, four punctures; group 4, five punctures; group 5, six punctures and group 6, seven to 10 punctures. Contingency table analysis and analysis of variance were used to compare the outcomes of the different groups.

RESULTS

The rates of ovulation, conception and restoration of menstrual regularity after LOD were significantly lower in group 1 compared with other groups. There were no significant differences in the success rates between the other groups.

CONCLUSION

Two punctures per ovary are associated with poor results. Three punctures per ovary seem to represent the plateau dose. The application of seven or more punctures per ovary may result in excessive destruction to the ovary without any improvement of the results and should therefore be discouraged.

The correlation of adhesions and peritoneal fluid cytokine concentrations: a pilot study

BACKGROUND

Intra-abdominal adhesion formation and reformation after surgery is a significant cause of morbidity. The greatest problem after the surgical removal of adhesions is their reformation. We examined the concentrations of interleukin (IL)-1, IL-6 and tumour necrosis factor (TNF)-alpha in the peritoneal fluid throughout the 48 h post-operative period following adhesiolysis, and correlated the results to the extent of adhesion reformation.

METHODS

Peritoneal fluid, collected from eight patients following laparoscopy and again at 12, 36 and 48 h after surgery, was analysed using enzyme-linked immunosorbent assay (IL-1 and IL-6) and bioassay (TNF-alpha). At 48 h, a second look laparoscopy was performed to inspect the pelvis for adhesion formation/reformation.

RESULTS

Three patients had adhesion reformation >10% at 48 h after surgery. The mean adhesion score 48 h after adhesiolysis was 5 (range 0-17). The mean reduction in adhesion score was 88% (range 83-100%). Newly formed adhesions were filmy, relatively soft and avascular in nature. Adhesion reformation of >10% was associated with (i) high concentrations of IL-6 at 12 h (P < 0.01) and (ii) high concentrations of IL-1 at 48 h (P < 0.001).

CONCLUSIONS

Results from this preliminary study suggest that future treatment strategies for adhesion prevention could be aimed at the control of cellular mediators in the peritoneal fluid during the initial adhesion formation period.

Peritoneal healing and adhesion formation/reformation

Intra-abdominal adhesion formation and reformation after surgery is a cause of significant morbidity, resulting in infertility and pain. The understanding of the pathogenesis of adhesion formation and reformation especially at the cellular and molecular level can help to further develop more effective treatments for the prevention of adhesion formation and reformation. Following an injury to the peritoneum, fibrinolytic activity over the peritoneal surface decreases, leading to changes in the expression and synthesis of various cellular mediators and in the remodelling of the connective tissue. The cellular response to peritoneal injury and adhesion formation and reformation are reviewed. Analysis of the available literature data on the cellular mediators in the peritoneal fluid showed variation in results from different investigators. The potential sources of variability and error are examined. It is still unclear if there is significant individual variation in the peritoneal response to injury.

Low-dose dexamethasone augments the ovarian response to exogenous gonadotrophins leading to a reduction in cycle cancellation rate in a standard IVF programme

BACKGROUND

Cancellation of assisted conception cycles because of poor ovarian response to gonadotrophins is a significant problem in assisted reproduction. Various adjuvant treatments have been suggested to improve responsiveness. This study reports on the potential benefits of low dose dexamethasone.

METHODS

Patients <40 years of age were invited to participate in a twin centre prospective double blind randomized placebo controlled study. A total of 290 patients were recruited and computer randomized using sealed envelopes to receive either 1 mg dexamethasone (n = 145) or placebo tablets (n = 145) in addition to a standard long protocol gonadotrophin-releasing hormone analogue with gonadotrophin stimulation regime.

RESULTS

A significantly lower cancellation rate for poor ovarian response was observed in the dexamethasone group compared with controls (2.8 versus 12.4% respectively, P < 0.002). Further comparisons between the dexamethasone group and controls were made of median fertilization rates (60 versus 61% respectively, NS), implantation rates (16.3 versus 11.6% respectively, NS) and pregnancy rate per cycle started (26.9 versus 17.2%, NS). The benefit was apparent in patients both with polycystic and normal ovaries.

CONCLUSION

Low dose dexamethasone co-treatment reduces the incidence of poor ovarian response. It may increase clinical pregnancy rates and should be considered for inclusion in stimulation regimes to optimize ovarian response.

The septate uterus: a review of management and reproductive outcome

OBJECTIVE

To review the literature on the diagnosis, prevalence, and treatment of the septate uterus, with special reference to hysteroscopic metroplasty and its effect on reproductive outcome.

DESIGN

Pertinent studies were identified through a computer MEDLINE search. References of selected articles were hand-searched for additional citations.

RESULT(S)

Reliable diagnosis of the septate uterus depends on accurate assessment of the uterine fundal contour. At present, the combined use of laparoscopy and hysteroscopy is the gold standard for diagnosis, although recent reports of two-dimensional, transvaginal, contrast ultrasound and of three-dimensional ultrasound appear promising. The prevalence of the septate uterus is increased in women with repeated pregnancy loss. A metaanalysis of published retrospective data comparing pregnancy outcome before and after hysteroscopic septoplasty indicated a marked improvement after surgery.

CONCLUSION(S)

The hysteroscopic approach to treatment, with its simplicity, minimal postoperative sequelae, and improved reproductive outcome, has enabled a more liberalized approach to treatment that is now being extended to include not only patients with recurrent pregnancy loss and premature labor but also patients with infertility, especially if IVF is being contemplated.

The role of T-helper cytokines in human reproduction

OBJECTIVE

To explore the role of maternal periimplantation endometrial T-helper-1 (TH-1) and T-helper-2 (TH-2) cytokines in the success or failure of human reproduction and their relation to the endocrine system and subsequent pregnancy outcome.

DESIGN

Controlled, prospective study.

SETTING

A tertiary care hospital with a university-based reproductive medicine clinic.

PATIENT(S)

Healthy women and women with recurrent miscarriage who had no history of infertility or autoimmune disease.

INTERVENTION(S)

Measurement of qualitative cytokine expression by RT-PCR and quantitative by ELISA, also hormone levels and pregnancy outcome.

MAIN OUTCOME MEASURE(S)

Expression of TH-1 and TH-2 cytokines and correlation with hormone levels and subsequent pregnancy outcome.

RESULT(S)

Levels of TH-1 cytokines were significantly greater and higher in women with recurrent miscarriage compared with controls, whereas levels of TH-2 cytokine interleukin-6 were significantly lower in women with recurrent miscarriage than in controls. There was no correlation between cytokine expression and serum hormone levels, and periimplantation cytokine levels were not predictive of subsequent pregnancy outcome in women with recurrent miscarriage.

CONCLUSION(S)

This study demonstrated in vivo that women with recurrent miscarriage exhibit primarily TH-1 cytokines, whereas healthy women exhibit decreased TH-1 cytokines and increased TH-2 cytokines. This suggests a potential role for a dichotomous T-helper response in the mediation of subsequent reproductive events. This maternal T-helper response appears to operate independently of hormonal factors in influencing the success or failure of human reproduction, as no correlation was evident between serum hormone levels and cytokine levels. An attempt to use periimplantation TH-1 and TH-2 cytokine profiles as a predictor of subsequent pregnancy outcome (live birth or no live birth) was limited by the small number of patients studied.

Morphological evidence for the 'implantation window' in human luminal endometrium

Endometrial tissue was taken from 21 normal fertile women (aged 18-40 years) between 4 and 13 days after the luteinizing hormone (LH) surge. Systematic random samples of luminal epithelium were taken for both light and electron microscopy and examined morphometrically. Throughout the luteal phase there were remarkably few changes in the volume fraction of nucleus, mitochondria, rough endoplasmic reticulum and 'vesicular system' to cell. Nuclear profile dimensions and cell height also did not change over time. Cell and organelle volume (estimated as volume weighted mean volume) did not change significantly, but showed numerically smallest values on day LH + 13. However the ratio of desmosomes to whole cell and both arithmetic mean thickness and harmonic mean thickness of basement membrane were minimal at the time when implantation would be most likely to occur, i.e. approximately 6 days after the LH peak. Therefore it appears that while some morphometric parameters in human luminal epithelial cells change little during the luteal phase, specific cellular changes occur to the basement membrane and desmosomes which may facilitate embryo implantation. These changes occurred around day LH+ 6 and may be a morphological representation of the 'implantation window'.

Myomectomy: a retrospective study to examine reproductive performance before and after surgery

The aim of this retrospective study was to establish the impact of myomectomy on pregnancy outcome with particular reference to its effect on the incidence of pregnancy loss. Myomectomy was performed using microsurgical procedures upon 51 women who had intramural or subserosal fibroids and wished to conceive. Overall, the conception rate following myomectomy was 57%. Multiple regression analysis showed that age was the only factor which influenced conception rate: </=35 years, 74% (23/31); >/=36 years, 30% (6/20; P < 0.005). The pregnancy loss rate prior to myomectomy was 60% (24/40), which was reduced to 24% (8/33) after myomectomy (P < 0.001). There was no instance of premature labour or scar rupture among 25 live births. This retrospective study suggests that myomectomy for intramural and subserosal fibroids may significantly improve the reproductive performance of women presenting with infertility or pregnancy loss.

Establishment of predictive variables associated with testicular sperm retrieval in men with non-obstructive azoospermia

Although testicular biopsy for sperm extraction is a procedure with a potential for complications, sperm retrieval is successful in 30-70% of patients with non-obstructive azoospermia. In order to predict the probability of retrieving at least one testicular spermatozoon we conducted a prospective study of a set of variables in 40 patients with non-obstructive azoospermia. Using the receiver operating characteristic curves, we determined the probability estimates of testicular volume, plasma follicle stimulating hormone (FSH) concentration, Johnsen score and visualization of testicular spermatids in discriminating between patients with successful and failed testicular sperm extraction. Visualization of testicular spermatids provided the best estimate of success of testicular sperm extraction. Of the factors studied using logistic-regression analysis (age, maternal and paternal age at birth, body mass index, luteinizing hormone, testosterone, FSH, testicular volume, the presence of testicular spermatids and Johnsen score), only the presence of spermatids and Johnsen score were independent variables able to predict the success of testicular sperm extraction. The visualization of the presence of spermatids gave a correct prediction of 77% and Johnsen score of 71%. The diagnostic model derived from these independent predictors when validated in 40 patients using the Jackknife technique gave a correct overall prediction of 87%. The probability of successful testicular sperm extraction in patients with non-obstructive azoospermia could be objectively predicted on the basis of simple histopathological criteria represented by the visualization of testicular spermatids and Johnsen score.

Morbidity and cost-effectiveness analysis of outpatient analgesia versus general anaesthesia for testicular sperm extraction in men with azoospermia due to defects in spermatogenesis

The outcome and costs of testicular sperm extraction under outpatient local analgesia or general anaesthesia were compared in men with non-obstructive azoospermia. Nineteen consecutive patients were allocated to receive general anaesthesia, while the subsequent 21 consecutive patients received outpatient analgesia in the form of i.v. midazolam sedation, lignocaine spray, scrotal infiltration with local anaesthetic and spermatic cord block. Blood pressure, pulse rate and respiratory rate were determined. Sedation and testicular pain were assessed by subjective scoring. Both groups showed haemodynamic stability with little alteration in blood pressure, pulse rate and oxygen saturation. Toxic symptoms of local anaesthetic were not encountered in the outpatient group. No relationship was found between testicular size and the duration of the operation. The median postoperative pain intensity, sedation scores and analgesic requirements were significantly less in the outpatient group (P < 0.05). These advantages led to a shorter recovery time (P < 0.0001), 3-fold cheaper care and greater patient satisfaction (P < 0.0001) in the outpatient group.

Correlation of testicular pathology and sperm extraction in azoospermic men with ejaculated spermatids detected by immunofluorescent localization

Limiting testicular biopsy for intracytoplasmic sperm injection (ICSI) to those with a high chance of having testicular spermatozoa has not been possible because of the poor predictive value of current clinical and laboratory methods. In order to predict testicular pathology and sperm extraction, we characterised the semen of 28 men with azoospermia due to gonadal failure in terms of the presence of spermatids using an immunological method. The results were compared with the assessment of testicular biopsies by histology and the extraction of spermatozoa into culture medium. Washed cellular elements in the ejaculate were smeared on microscope slides and fixed in 100% methanol, before incubation with acrosome-specific monoclonal antibody (18.6), fluorescein isothiocyanate-labelled anti-mouse goat IgG, and examination by epifluorescent microscopy. Semen from men with oligozoospermia and obstructive azoospermia served as positive and negative controls, respectively. Twelve patients who had positive immunofluorescence (one or more spermatids present) had spermatozoa retrieved from their testes (five hypospermatogenesis, seven focal spermatogenesis), and 16 patients with negative immunofluorescence (spermatids absent) had apparent Sertoli cell-only syndrome (12) or maturation arrest histological pattern (four). However, four patients with apparent Sertoli cell-only syndrome had testicular spermatozoa present after extraction from the biopsy. Plasma follicle stimulating hormone concentration and testicular volume did not predict retrieval of seminal spermatids or testicular spermatozoa. We conclude that the immunofluorescent localization of one or more spermatids in the ejaculate can be used to predict the likelihood of obtaining testicular spermatozoa for ICSI. However, in some patients with Sertoli cell-only syndrome, spermatozoa could still be recovered in the absence of apparent seminal spermatids.

A combinatorial phage display library for the generation of specific Fab fragments recognizing human spermatozoa and inhibiting fertilizing capacity in vitro

To select a source of lymphocytes for the generation of an anti-sperm-biased combinatorial phage display library, venous blood was obtained from 34 vasovasostomy (vasectomy reversal) patients approximately 3 mo after surgery. Using a variety of immunoassays, serum was analyzed for antibodies against human spermatozoa, and a patient was selected on the basis of high titer of antibodies that recognized the equatorial region of the sperm head and inhibited sperm fertilizing capacity in vitro. Total RNA isolated from the stored lymphocytes of this individual was reversed transcribed, and gamma1 (Fd) region and kappa chains were amplified by polymerase chain reaction for the successful construction of an antibody phage display library. The library was panned against human spermatozoa to isolate sperm-specific phage that recognized the equatorial region of the sperm head. Three preparations of Fab were tested via the hamster egg penetration test. Each preparation significantly (p < 0. 005) inhibited sperm-egg binding and fusion, with one preparation (designated Fab-G) causing complete inhibition. Sequence analysis of the kappa light gene encoding Fab-G revealed a 93% homology with the light chain of human anti-human immunodeficiency virus gp120 p35 variable region. This technology may have a practical application in characterization of the immune response to spermatozoa and for the design of sperm-based contraceptive vaccines.

A prospective study of multiple needle biopsies versus a single open biopsy for testicular sperm extraction in men with non-obstructive azoospermia

Little is known about the efficacy and the factors affecting the outcome of fine needle aspiration biopsy of the testis for sperm retrieval in azoospermic men with defective spermatogenesis. A prospective study was designed to compare the efficacy of needle and open (window) testicular biopsies for testicular epididymal sperm extraction (TESE) in 35 consecutive men with azoospermia due to defective spermatogenesis undergoing testicular biopsy for intracytoplasmic injection of oocytes. Each of the consecutive 35 patients underwent TESE using a 19 gauge butterfly needle followed by a window (1-1.5 cm-sized incision) testicular biopsy in the same procedure. The extraction of spermatozoa into culture medium was compared with the assessment of testicular biopsies by histology, the mode of biopsy (needle or open biopsy) and the amount of tissue retrieved by either method. Testicular spermatozoa were retrieved in 22 (63%) who had an open testicular biopsy compared with five (14%) patients who had multiple needle biopsies, respectively; the difference was statistically significant. Open testicular biopsy retrieves more testicular tissue than needle biopsy. Needle testicular biopsy retrieved testicular spermatozoa in 50% of those with hypospermatogenesis, 10% with focal spermatogenesis and in no patients with maturation arrest or Sertoli cell-only pattern. In contrast, sperm retrieval was successful in 100%, 90% and 66% of those with respective histologies using open testicular biopsy. Other than bruising, for which they required no analgesia, none of the patients suffered any obvious complications associated with traditional testicular biopsy. We conclude that open testicular biopsy is more effective than needle biopsy for the retrieval of testicular spermatozoa in azoospermic men with defective spermatogenesis. The difference observed may be related to the amount of testicular tissue retrieved and to the influence of testicular histology.

Correlation of testicular sperm extraction with morphological, biophysical and endocrine profiles in men with azoospermia due to primary gonadal failure

To identify the predictive factors for testicular sperm extraction (TESE) and to understand the pathology associated with TESE, we carried out a prospective study in 40 consecutive men with azoospermia due to primary gonadal failure. The main outcome measure was the retrieval of at least one testicular spermatozoon. Endocrine and biophysical profiles, testicular histology, Johnsen score and testicular spermatids were used as predictors of sperm extraction. Spermatogenesis was quantified with the Johnsen score. A variable pattern of spermatogenesis was common, being present in 20 (50%) patients. Visualisation of testicular spermatids on testicular histology showed a strong association with TESE (P < 0.0001). Statistically significant differences were detected in plasma follicle stimulating hormone (FSH) and testicular volume between patients who had hypospermatogenesis and Sertoli cell-only or maturation arrest. There were no significant differences in Johnsen score, biophysical and endocrine profiles between the groups with successful and failed TESE. However, a statistically significant trend occurred with changes in histological pattern [chi2 for trend, P = 0.001; Pearson's coefficient (r) = 0.6], Johnsen score (P = 0.022; r = 0.5), testicular volume (P = 0.01; r = 0.5) and plasma FSH concentrations (P = 0.044; r = 0.4), albeit to a limited degree. Difference in the interpretation of histological patterns with different assessors was observed. The type of occupation or risk factors for azoospermia showed no association with testicular pathology or TESE. Variable histological patterns in different tubules in the same individual may explain the poor correlation of TESE with endocrine and biophysical profiles, Johnsen score and histological pattern. Differences in the amount of tissue used for TESE and histopathology, and misinterpretation of testicular histology rather than failure to quantify spermatogenesis may explain the poor correlation between histological patterns and TESE. Testicular spermatids predicted TESE. However, considerable overlap in values means that no single variable can provide a perfect discrimination between the groups with successful and failed TESE.

Phosphoinositide 3-kinase is involved in the induction of the human sperm acrosome reaction downstream of tyrosine phosphorylation

In somatic cells phosphoinositide 3-kinase (PI 3-kinase) is activated upon interaction with both receptor tyrosine kinases (RTK) and G-proteins resulting in the production of moieties involved in the inositol phospholipid signalling pathway. As G proteins, RTK and the inositol phospholipids have all been implicated in the human sperm acrosome reaction, experiments were carried out to determine whether PI 3-kinase was also involved in this phenomenon. Wortmannin is a selective inhibitor of PI 3-kinase and was shown to significantly inhibit the acrosome reaction induced by both mannose-bovine serum albumin (mannose-BSA) (10, 50 and 100 nM) and a polyclonal antibody raised against an extracellular region of the sperm zona receptor kinase (ZRK, at 100 nM only). Wortmannin did not inhibit the A23187- or progesterone-induced acrosome reaction. These results suggest that PI 3-kinase is involved in the human sperm acrosome reaction. The levels of tyrosine phosphorylation of sperm proteins as detected by Western blotting using antiphosphotyrosine antibodies was not affected by wortmannin in agonist (A23187 and mannose-BSA)-stimulated spermatozoa. This indicated that PI 3-kinase operates downstream of tyrosine phosphorylation in the signal transduction cascade which leads to the human sperm acrosome reaction.

Changes in basement membrane thickness in the human endometrium during the luteal phase of the menstrual cycle

We have examined aspects of the fine structure of the basal laminae associated with the luminal and glandular epithelium and small blood vessels in the human endometrium. Four short studies are presented and reviewed. Study 1 examined biopsies from 20 fertile women taken on days after the luteinizing hormone surge (LH): LH +2, 4, 6, 8 and 10. The basal lamina (both lamina densa and lucida) increased in thickness over the period studied. Study 2 again studied the glandular epithelium and examined the effect of RU486 (a progesterone receptor blocker) administered on day LH +3 and biopsied on day LH +6. The basal laminae were found to be the same as LH +2 control group but thinner than LH +6 control. Study 3 documented increased thickness of the basal laminae between LH +6, 8 and 13 in the luminal epithelium. The within-group coefficient of variation was 16% and 27% for LH +6 and LH +13 groups but only 2 % for LH +8. Study 4 demonstrated an increase in basal lamina thickness associated with small blood vessels between LH +6 and LH +10 in normal fertile women. The basal lamina provides the interface between epithelial and mesenchymal environments; changes in its structure can alter the phenotypic expression of the epithelia. It is one of the maternal barriers that must be transgressed by the trophoblast during implantation. Together, these combined studies provide quantitative baseline structural information on the electron microscopical appearance of the basal lamina during the luteal phase of the menstrual cycle.

Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility

OBJECTIVE

To describe and analyse the factors affecting the pregnancy rate of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility.

DESIGN

A retrospective study.

SETTING

A specialist infertility clinic based at a teaching hospital in England.

POPULATION

One hundred and eighteen women, for whom hospital records and follow up data were available, with polycystic ovarian syndrome who underwent laparoscopic ovarian surgery for anovulatory infertility over a five year period, between January 1991 and December 1995.

MAIN OUTCOME MEASURES

Ovulation and pregnancy rate.

RESULTS

The cumulative conception rate 12 months after the treatment was 54%. Women who conceived following the surgery had a shorter duration of infertility, were treated with diathermy (rather than laser), had higher pre-operative luteinising hormone levels, were younger and were more likely to have ultrasonographic evidence of polycystic ovarian disease. Logistic multiple regression analysis showed that the duration of infertility, modality used in treatment (laser or diathermy) and the pre-operative levels were the main determinants of the outcome.

CONCLUSION

Women with polycystic ovarian syndrome respond favourably to laparoscopic ovarian drilling. The success rate in women with infertility duration of less than three years, treated with diathermy, in whom the pre-operative level was more than 10 IU/L reached 79%.

Profile of cytokine mRNA expression in peri-implantation human endometrium

The human embryo and subsequent fetus is a semi-allograft and immunologically foreign to the mother. Successful embryonic implantation and maintenance of normal pregnancy depends on intricate interactions between the invading embryo, maternal endometrium and maternal immune response. Cytokines are pivotal in determining the type of maternal T-helper immune response, which can be divided into T-helper 1 (TH1)-mediated delayed hypersensitivity and T-helper 2 (TH2)-mediated humoral immunity. We examined the pattern of TH1 [interleukin (IL)-2, IL-12 and interferon-gamma] and TH2 (IL-4 and IL-6) cytokine expression in the peri-implantation endometrium of 10 fertile, multiparous women. Endometrial samples were timed to the mid-cycle luteinizing hormone (LH) surge, with collection on days LH+7 to LH+9. Analysis for cytokine mRNA was by mRNA extraction and reverse transcription-polymerase chain reaction. The results show a lack of TH1 and predominant TH2 cytokine expression. We postulate that endometrial cytokines may contribute to the local modulation of maternal adaptive immune response in peri-implantation endometrium, to facilitate successful embryonic implantation and maintenance of pregnancy.

Identification of ovarian antibodies by immunofluorescence, enzyme-linked immunosorbent assay or immunoblotting in premature ovarian failure

The development of new techniques for the detection of ovarian antibodies has challenged early concepts about the rarity of ovarian antibodies in idiopathic premature ovarian failure (POF), but few attempts have been made to compare results between assays. We have sought to define the prevalence of ovarian autoimmunity in a group of 30 idiopathic POF patients compared to a group of 12 patients with POF plus an associated autoimmune disease and a group of 38 controls, using an enzyme-linked immunosorbent assay (ELISA) and indirect immunofluorescence (IFL). Ovarian antibodies were detected in 27% of idiopathic POF patients by ELISA (not significantly different compared to POF patients with associated autoimmune disease; P < 0.0003 compared to controls) but only 7% of these patients were positive by IFL. In a further, pre-selected group of individuals, all positive for ovarian antibodies by IFL, 53% had measurable antibodies by ELISA. Some overlap was therefore demonstrated between the two techniques but many POF patients had ovarian antibodies detectable by only one method. Immunoblotting studies revealed that no consistent pattern of binding could be demonstrated for these patients. These results call into question the specificity of ovarian antibodies as a marker for autoimmune POF.

Natural cycle in-vitro fertilization in couples with unexplained infertility: impact of various factors on outcome

This study evaluated outcome in 117 couples with unexplained infertility who underwent 162 attempts at natural cycle in-vitro fertilization (NIVF) between 1991 and 1993. An egg was obtained in 138 cycles and a single embryo was transferred in 89 cycles. There were 16 implantations (four biochemical pregnancies, three clinical abortions and nine live births). The implantation rate per embryo was 16/89 (18.0%), which translated into a live birth rate per egg collection of 9/138 (6.5%). The impact factors that were assessed included oocyte quality, sperm quality, embryo quality and woman's age. The outcome measures used were fertilization/inseminated egg and implantation/replaced embryo. All embryo transfers were of single embryos. We conclude that, in couples with unexplained infertility, outcome following NIVF is affected by both egg and sperm quality and by the age of the woman. Embryo quality was independent of the above factors but was also critical for successful implantation.

Comparison between stimulated in-vitro fertilization and stimulated intrauterine insemination for the treatment of unexplained and mild male factor infertility

A prospective trial was undertaken to evaluate the efficacy of stimulated in-vitro fertilization (SIVF) and stimulated intrauterine insemination (SIUI) in couples with unexplained and mild male factor infertility. In all, 80 couples were allocated to treatment with SIVF or SIUI, both treatments following the same protocol [clomiphene citrate and follicle stimulating hormone (FSH) injection], except that higher doses of FSH were used in the SIVF treatment cycles. Initially, 41 couples were allocated to and started treatment with SIVF but eight cases were eventually converted to SIUI because of under-response. Similarly, although 39 couples were initially allocated to SIUI treatment, five of these converted to SIVF because of over-response. The treatment cycles that were converted either to SIUI or to SIVF were not considered as treatment failures but as treatment changes and so were included in the analyses. Of the final 38 SIVF cycles, four were cancelled (dysfunctional response), failed fertilization occurred in five cycles and 29 subjects reached embryo transfer. There were two biochemical pregnancies [positive human chorionic gonadotrophin (HCG) only], two clinical abortions and seven live births. Of the final 42 SIUI cycles, only two were cancelled, insemination being performed in the remaining 40 cases. The result was one clinical abortion, three ectopics and eight live births. The proportion of cycles with positive HCG was identical (28.9% per cycle treated for SIVF and 28.6% for SIUI) and the livebirth rates were also not different (18.4% per cycle treated for SIVF and 19.0% for SIUI). The cost per maternity of SIUI was approximately half that of SIVF (Pounds Sterling 1923 versus Pounds Sterling 4611) and so we conclude that, as SIUI had an efficacy that was not significantly different from SIVF (using similar protocols) but was more cost-effective, it must be considered the more appropriate form of management for the treatment of unexplained and mild male factor infertility. Indeed, it is hard to justify the routine use of IVF, as a first approach, in unexplained infertility.

Elevating intracellular calcium levels in human sperm using an internal calcium ATPase inhibitor, 2,5-di(tert-butyl) hydroquinone (TBQ), initiates capacitation and the acrosome reaction but only in the presence of extracellular calcium

The aim of this study was to investigate the effect of an internal calcium ATPase inhibitor, TBQ, on human sperm capacitation and the acrosome reaction during incubation in a calcium-depleted media. Sperm were isolated into and incubated for up to 6 hr in media depleted of Ca2+ and two Ca(2+)-containing media controls. At set time intervals, sperm in each media group were treated with 100 microM TBQ for 5 min. Afterwards, sperm were induced to acrosome react using the divalent cation ionophore, A23187, as a measure of sperm fertilizing potential. It was established, using the Chlortetracycline assay, that incubation of sperm in a Ca(2+)-depleted media inhibited or delayed sperm capacitation resulting in fewer spontaneous or A23187-induced acrosome reacted sperm. However, incubation of sperm in a Ca(2+)-depleted media did not appear to inhibit sperm motility. The treatment of sperm with TBQ during their incubation in Ca(2+)-depleted media was found to have very little effect resulting in low numbers of capacitated and acrosome reacted sperm. The results from this study suggest that human sperm have an obligatory requirement for extracellular calcium during capacitation and the acrosome reaction, but may require either very little extracellular Ca2+ to maintain motility or possess internal Ca2+ stores sufficient for their requirements. In addition, TBQ did not increase the number of capacitated and acrosome reacted sperm during incubation in a Ca(2+)-depleted media suggesting that the TBQ-effect of accelerating sperm capacitation is dependent on presence of extracellular Ca2+.

Response of human spermatozoa to an internal calcium ATPase inhibitor, 2,5-di(tert-butyl) hydroquinone

This study has investigated the effect of elevating intracellular calcium levels, using an internal calcium ATPase inhibitor, 2,5-di(tert-butyl) hydroquinone (TBQ), on human sperm function. Isolated sperm samples from five fertile donors were incubated in a capacitating media for up to 6 hr. After 0, 3, and 6 hr incubation, sperm were exposed to a range of TBQ concentrations; 100 microM, 10 microM, and 1 microM, for a fixed incubation period of 5 min. Controls were run for each experiment where sperm were incubated for 5 min in the absence of TBQ. Sperm capacitation and the acrosome reaction were monitored prior to and after exposure to TBQ, using the Chlortetracycline assay. In addition, sperm motility was assessed at each time point and after sperm had been exposed to TBQ. The treatment of sperm with TBQ caused a significant increase in the number of capacitated sperm with an optimum response being achieved in the presence of 100 microM TBQ. However, sperm motility was found not to be effected by the addition of TBQ. The results from the present study suggest that elevating intracellular calcium levels in human sperm by short exposure to a high concentration of TBQ can rapidly accelerate the capacitation process. Furthermore, the observation that TBQ did not elicit a change in sperm motility suggests that TBQ may be highly specific in its mode of action by acting within the head region of human sperm.

Complications of laparoscopic pelvic surgery: recognition, management and prevention

Laparoscopic surgery has many advantages but it is not without complications. The complexity of the surgery significantly influences the complication rate. Laparoscopic surgeons ought to be aware of the possible complications and how they could be prevented, recognized without delay, and managed safely and efficiently. Important complications include injuries to the vessels, bowel and urinary tract. Incisional hernia ought to be reduced by careful closure of the fascia whenever a trocar > or =10 mm is used at the extraumbilical site. Gas embolism is a rare but potentially life threatening complication. Shoulder pain is a minor complication but is exceedingly common; it is less likely to occur if as much gas as possible is removed at the end of the operation while the patient is still in head down Trendelenburg position. Rare complications include pneumothorax, subcutaneous and pre-peritoneal emphysema, cardiac arrhythmia, nerve injury and venous thrombosis. Laparoscopic surgeons should also understand the principles of electrosurgery and how to avoid complications arising from the use of electrical energy including capacitative coupling, direct coupling and insulation failure.

The effect of a single dose of mifepristone (RU486) on the fine structure of the human endometrium during the early luteal phase

This study examined the fine structure of the human endometrial glandular epithelium after the administration of a single dose of RU486 (mifepristone), given in the early luteal phase. The drug was administered on days 2, 3, 5 and 6 after the luteinizing hormone peak (LH + 0). Biopsies were performed on days LH + 5, 6, 8 and 9. These were compared with control biopsies taken on corresponding days. Qualitatively, the main cytological effect of the RU486 was on the secretory apparatus and on the polarity of the cell. The formation of the nuclear channel system was also affected by the drug. A two-way analysis of variance on cell and nuclear volume data revealed no significant effect of day of biopsy, condition or interaction. Mitochondrial volume and secretory apparatus volume data revealed a significant effect of day of biopsy and interaction term; mitochondrial volume at LH + 5 was 95.9 +/- 25.3 microm3 (mean +/- SD) for control and 57.7 +/- 31.9 microm3 for RU486-treated epithelium. The volume of the secretory apparatus in the treated group was smaller on days LH + 5 and 6 (14.6 +/- 4.2 microm3, 6.41 +/- microm3) when compared to day-matched control biopsies (35.9 +/- 10.5 microm3, 41.7 +/- 26.4 microm3). RU486 administration in the early luteal phase disrupted the secretory activity of the cells. These findings provide an insight into the cellular mechanisms of progesterone receptor blockade in the peri-implantation period.

Impact of the learning curve on term delivery rates following laparoscopic salpingostomy for infertility associated with distal tubal occlusive disease

The objective of this study was to determine the impact of the learning curve of one surgeon on the term delivery rate following laparoscopic salpingostomy for tubal infertility. This was a retrospective audit of ongoing clinical practice, undertaken in two tertiary level infertility programmes. Subjects in this study were women undergoing surgery for total occlusion of the distal Fallopian tube. The main outcome measure was cumulative term delivery rates. On stepwise life-table analysis the length of infertility, primary and secondary infertility, tubal diameter and whether surgery was performed in the first or second half of the series were significantly associated with outcome. These data suggest that there is a learning curve in obtaining skills to perform laparoscopic salpingostomy, that patient selection may improve with experience, and that selection criteria should be emphasized during didactic teaching and the preceptorship process.

The potential shortcomings of measuring hyperactivated motility by computer-aided sperm analysis when sperm motion is multiphasic

This paper was written from the standpoint that computer-aided sperm analysis (CASA) instruments, which capture a 'snapshot' of sperm trajectories in order to generate their data, may provide a poor measure of hyperactivated motility in a sperm population where hyperactivation is multiphasic in nature. To illustrate this point, a series of theoretical sperm populations were constructed which varied subtly but significantly in the nature of the hyperactivated behaviour expressed by spermatozoa. The parameters which were manipulated were: (i) the number of hyperactivated phases exhibited within a given period of time; (ii) the duration of these phases; and (iii) proportion of spermatozoa within the population which exhibited hyperactivated phases. These populations were then subject to an analysis in which snapshots of sperm motion were examined to determine the percentage of hyperactivated spermatozoa for that population. The results indicated that whilst this snapshot approach to quantifying hyperactivation could provide a figure for the percentage of hyperactivated spermatozoa within the sample window, this often inaccurately described the underlying behaviour of the population. Since there is very likely to be a significant amount of biological information contained within the nature of multiphasic behaviour, this paper has argued that this aspect of snapshot analysis is one which requires serious consideration by CASA manufacturers and medical researchers.

The pattern of cytokine mRNA expression in ovarian endometriomata

Intraovarian cytokines play a pivotal role in the normal growth and development of the ovarian follicle. The purpose of this study was to investigate the pattern of cytokine mRNA expression in ovarian endometriomata. A total of 10 patients with histologically confirmed endometriomata undergoing surgery formed the study group while nine patients undergoing sterilization with no evidence of a cyst in the ovary formed the control group. Biopsies of the ovary were obtained at surgery and stored in liquid nitrogen until processed by reverse transcription-polymerase chain reaction amplification to identify the presence of mRNA for interleukin (IL)-1, IL-2, IL-4, IL-6, IL-8, IL-10, IL-13, tumour necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma). IL-6 and IL-10 mRNA were expressed by nine and seven patients respectively in the endometriosis group compared with three and one patients in the control group; this difference was significant (P < 0.05). IL-1 alpha mRNA was expressed by seven of 10 patients with endometriosis but by only one of the control group; this was again significantly different (P < 0.04). Ovarian IL-2 and IL-4 mRNA were not expressed in either group. There was no significant difference in the expression of IL-8, IL-13, IFN-gamma and TNF-alpha mRNA in the two groups. These findings suggest that abnormal local expression of certain cytokines may contribute to the development of endometriomata.

Retrograde tubal embryo transfer in natural cycle in-vitro fertilization

Two modes of embryo transfer, uterine and tubal, were compared following natural cycle in-vitro fertilization (IVF). Only patients with patent Fallopian tubes were included in the study. Tubal embryo transfer was performed by retrograde tubal cannulation without analgesia on an outpatient basis. Tubal transfer conferred no benefit compared with uterine transfer in male factor infertility with positive fertilization (pregnancy rates of 15.8% in both groups). Although tubal embryo transfer in the patients with unexplained infertility improved the pregnancy rates from 7.8% in uterine transfer (5/64) to 17.6% in the tubal transfer group (13/74), this improvement was not statistically significant.

Is subclinical ovarian failure an autoimmune disease?

Young women with unexplained infertility who exhibit elevated basal serum follicle stimulating hormone (FSH) concentrations (>10 IU/l) have poor outcomes in in-vitro fertilization. A subgroup of these women has regular menses, representing 'subclinical' ovarian failure, which may have an autoimmune basis and could potentially be treated by immunosuppression. To investigate this further, a range of immunological markers was used to assess autoimmune activity in 14 women aged <40 years with elevated FSH compared with 15 infertile women with normal FSH and 10 pre-menopausal, healthy controls. All samples were taken during natural menstrual cycles. Organ-specific antibodies against ovary, endometrium and thyroid, and non-organ-specific antibodies against histones and cardiolipin, were not significantly increased in elevated FSH patients compared with other control groups. Soluble CD23 and soluble intercellular adhesion molecule concentrations were not elevated in the sera of the women tested, and circulating T cell subsets remained unaltered. Significantly, increased concentrations of the complement breakdown product C3a and terminal complement complexes were detected in the elevated FSH group compared with the normal FSH group, although the latter also had significant complement activation compared with laboratory controls. Autoimmunity appears as an infrequent cause of 'subclinical' ovarian failure, but there is evidence of activation of complement in the sera of infertile women.

Continuous assessment of human spermatozoa viability during cryopreservation

Cryomicroscopy has enabled direct observation of freezing and thawing of human spermatozoa. When used with a fluorescent viability kit, sperm membrane damage was not apparent down to temperatures of -5 degrees C, but significant damage occurred after thawing (55% of spermatozoa had damaged membranes). Semen samples were cooled or frozen to temperatures (at decrements of 10 degrees C) from 0 degree C to -110 degrees C. At all these temperatures the proportion of live to membrane-damaged cells remained constant. Samples held at temperatures above -30 degrees C were not adversely affected. Below -30 degrees C there was a gradual increase in the proportion of membrane-damaged cells on thaw and a decrease in the number of live cells recovering motility. At temperatures between -50 degrees C and -60 degrees C there was an equal proportion of live motile, immotile, and membrane-damaged cells. It is concluded that some irreversible damage to spermatozoa was a result of freezing processes in cells frozen to -30 degrees C or less, but most of the cryodamage was incurred during thawing, possibly due to recrystallization.

Direct assessment of cryopreservation of human spermatozoa using a cryomicroscope and computer-aided sperm analysis

Use of a cryostage has enabled direct observation of human spermatozoa as they are cryopreserved and thawed. Crystallization and recrystallization events are readily observed. In combination with computer-aided semen analysis (CASA) equipment it was possible to determine the consequence of altering the cooling, freezing and thawing rates of a temperature-rate profile on sperm motility. Increasing the cooling rate to 50 degrees C/min resulted in significantly lower pre-freeze to post-thaw ratios for average path velocity (VAP, 13%), mean straight line velocity (VSL, 35%), mean linearity (LIN, 28%) and straightness (STR, 24%), while the ratio of the number of cells crossing the field of view (NCF) significantly increased (30%) compared to a standard freeze-thaw temperature rate profile. The NCF pre-freeze to post-thaw ratio was associated with the percentage of cell recovery after cryopreservation. Faster thaw rates resulted in better survival of the cells, perhaps due to the shorter time during which recrystallization occurred. The NCF ratios were significantly higher (33 and 30% for thaw rates of 50 and 100 degrees C/min respectively) than for the standard profile samples. Previous studies on cell survival have shown a link between the cooling and thaw rates. The cryostage should prove invaluable in future studies to identify the causes of cryodamage to spermatozoa. When used in combination with CASA, changes to sperm function during cryopreservation can be accurately measured.

Cytokines and immuno-endocrine factors in recurrent miscarriage

Recurrent miscarriage remains an enigma. The main aetiologies are endocrinological, immunological and unexplained. With the growth in molecular biology, it is now possible to look at the effect of these aetiologies in more detail, allowing greater understanding of the underlying pathogenesis.

Changes in nuclear morphology in the human endometrial glandular epithelium in women with unexplained infertility

In the light and electron microscopical study reported here, we documented the structure of the nucleus, nucleolus and nuclear channel system (NCS) in the uterine glandular epithelium in both fertile and infertile women during the early luteal phase. Nuclear volume was found to be larger in the infertile group at day 5 after the luteinizing hormone surge (LH+5) compared to day-matched fertile subjects. A two-way analysis of variance performed on nucleolar volume data from fertile and infertile women biopsied on days LH+5, +5, and +6 revealed a significant effect of condition but no effect of day or interaction. Nucleolar volume decreased from day LH+2 to day LH+6 in the fertile group, the sharpest decrease occurring between day LH+3 and day LH+4. The largest mean volume of the NCS was found at day LH+5 in the fertile group and day LH+6 in the infertile group. The results suggest a delay in the development of this organelle in the infertile women. The present study has documented alterations in the nuclei of uterine glandular cells from infertile patients. In these infertile women, there is also a delayed elaboration of the secretory apparatus and this delay correlates well with the delayed/reduced expression of a luteal-specific glyco-protein.

Soluble CD23 protein in the peritoneal fluid of patients with endometriosis

Activated B cells are known to produce soluble CD23 protein (sCD23) from their membranes. We recently showed a higher concentration of sCD23 in the serum of patients with endometriosis. As the commonest site of endometriosis is the peritoneal cavity, we sought to evaluate the concentration of sCD23 in the peritoneal fluid of 47 fertile symptomatic women with endometriosis and 35 fertile women without endometriosis. Endometriosis was diagnosed by laparoscopy and confirmed by histopathology. There was a statistically significant difference between the sCD23 concentrations in the endometriosis and control groups (P < 0.05). When endometriosis was defined based on the revised American Fertility Society (AFS) Score, patients with mild (AFS 1 and II) but not severe (AFS III and IV) endometriosis showed a higher and significant difference in the concentration of sCD23 when compared with the controls (P < 0.05). There was no significant correlation between the peritoneal fluid concentration of sCD23 and the phase of the menstrual cycle. We conclude that the concentration of sCD23 is higher in the peritoneal fluid of patients with endometriosis when compared with the controls, suggestive of B cell activation in patients with endometriosis. Furthermore, mild endometriosis is immunologically more active than severe endometriosis as defined by the current classification.

The human ovarian granulosa cell: a stereological approach

The human ovarian granulosa cell is perhaps the most widely studied endocrine cell, but little quantitative structural information exists for this cell. In the present study new and traditional stereological probes have been employed to provide quantitative structural information on these functionally important cells. Granulosa cells were obtained from follicular aspirations from 10 women during in vitro fertilisation procedures. Initially 2 methods were used to estimate the mean nuclear volume of these cells: the mean number weighted nuclear volume was estimated by the Selector and the mean volume weighted nuclear volume by the point sampled intercept method. It was found that the difference between the 2 volume estimates was only 8.5%. The volume weighted mean nuclear volume was used as an estimate of nuclear volume. This was subsequently corrected (taking the percentage difference as the empirical bias) and combined with fractional cell volumes (Vv) to produce estimates of cell, mitochondrial, lipid and nucleolar volume. The proportion of the cell occupied by the nucleus had a remarkably low interindividual variation (CV = 7.6%). The proportion of the nucleus occupied by euchromatin also had a striking low variation (CV < 6%). All other cellular parameters had CVs of less than 35%. The lipid composition of these cells showed the greatest interindividual variability, with a CV of 42% for relative and 54% for absolute volume. The present study outlines a simple protocol for the quantitation of granulosa cell structure using new unbiased stereological probes and providing baseline structural information.

Comparative study of the effect of human cervical mucus and a cervical mucus substitute, Healonid, on capacitation and the acrosome reaction of human spermatozoa in vitro

The present study was designed to investigate the effect of human cervical mucus on capacitation and the acrosome reaction of human spermatozoa and compare its effect to that of a cervical mucus substitute, sodium hyaluronate (Healonid). Spermatozoa from donors of proven fertility were isolated from semen using cervical mucus, Healonid or a direct swim-up (acting as the control). Sperm capacitation and the acrosome reaction were monitored by the chlortetracycline assay. In the mucus-treated group, there was a significantly higher percentage of capacitated spermatozoa, but a low incidence of spontaneous and A23187-induced acrosome reactions compared to the control. The use of Healonid during sperm isolation mimicked the effect of mucus relatively successfully. Since mucus and Healonid show very little chemical similarity, this finding would imply that cervical mucus exerts a physical effect during its interaction with spermatozoa, although a chemical effect cannot be completely dismissed. In conclusion, this study confirms early reports describing the ability of cervical mucus to capacitate spermatozoa but at the same time conserve sperm function. The finding that Healonid exerts an almost identical effect on spermatozoa would lend support to its use as a cervical mucus substitute during in-vitro fertility assessments and research studies.