The role of cervical mucus--semen interaction in infertility of unknown aetiology

An in-vitro penetration assay, which incorporates measurements of sperm motility and forward velocity, was used to investigate sperm-cervical mucus interaction in 20 couples with unexplained infertility. Evidence of impaired cervical mucus penetration was found in this group of patients and in seven couples the results correlated with previous assessment by laparoscopic sperm recovery. The impairment of cervical mucus penetration was found to be due to defective sperm function rather than to the quality of the cervical mucus itself. Of the criteria of semen quality measured in this study, sperm motility and the zona-free hamster egg penetration test showed significant correlations with cervical mucus penetration.     

The aetiology of infertility in 1162 investigated couples

The aetiological factors associated with 1162 couples who attended a single infertility clinic and who were assessed according to a fixed protocol over an eight-year period were analysed retrospectively. Male problems accounted for 17 per cent, ovulation disorders 31 per cent, tubal factors were present in 18 per cent and idiopathic infertility was observed in 32 per cent. Single factor infertility was present in 58.8 per cent and multiple factors were present in 9.8 per cent of all cases. Although results may be biased by sub-specialty interests, only by continuous updating with reference to the most modern accepted methods of investigation can the likely demand for specialised infertility services and in vitro fertilisation be determined with accuracy.     

Abdominal pain of unknown aetiology in pregnancy

The outcome of 140 pregnancies complicated by unexplained abdominal pain was compared with that in a comparison group of 280 women who gave birth at the same time. The two groups were comparable for maternal age and parity but the study group contained a significantly higher proportion of smokers, unmarried women, and women whose partners were unemployed (P less than 0.001). All the pregnancies resulted in livebirths. There were no statistically significant differences in birthweight, gestational age at delivery or mode of delivery between the two groups.     

Abdominal pain of unknown aetiology in pregnancy

Summary. The outcome of 140 pregnancies complicated by unexplained abdominal pain was compared with that in a comparison group of 280 women who gave birth at the same time. The two groups were comparable for maternal age and parity but the study group contained a significantly higher proportion of smokers, unmarried women, and women whose partners were unemployed ( P <0·001). All the pregnancies resulted in livebirths. There were no statistically significant differences in birthweight, gestational age at delivery or mode of delivery between the two groups.     

The role of leiomyomas in infertility.

STUDY OBJECTIVE: To assess the role of leiomyomas and their surgical removal on pregnancy rates. DESIGN: (Canadian Task Force classification II-1). Setting. Academic center. PATIENTS: Two hundred twelve women who were investigated for infertility. INTERVENTION: Laparoscopic myomectomy. MEASUREMENTS and MAIN RESULTS: Patients were divided according to case control criteria as those who underwent laparoscopic removal of myomas (106) and those who did not (106); both groups were compared with 106 women with unexplained infertility without myomas. Of the 318 women, 83 (26%) became pregnant and delivered live infants. The 44 (42%) who underwent surgical removal of leiomyomas had higher delivery rates than 12 (11%) who did not undergo surgery (p <0.001) and 27 (25%) who did not have myomas (p <0.001). Patients whose myomas were not surgically treated had fewer deliveries than women who did not have myomas (12 vs 27, p <0.002). Fifteen women had spontaneous abortions before week 12: 3 (3%) who had surgery, 10 (9%) who did not have surgery, and 2 (2%) who did not have myomas. CONCLUSION: Laparoscopic myomectomy improved pregnancy rates over nonsurgical management of myomas.     

The role of microsurgery in male infertility

Microsurgery has become an important tool in the management of the infertile male. Although macrosurgical techniques are still required for preservation and protection of cryptorchid testes, microscopic techniques are also useful in the preservation of testicular tissue. We now use the microscope in all vasovasostomy and vasoepididyostomy procedures, but its final role in the treatment of male infertility has yet to be determined.     

The role of counseling in infertility.

Sixty-two couples with infertility received infertility counseling along with the infertility investigation and treatment. At the end of the study a questionnaire was sent to all patients in order to evaluate the incidence of psychologic symptoms associated with their infertility and their response to counseling. The study confirmed the presence of a high incidence of emotional symptomatology in the self-selected patients. It showed that male partners are also affected, but less so. Finally, it has demonstrated that infertility counseling serves to enhance the quality of life in many patients who have become the victims of their "infertility crises."     

The role of childbirth in the aetiology of rectocele

OBJECTIVE: Clinically, rectocele is common in parous women and assumed to be due to distension or tearing of the rectovaginal septum in labour. In a prospective study, we examined the prevalence of such defects in primiparae before and after childbearing in order to define the role of childbearing in the aetiology of rectocele. DESIGN: Prospective observational study. SETTING: Tertiary urogynaecological clinic. POPULATION: A total of 68 nulliparous women between 35 + 6 and 40 + 1 weeks of gestation. METHODS: Participants underwent a standardised interview and were assessed by translabial ultrasound. Presence and depth of a rectocele was determined on maximal Valsalva, as was descent of the rectal ampulla. Fifty-two women were reassessed 2-6 months postpartum. MAIN OUTCOME MEASURES: Presence of a true rectocele, rectal descent. RESULTS: True rectoceles were identified in 2 of the 68 women before childbirth and in 8 of the 52 women after childbirth (P = 0.02). After childbirth, the ampulla descended >22 mm further than before (P < 0.0001 on paired t test). Symptoms such as digitation (n = 2), straining at stool (n = 10) and incomplete emptying (n = 11) were not uncommon 2-6 months postpartum; but out of eight rectoceles, four were asymptomatic. CONCLUSIONS: True rectoceles occur in young nulliparae. However, childbirth is associated with an increase in prevalence and size of such defects.     

Oxidative stress in the male germ line and its role in the aetiology of male infertility and genetic disease

The human male is characterized by extremely poor semen quality as reflected in the number, morphology and motility of the spermatozoa and a high incidence of nuclear and mitochondrial DNA damage. As a consequence of these factors, defective sperm function is thought to be a major contributor to the aetiology of human infertility, as well as childhood diseases including dominant genetic mutations such as achondroplasia and cancer. Factors associated with the origin of poor semen quality include: (i) a lack of selection pressure for high fecundity genes in developed countries, (ii) an evolutionary lineage associated with the deterioration of several male fertility genes in humans and their close ancestors, (iii) genetic factors including, but not limited to, Y-chromosome deletions (iv) paternal age and (v) environmental factors. A model is proposed whereby factors such as ageing or environmental toxicants initiate DNA strand breakage in the spermatozoa of affected males, eventually leading to a mutation in the embryo. This hypothesis stresses the importance of discovering the identity of those environmental factors that are capable of damaging DNA integrity in the male germ line. Such information could make an important contribution to understanding of the origins of both male infertility and a variety of pathological conditions that affect humans, including cancer and dominant genetic disease.     

The cervical factor of infertility and intrauterine insemination

Results with intrauterine insemination in 25 couples are presented. The indication for this procedure was a cervical factor of infertility. After an extensive fertility survey in both partners, intrauterine insemination was performed four to seven times per cycle with up to 0.8 ml fresh semen per insemination. Only the first ejaculatory spurt was used. Prophylactic antibiotics were given to all female partners during the insemination period. Within a mean of 6 months 13 couples reported pregnancies (52%). Except for one midtrimester abortion that was probably due to obstetrical reasons, the abortion rate was 33.3%. There were no side effects related to the insemination procedure. Our data indicate that, with appropriate safeguards, intrauterine insemination should be regarded as a safe and effective method for the treatment of the cervical factor of infertility.     

The cervical factor in infertility: diagnosis and treatment

One hundred and fourteen women with an abnormal fractional postcoital test (PCT) and no other demonstrable cause of female infertility were included in this study. By utilizing the results of the postcoital test, it was possible to divide the patients into three major groups: (1) those with anatomical cervical defect, (2) those with abnormal cervical mucus, and (3) those with an abnormal PCT and normal cervical mucus. In the latter group the abnormality was due to either an abnormal male factor or an undetermined factor. The treatment used in all cases was either steroidal (diethylstibestrol) or mechanical (cervical cup insemination). In 53 of the patients there was an improvement in the PCT as a direct result of therapy. Twenty-three of these patients became pregnant--a pregnancy rate of 43%. Of the entire group of 110 patients (excluding 4 patients whose husbands had azoospermia), only 21% became pregnant. Of the 57 patients who failed to respond to therapy, 41 have been followed for 1 year, and only 2 pregnancies have been noted without therapy. No correlation was found between an abnormal PCT and the immunologic factor.     

The role of epigenetics in idiopathic male infertility

Infertility is a complex disorder with multiple genetic and environmental causes. Although some specific mutations have been identified, other factors responsible for sperm defects remain largely unknown. Despite considerable efforts to identify the pathophysiology of the disease, we cannot explain the underlying mechanisms of approximately half of infertility cases. This study reviews current data on epigenetic regulation and idiopathic male infertility. Recent data have shown an association between epigenetic modifications and idiopathic infertility. In this regard, epigenetics has emerged as one of the promising research areas in understanding male infertility. Many studies have indicated that epigenetic modifications, including DNA methylation in imprinted and developmental genes, histone tail modifications and short non-coding RNAs in spermatozoa may have a role in idiopathic male infertility.     

The role of intrauterine insemination in male infertility

Male infertility is a common condition and intrauterine insemination (IUI) is used to treat the mild to moderate forms. Male subfertility determination is usually based on routine semen analysis but recent publications have questioned its diagnostic and prognostic accuracy as well as the effectiveness of IUI itself, as a treatment modality. We carried out a structured review of the literature to assess the current evidence regarding the diagnosis of male infertility, the effectiveness and cost effectiveness of IUI in male infertility and factors that affect the outcome of IUI. There is still uncertainty regarding the criteria for diagnosing male infertility and predicting treatment outcome based on standard semen parameters. The presence of seminal defects compromises the outcome of IUI in comparison with unexplained infertility. The total motile sperm count (TMSC) appears to have a consistent, direct relationship with treatment outcome, but there is no definite predictive threshold for success. However, it is reasonable to offer IUI as first-line treatment if TMSC is greater than 10 million when balancing the risk and cost of alternate treatments, such as in vitro fertilization (IVF). Sperm DNA studies and sperm preparation techniques warrant further studies in order to establish their clinical relevance. There are limited data on the clinical and cost-effectiveness of IUI in male infertility and large high-quality randomized controlled trials are warranted. However the difficulties in organizing such a study, at the present time, are a matter for discussion.     

The role of trace elements in male infertility

The elemental status of seminal plasma collected from four populations subdivided on the basis of sperm counts is presented. Elemental analysis was performed by inductively coupled plasma-source mass spectrometry (ICP-MS) for calcium, cadmium, cobalt, chromium, copper, iron, magnesium, manganese, molybdenum, nickel, lead, rubidium, selenium, vanadium, and zinc. The majority of elements reflected no statistically significant differences among the four groups. The role of trace elements in infertility may be more directly related to sperm and whole semen than seminal plasma levels.