Role of a bipolar resectoscope in subfertile women with submucous myomas and menstrual disorders

AIM: To evaluate the role of the Gynecare (Ethicon, Somerville, NJ, USA) bipolar resectoscope in resecting fibroids, and the effect of hysteroscopic myomectomy on infertility and pregnancy outcomes. METHODS: From January 2000 to December 2005, we studied 59 women of reproductive age with menorrhagia, submucous myomas and one or more infertility factors. All women who participated had been subfertile for over 2 years. Fifteen of the 59 women displayed submucous myoma type O (intracavitary), 34 displayed submucous myoma type I (less than 50% within the myometrium) and the remaining 10 women displayed myoma type II (over 50% being within the myometrium).The mean age and standard deviation of these patients was 34.6 +/- 4.4 years and the average size of myomas was 15 +/- 10 mm. Treatment of these myomas was by hysteroscopic resection using a bipolar resectoscope. RESULTS: Menorrhagic incidents improved in 20 of 32 women (62.5%). Twenty-five women (42.4%) succeeded in becoming pregnant. The pregnancy rate was notably higher when the sole reason of subfertility was the presence of myoma (54.16%), and when the size of the myoma was equal to 2.5 cm (75%) or more. CONCLUSION: The use of the bipolar resectoscope in hysteroscopic removal of small submucous myomas is shown to be both feasible and effective in controlling menorrhagia and increasing the pregnancy rate in subfertile women, when submucous myomas are the only reason of infertility.     

A prospective comparative study between hysterosalpingography and hysteroscopy in the detection of intrauterine pathology in patients with infertility

AIM: To investigate the accuracy of hysterosalpingography (HSG) in comparison to hysteroscopy in the detection of intrauterine pathology in patients with infertility, where hysteroscopy is the gold standard. METHODS: A prospective, comparative study included 336 patients undergoing both HSG and diagnostic hysteroscopy. Main outcome measures were sensitivity, specificity, positive and negative predictive value, and accuracy rate of HSG. RESULTS: Intrauterine abnormalities were shown on HSG in 286 patients and confirmed in 200 at hysteroscopy. Contrarily intrauterine lesions were detected by hysteroscopy in 4 out of 50 patients in whom HSG were normal. The most common intrauterine finding of 336 patients on hysteroscopy were intrauterine adhesions (IUA) (74), followed by endometrial polyps (56), and submucous myoma, 26 patients. Statistical analysis revealed that HSG in the detection of intrauterine pathology had a sensitivity of 98.0%, specificity of 34.9%, positive predictive value of 69.9%, negative predictive value of 92.0%, and accuracy rate of 73.2% with false-positive and false-negative rates of 30.1% and 8.0%, respectively. The common incorrect diagnoses of HSG were misdiagnosing a condition of cervical stenosis as severe IUA in 24 patients, endometrial polyps as submucous myoma in 22 out of 50 patients, and submucous myoma as endometrial polyps in 12 out of 72 patients. CONCLUSIONS: Hysterosalpingography is still a useful screening test for the evaluation of the uterine cavity. If a hysterogram demonstrates intrauterine abnormalities, hysteroscopy should be considered to make a definite diagnosis and treatment. Both procedures should be complementary to each other.     

Activation of the immune system and sperm DNA fragmentation are associated with idiopathic oligoasthenoteratospermia in men with couple subfertility

Ejaculates from men without known causes for male subfertility and asymptomatic for genital tract inflammation showed infiltration of macrophages, and their activation state (HLA-DR(+)) was negatively correlated with semen parameters and positively correlated with sperm DNA damage. An activation of the immune system is thus detectable in idiopathic oligoasthenoteratozoospermia of unknown origin.     

Cost-effective treatment of the infertile couple

Objective: To review the published literature on the cost-effective approach to infertility treatment.

Design: The literature on the economics and cost-effectiveness of infertility treatments was reviewed. Studies related to this topic were identified through MEDLINE.

Result(s): Few cost-effectiveness studies about infertility treatment have been published. In the absence of tubal blockage and severe male factor, use of IUI and hMG-IUI is more cost-effective than IVF. In vitro fertilization is at least as cost-effective as tubal surgery. Although IVF costs are high, they fall well within the range of other accepted medical treatments and are below the general public’s willingness to pay for these treatments.

Conclusion(s): Cost-effectiveness analysis is an important means of improving quality of care while controlling costs. Further work regarding cost-effectiveness of treatments among different diagnostic groups is needed.     

Effects of life events on infertility diagnosis: comparison with presumably fertile men and women

Objective: To compare the occurrence and degree of stress attributed to life events during childhood/adolescence and adulthood between individuals diagnosed with infertility and presumably fertile individuals, and to examine the effect of life events occurrence and stress levels on an infertility diagnosis.

Background: Although stress has been explored as a consequence of the experience of infertility, its role as a predictor of this disease still lacks research, particularly regarding the use of adequate control groups composed of non-parents.

Methods: The final sample had 151 infertile subjects (74 males and 77 females) and 225 presumably fertile participants (95 males and 130 females), who completed a questionnaire indicating occurrence (y/n) and degree of stress of life events (1–5) during childhood/adolescence and adulthood.

Results: Significant differences regarding occurrence were found in seven stressful life events in men and in nine events in women, with infertile groups presenting higher occurrence than presumably fertile groups. Eleven stressful life events were rated differently by men and women regarding the degree of stress, with group significant differences observed in both directions. While most events were rated as more stressful by infertile men, infertile women reported less stress resulting from these events than presumably fertile women. After controlling for age, the degree of stress induced by life events in childhood/adolescence and adulthood were not significant predictors of infertility diagnosis, for both men and women.

Conclusion: The amount of stress associated with earlier or concurrent life events does not seem to be related with infertility. Further prospective research is needed to validate these findings.     

Effect of cigarette smoking on levels of seminal oxidative stress in infertile men: a prospective study

OBJECTIVE: To investigate levels of seminal oxidative stress (OS) and sperm quality in a group of infertile men with a history of cigarette smoking.DESIGN: A prospective clinical study.SETTING: Male infertility clinic, Urological Institute, the Cleveland Clinic Foundation, Cleveland, Ohio.PATIENT(S): Infertile men who smoked cigarettes (n = 20), infertile men who were nonsmokers (n = 32), and healthy nonsmoking donors (n = 13).INTERVENTION(S): Genital examination, standard semen analysis, sperm DNA damage.MAIN OUTCOME MEASURE(S): Levels of seminal reactive oxygen species (ROS) and total antioxidant capacity (TAC) measured by a chemiluminescence assay and seminal OS assessed by calculating a ROS-TAC score. Sperm DNA damage was measured by sperm chromatin structure assay.RESULT(S): Smoking was associated with a 48% increase in seminal leukocyte concentrations (P<.0001), a 107% increase in ROS levels (P=.001), and a 10-point decrease in ROS-TAC scores (P=.003). Differences in standard sperm variables and DNA damage indices between the infertile smokers and infertile nonsmokers were not statistically significant.CONCLUSION(S): Infertile men who smoke cigarettes have higher levels of seminal OS than infertile nonsmokers. Given the potential adverse effects of seminal OS on fertility, physicians should advise infertile men who smoke cigarettes to quit.     

Accuracy of sperm velocity assessment using the Sperm Quality Analyzer V

Aim:  The correct diagnosis of the functional capacity of human sperm is limited. The Sperm Quality Analyzer (SQA) with the visualization system (SQA V, Medical Electronic System, Hatavorzo, Israel), an upgraded version of SQA, was recently developed to provide a rapid and low-cost quantitative evaluation of sperm quality as well as sperm velocity assessment. The aim of the present study was to evaluate whether the SQA V's new parameters correlate with computer-aided sperm analysis (CASA) estimates.
Methods:  Semen quality analysis of 66 fresh samples was determined using SQA V and CASA.
Results:  There were significant correlations of total sperm concentration ( P  < 0.001), sperm motility ( P  = 0.145), and percentage of progressive motile sperm ( P  = 0.001), between the SQA V variables and the CASA estimates. The sperm velocity assessed by SQA V was significantly correlated with some of the CASA estimates, including sperm motility ( P  = 0.001), the percentage of progressively motile sperm ( P  < 0.001), straight-line velocity ( P  < 0.001), curvilinear velocity ( P  < 0.001) and average path velocity ( P  < 0.001). However, it did not correlate with amplitude of lateral head displacement, beat cross frequency, straightness, or linearity, assessed by CASA.
Conclusion:  Assessment of sperm motility has been shown as one of the important factors to predict the functional capacity of human sperm. On the basis of the present study, SQA V is considered useful for screening sperm quality in the management of male infertility. (Reprod Med Biol 2003; 2 : 151–157)     

Influence of varicocele embolization on the choice of infertility treatment

OBJECTIVE: To investigate whether embolization of a varicocele improves semen quality and enables use of less-invasive modes of assisted reproductive technology (ART) in infertile men with a physically palpable varicocele confirmed by phlebography. DESIGN: Retrospective chart review. SETTING: University infertility clinic. PATIENT(S): Fifty patients with varicoceles that were treated with embolization and 11 patients with untreated varicoceles (control group). In both groups the clinical varicoceles had been phlebographically confirmed. INTERVENTION(S): Phlebography and embolization. MAIN OUTCOME MEASURE(S): Semen characteristics and mode of ART before and after treatment. RESULT(S): Median improvements of semen parameters, such as concentration and motility after processing, were significantly greater in the embolization group than in the untreated group. In the embolization group, semen samples improved to levels requiring less-invasive modes of ART in significantly more patients than in the untreated group. Deterioration of semen samples, requiring more invasive techniques, was significantly more frequent in the untreated group than in the embolization group. CONCLUSION(S): Embolization of a varicocele in infertile men significantly improved semen, such that much more often a less-invasive form of ART than was planned before treatment became feasible. Embolization of a varicocele might even prevent further deterioration of semen samples to levels requiring more-invasive ART.     

Clinical patterns and major causes of infertility in Mongolia

OBJECTIVE: To determine the clinical patterns and major causes of infertility in Mongolia, based on the clinical and laboratory findings of both partners, and to compare the findings with data from the published World Health Organization (WHO) multicenter study. METHODS: Four hundred and thirty infertile couples who attended the Infertility Clinic of the State Research Center on Maternal Child Health in 1998-2002 were included in the study. The couples had not had a viable birth after at least 1 year of unprotected intercourse and agreed to be fully investigated according to the WHO protocol 'Standardized Investigation of the Infertile Couple'. RESULTS: The mean duration of infertility of couples was 4.9 +/- 0.2 years. 43.7% of women had secondary infertility. In the females, the prevalence of past history of sexually transmitted infection (STI) and pelvic inflammatory disease were 33.5% and 25.1%, respectively. In the male partner, 44.2% reported a history of STI and 27.7% had previous testicular damage. 32.8% of women had a tubal factor. The most common causes of male infertility were obstructive azoospermia (8.4%), male accessory gland infection (6.7%) and acquired testicular damage (5.4%). In 45.8% of couples, infertility was due to a female factor and in 25.6% of cases, infertility was due to a male factor. 9.8% of couples had no demonstrable cause in either partner and 18.8% of couples had an infertility diagnosis in both partners. CONCLUSION: Patterns of female infertility did not differ significantly from those in the WHO study. Male infertility had a unique pattern, as there was a high prevalence of obstructive azoospermia and previous testicular damage.     

Male fertility and infertility

Male factor infertility accounts for 30–50% of infertility cases. Over the past two decades, there have been several papers published describing declining numbers and quality of sperms. An increasing incidence of urogenital abnormalities in the new born and rising incidences of testicular cancer from many different countries have stimulated public interest and concern about male infertility. In this review different aetiological factors in male infertility are considered with an attempt to provide an up-to-date account on the investigations and management of male infertility.