Genital footprints of extragenital tuberculosis in infertile women: Comparison of various diagnostic modalities

BackgroundGenital tuberculosis (TB) continues to remain an important cause of infertility in women, especially in developing countries. It is mostly consequent to a primary infection elsewhere in the body. The diagnosis is challenging, considering its paucibacillary nature. Although there are many studies on association of genital tuberculosis with infertility, there is paucity of literature on impact of extragenital tuberculosis on fertility of women through involvement of female reproductive organs. The various diagnostic modalities available have limitations and quest is ongoing for the best diagnostic test.MethodThis was a prospective observational study conducted at the infertility clinic of a tertiary care health facility where 60 infertile women with either tubal factor or unexplained infertility with or without past history of extragenital tuberculosis were enrolled as study subjects or controls respectively. Mantoux test was performed in all women and diagnostic laparo-hysteroscopy was performed in all women to look for any evidence of uterine and/or tubal damage. The peritoneal fluid was sent for GeneXpert and Liquid culture for mycobacterium tuberculosis. Results of Mantoux test, GeneXpert and liquid culture were compared with the laparohysteroscopic findings.ResultOf the thirty infertile women in the study group, 27/30 (90%) had a history of pulmonary tuberculosis and 3/30 (10%) had history of tubercular cervical lymphadenopathy. It was observed that Mantoux test was positive (induration >10 mm) in 27/30 (90%) of women in the study group as compared to only 4/30 (13.3%) controls. Abnormal hysteroscopic findings were documented in 26.6% (8/30) study group women as compared to 6.6% (2/30) women in the control group. Similarly, 60% (18/30) of women in the study group had abnormal laparoscopic findings compared to 33% (10/30) in the control group. Seven out of thirty (23.3%) women were positive for GeneXpert in the study group compared to only 1/30 (3.3%) in the control group. Similarly, liquid culture was positive in 6/30 (20%) of women in the study group as compared to 1/30 (3.3%) in the control group. All the above differences were statistically significant. We observed that the sensitivity of Mantoux test (75.8%) stand alone was higher than the other tests combined (50%). However, specificity and positive predictive value (PPV) increases markedly (up to 100%) to when all the three tests are combined.ConclusionThe authors conclude that all women presenting with infertility should be screened for a past history of tuberculosis and actively worked up for genital tuberculosis in case the history is positive. The various available tests (Mantoux test, GeneXpert and liquid culture) have their limitations for the diagnosis of genital tuberculosis. Thus an approach of early resort to laparohysteroscopy in suspected patients is desirable so that definitive management may be instituted timely and promptly.     

EMs生育指数对Ⅲ～Ⅳ期EMs合并不孕术后非ART妊娠结局的预测价值

目的:探讨子宫内膜异位症生育指数(EFI)对中重度(Ⅲ~Ⅳ期)子宫内膜异位症(EMs)相关不孕术后非辅助生殖技术(ART)妊娠结局的预测价值。方法:回顾性分析北京大学深圳医院2011年1月—2012年12月行腹腔镜手术治疗的Ⅲ~Ⅳ期EMs合并不孕患者48例,按照EFI评分标准进行评分,随访其妊娠结局。结果:48例患者术后2年累积非ART妊娠25例(52.1%),术后6个月非ART妊娠20例(41.7%),术后7~12个月非ART妊娠4例(8.3%),术后13~24个月非ART妊娠1例(2.1%),随访不同时间段非ART妊娠率差异有统计学意义(χ2=30.301,P=0.000)。术后2年累积非ART妊娠率与EFI评分及术后是否使用促排卵治疗有关(P0.05),而与r-AFS分期无关(P0.05)。EFI评分的受试者工作特征(ROC)曲线下面积(AUC)为0.681(95%CI:0.527~0.834,P=0.033)。通过ROC曲线确定的EFI预测术后2年内非ART妊娠的临界值为5.5分(约登指数最大),其预测的敏感度为85.2%,特异度为42.9%。结论:EFI对于中重度EMs合并不孕患者术后非ART妊娠率有较好的预测价值。     

卵母细胞成熟障碍4例与同期卵母细胞大部分不成熟患者比较分析

目的分析4例体外受精-胚胎移植（IVF—ET）患者共8个辅助助孕周期,全部73个卵母细胞均处于GV、MetaphaseI期的可能原因。并与同期13例IVF—ET患者比较分析,比较组患者〉50％卵母细胞处于GV、MetaphaseI期。方法回顾分析本中心12年辅助助孕工作中出现的4例患者共8个周期所获卵母细胞均处于GV、MI的临床及实验室资料,并与同期13例超过50％卵母细胞处于GV、MI患者的临床、实验室资料进行比较。结果4例患者73个卵母细胞均处于GV或MI期,经体外成熟培养,24,48,72h仍无极体排出,停滞于GV、MI期。同期13例患者大部分卵母细胞不成熟,但体外培养后部分卵母细胞可进一步成熟,并可受精,获得妊娠。结论细胞和遗传机制引起卵母细胞成熟障碍,现有体外成熟培养方法尚无法促其成熟,目前赠卵是该类患者获得妊娠可供选择的助孕方法。但对于在控制性超促排卵中,出现大部分卵母细胞不成熟的患者可以通过延长促超排时间,增大hCG注射日卵泡直径,体外成熟培养等方法获得成熟的卵母细胞,获得妊娠。     

Treatment of infertility in women with polycystic ovary syndrome: approach to clinical practice

Polycystic ovary syndrome represents 80% of anovulatory infertility cases. Treatment initially includes preconception guidelines, such as lifestyle changes (weight loss), folic acid therapy to prevent the risk of fetal neural tube defects and halting the consumption of tobacco and alcohol. The first-line pharmacological treatment for inducing ovulation consists of a clomiphene citrate treatment for timed intercourse. The second-line pharmacological treatment includes the administration of exogenous gonadotropins or laparoscopic ovarian surgery (ovarian drilling). Ovulation induction using clomiphene citrate or gonadotropins is effective with cumulative live birth rates of approximately 70%. Ovarian drilling should be performed when laparoscopy is indicated; this procedure is typically effective in approximately 50% of cases. Finally, a high-complexity reproduction treatment (in vitro fertilization or intracytoplasmic sperm injection) is the third-line treatment and is recommended when the previous interventions fail. This option is also the first choice in cases of bilateral tubal occlusion or semen alterations that impair the occurrence of natural pregnancy. Evidence for the routine use of metformin in infertility treatment of anovulatory women with polycystic ovary syndrome is not available. Aromatase inhibitors are promising and longer term studies are necessary to prove their safety.     

不孕患者自身因素和胚胎形态学评价指标与囊胚形成关系的分析

目的探讨不孕患者自身因素以及体外培养Day3胚胎形态学指标与囊胚形成之间的相关性。方法将1894个体外受精-胚胎移植治疗周期的Day3移植后剩余的16191个胚胎进行囊胚培养至Da如,分析女方年龄、不孕因素、体外受精方式、DAY3胚胎卵裂球数目以及碎片程度与囊胚形成的关系。结果女方年龄≤30岁组、31-35岁组和≥36岁组之间的囊胚形成率分别为31．38％（2315／7376）、29．42％（1773／6025）和22．15％（618／2790）,并且组与组之间有统计学差异,P〈0．05;不明原因不孕组的囊胚形成率26．41％（904／3423）低于排卵障碍组29．84％（588／1970）、盆腔输卵管组29．28％（2124／7255）、子宫内膜异位组30．26％（361／1193）和男方因素组3l-02％（729／2350）,且P〈0．05;常规体外受精组的囊胚形成率29．25％（3234／11055）与卵胞浆单精子注射组27．69％（1472／5136）无统计学差异;DAY3卵裂球数目≥7个组、5—6个组和≤4个组的囊胚形成率分别为47．78％（1035／2166）、31．53％（2079／6594）和21．42％（1592／7431）,并且组与组之间有统计学差异,P〈0．05;DAY3碎片程度≤10％组、11—30％组和≥31％组的囊胚形成率分别为33．54％（2719／8106）、25．99％（1951／7507）和6．23％（36／578）,并且组与组之间有统计学差异,P〈0．05。结论女方年龄、不明原因不孕以及Day3胚胎形态学指标卵裂球数目和碎片程度都是影响囊胚形成的重要因素。在保证囊胚体外培养条件的基础上,综合评价患者自身条件以及胚胎发育情况,可以为临床合理运用囊胚培养方案提供依据。     

Anti‐Müllerian hormone as a marker of ovarian reserve: What have we learned,and what should we know?

Ovarian reserve reflects the quality and quantity of available oocytes. This reserve has become indispensable for the better understanding of reproductive potential. Measurement of the serum anti‐Müllerian hormone (AMH) level allows quantitative evaluation of ovarian reserve. It has been applied to a wide range of clinical conditions, and it is well established that the measurement of serum AMH levels is more useful than qualitative evaluation based on the menstrual cycle. AMH levels are monitored during infertility treatments; in patients undergoing medically assisted reproductive technology; and in the diagnosis of ovarian failure, polycystic ovarian syndrome, and granulosa cell tumor. It is also useful in the evaluation of iatrogenic ovarian damage. Population‐based studies have indicated a potential role for serum AMH in the planning of reproductive health management. While AMH is currently the best measure of ovarian reserve, its predictive value for future live births remains controversial. Furthermore, there is a serious practical issue in the interpretation of test results, as currently available assay kits use different assay ranges and coefficients of variation due to the absence of an international reference standard. The pros and cons of the serum AMH level as a definitive measure of ovarian reserve merits further review in order to guide future research.     

病毒感染与男性不育相关性研究进展

目前研究将病毒感染视为可能影响男性生育力的破坏性因素。男性生殖系统的炎症与不育相关。本文概述了影响男性生殖系统的主要病毒及其对生育力的有害影响。仍需进行大量研究以阐明不同类型的病毒在男性生殖系统中作用的机制,从而开发出更适宜的治疗方案。     

体外受精-胚胎移植（IVF-ET）患者阶段性心理状况研究分析

目的：了解行体外受精-胚胎移植( IVF-ET)患者在治疗过程中的心理状况。方法采用随机抽样法取初次行IVF-ET 患者180例,选用一般情况调查表、Olson-婚姻质量问卷( ENRICH )、症状自评量表(SCL-90)、睡眠治疗调查表(PSQI)进行调查分析。结果 IVF-ET患者治疗过程中心理状况、睡眠质量明显低于国内正常水平,婚姻质量也低于国内正常水平。结论 IVF-ET患者治疗过程中心理状态差,护理人员应参考相应的心理问题,有针对性地对IVF-ET患者提供相应的心理护理。