Tubal ectopic pregnancy after in vitro fertilization and embryo transfer: a role for proximal occlusion or salpingectomy after failed distal tubal surgery?

OBJECTIVE: To assess predisposing factors to tubal pregnancy after in vitro fertilization-embryo transfer (IVF-ET). DESIGN: Retrospective analysis of 891 ET cycles. SETTING: University-based IVF program. PATIENTS, PARTICIPANTS: All ET cycles performed in the study period were included; the indication for IVF was tubal factor in 640 (72%) and other (nontubal) factors in 251 (28%) cycles. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Observing a higher than expected number of tubal pregnancies in our program; we examined subgroups to determine those at highest risk. RESULTS: Tubal pregnancies comprised 12% of clinical pregnancies in the tubal factor group but only 2.6% in the cycles nontubal factor group (P less than 0.05). Of 640 ET cycles in the tubal factor group, 359 were performed in patients who had prior tubal reconstructive surgery; tubal pregnancies comprised 15.6% of the clinical gestations in this subgroup. In the remainder of the tubal factor group (no prior tubal surgery), 281 ET cycles yielded a tubal pregnancy rate of only 5.5% (P less than 0.05). CONCLUSIONS: Women with prior reconstructive surgery for distal tubal disease are at highest risk of developing tubal pregnancy after IVF.     

The chromosomal complements of cleaved human embryos resulting from in vitro fertilization

Chromosome preparations were made from 25 cleaved abnormal human embryos at the two-to eight-cell stage after in vitro fertilization. Morphologically, these embryos showed either variable degrees of degeneration or an abnormal number of pronuclei before first cleavage. Among 14 successfully karyotyped embryos, only 3 had a normal chromosomal complement. Eleven showed chromosomal abnormalities, including triploidy, hapioidy, and mosaicism. This finding documents a high incldence of chromosomal errors in morphologically abnormal early preimplantation embryos.     

Laparoscopic surgical treatment of tubal pregnancy. A safe, effective alternative to laparotomy.

This study analyzed the intraoperative morbidity, postoperative course, postoperative hospital stay and fertility outcome in 216 consecutive tubal pregnancies treated with either laparoscopy (n = 98) or laparotomy (n = 118). Among the 98 cases treated with laparoscopy, the procedure was successfully completed in 95 (97%). In three cases laparotomy had to be performed to conclude the procedure. Retained trophoblast was observed in 3.8% of cases treated conservatively with laparoscopy and 1.3% of cases treated conservatively with laparotomy (P greater than .05). The total anesthesia time, amount of postoperative analgesia required and postoperative hospital stay were significantly less in cases treated with laparoscopy (P less than .001). The subsequent fertility outcome was similar in both groups. Laparoscopic treatment of tubal pregnancy is a safe and effective alternative to laparotomy, yielding similar fertility outcomes and requiring significantly less postoperative analgesia and a significantly shorter hospital stay.     

Chromosome investigation in in vitro fertilization failure

Purpose A chromosomal complement of 227 human oocytes was studied to provide information on the frequency and type of chromosomal abnormalities in oocytes failing in vitro fertilization.Results Normal haploid chromosome complement was found in 54.6%; chromosomal abnormalities consisting of diploid sets were identified in 16.7% and aneuploidy was observed in 26%. Premature condensation of sperm chromosomes of the G1-phase was observed in 22.9% oocytes. Male infertility was correlated with an increase in the rate of aneuploidy when compared with tubal infertility. The rate of chromosome abnormalities for the oocytes recovered from women who had no fertilized oocytes was significantly higher compared to those with at least one oocyte fertilized.Conclusion A high frequency of chromosome abnormalities in unfertilized oocytes suggests that natural selection against chromosome abnormalities may occur even prior to fertilization.     

Laparoscopy

In the last five years, laparoscopy has become increasingly popular in North America. The procedure has been mainly embraced by the gynecologist and its use in this field has largely supplanted culdoscopy. Other specialties, nevertheless, have been slower in recognizing its value.

The procedure has wide applications in gynecology. In pediatrics, laparoscopy proves useful in elucidation of amenorrhea, intersex and precocious puberty. In general surgery, laparoscopy has been recognized as a useful tool in the patient with multiple trauma, and in establishing the diagnosis of many intra-abdominal conditions.

Numerous perlaparoscopic operative procedures which include biopsies and tubal sterilizations may be carried out by an experienced operator. Complications associated with the procedure are few, but may be severe. These can be avoided by careful adherence to proper technique.

     

Microsurgical transposition of the human fallopian tube and ovary with subsequent intrauterine pregnancy

This is the report of a case of a single left unicornuate uterus in a woman whose ipsilateral tube and ovary had been removed subsequent to a left tubal pregnancy. On the right side were present an ovary and a short oviduct (composed of infundibulum and ampulla) immobilized high on the pelvic side wall. Surgical transposition of the right ovary and tube with preservation of their vascular supply permitted anastomosis between the left intramural and the right ampullary tubal segments. The ovary was mobilized to restore a proper spatial relationship with the fimbrial extremity of the tube. In the third postoperative cycle, the patient was successful in achieving an intrauterine pregnancy and has now been delivered of a normal live infant. The potential of microsurgical techniques in restoring fertility in the face of unusual pelvic anatomy is reiterated.     

Surgical treatment of polycystic ovary syndrome associated with infertility

Laparoscopic ovarian drilling is a relatively simple procedure performed by minimal access and usually on an outpatient basis. It provides an alternative treatment option for polycystic ovary syndrome (PCOS) patients anovulatory to clomiphene citrate. The mechanism of action of laparoscopic ovarian drilling is unclear; its beneficial effect is apparently due to destruction of the androgen-producing stroma. The procedure appears to have little or no effect on insulin sensitivity and lipoprotein profile. The majority (56-94%) of PCOS patients who are clomiphene citrate resistant ovulate after drilling, and at least half of them go on to achieve a pregnancy. Predictive factors for pregnancy are younger age and lower body mass index. The endocrine changes resulting from ovarian drilling last for an extended period of time. Exogenous gonadotrophin treatment and laparoscopic ovarian drilling appear to yield comparable ovulation and pregnancy rates; however, multiple pregnancy is rare with drilling. There are several complications associated with the procedure, including post-operative periadnexal adhesion formation. Alternative treatment options, including lifestyle modification (diet and exercise) and metformin, may well reduce the need for ovarian drilling in well-selected cases. Progress in understanding of this complex syndrome and effective new treatments will further diminish the need for surgery.     

Reproductive outcome after hysteroscopic metroplasty in women with septate uterus and otherwise unexplained infertility

OBJECTIVE: To evaluate the reproductive outcome of hysteroscopic metroplasty performed in women with septate uterus and otherwise unexplained primary infertility. DESIGN: Prospective, observational study. SETTING: Tertiary center for reproductive medicine. PATIENT(S): Sixty-one patients with uterine septa and otherwise unexplained primary infertility. INTERVENTION(S): Hysteroscopic division of the uterine septum. MAIN OUTCOME MEASURE(S): Reproductive outcome after hysteroscopic metroplasty. RESULT(S): Of 61 women, 25 (41%) conceived within 8-14 (mean 11.2) months after hysteroscopic metroplasty. Of these, 18 (29.5% of the total group) had live births (13 carried to term and 5 had preterm deliveries), and 7 (11.5% of the total group) had spontaneous abortions. Cervical cerclage was performed in 9 women; only 1 (11.1%) of these patients and 4 (44.4%) of the 9 who did not have a cerclage had preterm deliveries. Twelve of the 18 women (66.6%) who had live births were delivered by cesarean section. CONCLUSION(S): Women with uterine septum and otherwise unexplained infertility might benefit from hysteroscopic metroplasty.     

What to do after a failed attempt of vacuum delivery?

OBJECTIVES: To determine whether there is a difference in maternal and neonatal outcomes if a sequential operative vaginal or cesarean delivery follows failed vacuum delivery. STUDY DESIGN: A cross sectional study. We have analyzed maternal and neonatal outcomes of 215 vacuum extractions (group 1), 106 forceps assisted deliveries (group 2), 28 deliveries in which failed vacuum extraction were followed by forceps delivery (group 3) and 22 deliveries in which failed vacuum extraction were followed by cesarean delivery (group 4). RESULTS: Compared to other groups, patients in group 4 had significantly more post partum anemia, meconium stained amniotic fluid and hospital stay (both maternal and neonatal) as well as lower pH. Apgar scores were similar in groups 3 and 4. Incidence of respiratory distress syndrome, cephalhematoma and jaundice were similar in neonates of all groups. CONCLUSIONS: If an attempted vacuum delivery has failed, the risk of adverse neonatal outcome is increased with either subsequent forceps or cesarean delivery. It should remain in the judgment of the attending obstetrician to choose the method most suitable under the given circumstances.     

Influence of mental stress on intraocular pressure and visual field testing: is there a white coat syndrome in glaucoma?

Graefe's Archive for Clinical and Experimental Ophthalmology - To investigate the effects of mental stress stimulus on intraocular pressure (IOP) measurement and visual field (VF) testing....