The use of a hysteroscopic resectoscope for repeat evacuation of retained products of conception procedures: a case series

The blind nature of the surgical management of retained products of conception allows for a significant risk of uterine perforation or the need for repeat evacuation and subsequent morbidity due to a failed procedure. These risks may be increased postpartum or at a repeat surgical procedure. We present a case series of five patients with clinical, sonographic, or histological diagnosis of retained products of conception following either failed surgical evacuation or postpartum. All were treated surgically without complication using the loop of a saline hysteroscopic resectoscope to allow removal under direct vision of retained tissue.     

The effect of human immunodeficiency virus on sperm parameters and the outcome of intrauterine insemination following sperm washing

BACKGROUND: This is the first study to assess the outcome of sperm washing and intrauterine insemination (IUI) cycles in human immunodeficiency virus-positive (HIV(+)) men to determine any predictors of success, as well as evaluating the effect of HIV on sperm parameters. METHODS: Semen characteristics were evaluated in 106 HIV(+) men and a control group of 234 HIV(-) men, and the effect of markers of HIV disease assessed. Age, stimulation regime, sperm parameters, markers of HIV disease and the use of anti-retrovirals were assessed as predictors of the outcome of sperm washing/IUI cycles in the HIV(+) men. RESULTS: Ejaculate volume, sperm concentration, total count, progressive motility and normal morphology were all significantly higher in the control group compared to the HIV(+) men (P<0.05). A significant positive correlation was observed between CD4 count and sperm concentration, total count, motility, progressive motility type 'a'+'b' and post-preparation concentration and a significant negative correlation with normal sperm morphology of both raw and post-preparation samples. No correlation was observed between viral load (VL), years since diagnosis, use of anti-retrovirals or duration of use and any sperm parameter. The only factors that significantly improved IUI outcome were a VL <1000 copies/ml and the use of anti-retrovirals. CONCLUSIONS: These data demonstrate that sperm parameters are significantly impaired by the presence of HIV infection and in particular correlate with CD4 count. Undetectable VL and the use of anti-retrovirals improve the outcome of IUI/sperm washing in HIV(+) men.     

Treatment and preservation at the extremes of reproductive age: a case report outlining the ethical dilemmas

Purpose

The purpose of the study was to report a livebirth from a cryopreserved embryo created from autologous oocytes collected at 47 years and 9 months that outlines the ethical difficulties of decision-making at the extreme of reproductive age.

Methods

The method used was IVF and embryo cryopreservation within an assisted conception unit prior to adjuvant cancer treatment in a nulliparous patient diagnosed with breast carcinoma (47 years and 9 months at oocyte collection).

Results

A 47-year-old nulliparous woman was diagnosed with breast malignancy during work-up for fertility treatment. Ovarian stimulation yielded one embryo from four oocytes that was cryopreserved to allow completion of adjuvant treatment. Subsequent embryo transfer cycle led to a live birth of a healthy baby girl at term, weighing 3.37 kg.

Conclusion

This paper demonstrates the oldest reported age of autologous oocyte collection to have achieved a livebirth. In women where most would consider treatment futile, we highlight the difficulties in decision-making in this group of patients.     

Sperm DNA fragmentation in subfertile men: the effect on the outcome of intracytoplasmic sperm injection and correlation with sperm variables

OBJECTIVE

To present the first UK data on sperm DNA fragmentation levels in subfertile men and fertile controls, the correlation with semen variables, and to assess the effect on the outcome of intracytoplasmic sperm injection (ICSI).

PATIENTS, SUBJECTS AND METHODS

In all, 56 subfertile men undergoing ICSI (28 with positive and 28 with a negative outcome for paternity) and 10 control fertile semen donors were recruited. The sperm DNA fragmentation index (DFI) was assessed on raw pre‐preparation samples using the sperm chromatin structure assay. A mean of 5212 sperm were analysed per sample and DFI data are presented by fertility status, ICSI outcome and correlated with semen variables (assessed using World Health Organisation criteria).

RESULTS

Total DFI was significantly higher in subfertile men than in fertile controls (mean and median of 22.8% and 17.0% vs 8.4% and 5.0%; P < 0.001), as was the proportion of both moderate DFI (16.4% and 13.0% vs 6.4% and 4.0%; P = 0.001) and high DFI (6.2% and 6.1 vs 2.0% and 1.0%; P = 0.01). This difference remained significant when the control men were compared only with the subfertile men with successful paternity. There was no significant difference in DFI in the subfertile men when analysed by ICSI outcome (mean and median of 24.5% and 17.0% vs 22.3% and 21.0% for successful and unsuccessful cycles, respectively; P = 0.94). There was a positive statistically significant correlation (r = 0.37; P = 0.02) between the DFI and sperm morphology.

CONCLUSIONS

This study confirms a relationship between male subfertility and sperm DFI; we discuss the correct role for genetic testing of sperm in the evaluation of subfertile men. Although DNA fragmentation data might help to decide a suitable treatment, once it is decided to proceed with ICSI, DFI levels have no effect on the outcome.     

Research into the efficacy and cost-effectiveness of brief, free of charge and anonymous sex counselling to improve (mental) health in youth: Design of a randomised controlled trial

Background  

The capacity to form romantic relationships and sexual health of adolescents in the Netherlands are compromised by several factors, including young age of first intercourse and adolescent depression. Several thresholds like own expenses, trust and embarrassment prevent adolescents to seek help for their sexual problems. To overcome these thresholds, brief sex counselling has been developed. It has been used since 2006 within the Rotterdam-Rijnmond Public Health Service, but there is lack of information about the (cost-) effectiveness. In the current study we will evaluate the (cost-) effectiveness of brief sex counselling for sexual problems in adolescents and young adults between 18 and 25 years of age.     

Does the cause of obstructive azoospermia affect the outcome of intracytoplasmic sperm injection: a meta-analysis

OBJECTIVE: To define whether the outcome of intracytoplasmic sperm injection (ICSI) using sperm surgically retrieved from men with obstructive azoospermia (OA) depends on the cause of obstruction. PATIENTS AND METHODS: We first analysed our data and then used a meta-analysis of published data (including ours) to compare the outcome of ICSI in OA, classified in terms of congenital and acquired causes. The present study comprised 82 couples who underwent 127 ICSI cycles using surgically retrieved sperm. The cause was classified as congenital bilateral absence of vas deferens (CBAVD, in 20), after vasectomy (56), infective/inflammatory (21), noninfective (24) and ejaculatory (five). Five reports (687 cycles) including the present were identified as suitable for meta-analysis. RESULTS: Analysis of the present data showed that fertilization and live-birth rates were highest in men with a previous vasectomy and no infective cause (vasectomy 51% and 23%; not infective 53% and 29%, respectively) and lowest in men with infective or inflammatory causes. There was no difference in outcome if the sperm was fresh or frozen, or whether epididymal or testicular. Meta-analysis comparing congenital (CBAVD) and acquired causes showed a significantly increased fertilization rate (95% confidence interval, 0.84-1) with acquired causes. Meta-analysis of the three papers reporting delivery outcome showed no difference in live-birth rate but a significantly higher miscarriage rate in the congenital group (relative risk 2.67). CONCLUSION: In ICSI cycles in men with OA the cause appears to influence the outcome, but outcome is not affected by whether the retrieved sperm is fresh, frozen, epididymal or testicular. The meta-analysis suggested a higher fertilization rate and lower miscarriage rate in acquired causes of OA.     

Reply to 'The effect of human immunodeficiency virus on semen parameters and intrauterine insemination outcome'

Sir, We read with great interest the letter by van Leeuwen et al.,and thank them for their interest in our research. We will addresstheir comments in turn. First, they suggest that differences other than the presenceof an human immunodeficiency virus (HIV) infection may existbetween our study group and controls that could explain theobserved differences in semen quality. However, as Table I ofour paper demonstrated, there was no significant differencein age between the     

Reporting on longitudinal live birth rates and cumulative delivery rates are more realistic outcome measures than sperm retrieval rates in couples undergoing mTESE–ICSI

The live birth rates (LBRs) in men with non-obstructive azoospermia (NOA) undergoing microdissection TESE (mTESE) are under reported, with surgical sperm retrieval rate often used as the primary outcome measure. We analysed longitudinal and cumulative delivery rates following mTESE– intracytoplasmic sperm injection (ICSI) in NOA. Sperm was retrieved in 45% of patients undergoing mTESE. Median male and female age were 42 years (IQR 37–47) and 35 years (IQR 31–38) respectively. A total of 141 ICSI cycles and 23 frozen embryo transfers resulted in 62 pregnancies and 37 LBRs. The longitudinal LBR, crude and expected cumulative delivery rates after five cycles were 15.5%, 48.7% and 71.1%, respectively. Reassuringly, there was no significant difference in pregnancy rate (PR) (p?=?0.37) or LBR (p?=?0.68) using fresh or frozen sperm or embryo (p?=?0.74). Sperm retrieval was significantly correlated with Johnsen score (JS) (p?=?0.006) and hypospermatogenesis (HS) (p?=?0.04), whilst LBR only significantly correlated with female age (p?=?0.04). The longitudinal LBR for a couple embarking on mTESE for azoospermia is only 15.5%, although the cumulative delivery rates are promising. Reassuringly, the outcomes using fresh versus frozen embryos or sperm are comparable. Reporting on delivery rates from a single mTESE procedure are more objective and realistic measures of treatment success in men with NOA.