Abnormal findings on hysterosalpingography: effects on fecundity in a donor insemination program using frozen semen

OBJECTIVE

We sought to evaluate the effect of abnormal baseline hysterosalpingography (HSG) on subsequent fecundity during the first six cycles of treatment.

METHODS

Hysterosalpingography was performed on 208 asymptomatic ovulatory women with no history of pelvic disease who were referred for donor insemination. The findings were categorized into five groups: 1) normal study, 2) uterine anomaly or filling defect with bilateral tubal patency, 3) normal uterine anatomy with unilateral tubal patency, 4) normal uterine anatomy with bilateral tubal blockage, and 5) normal uterine anatomy with hydrosalpinx. Subjects in groups 4 and 5 received inseminations only if patency of at least one fallopian tube was demonstrated with laparoscopy. Life-table analysis was performed to calculate the average monthly fecundity and cumulative conception rates for each group. The Mantel-Haenszel test was used to compare group fecundities.

RESULTS

A total of 1460 donor insemination cycles were performed. The number of cycles in each group were as follows: group 1, 1173 (80%); group 2, 153 (10%); group 3, 90 (6.2%); group 4, 16 (1.1%); and group 5, 28 (1.9%). None of the patients in group 4 or 5 conceived. The cumulative conception rates in the first three groups were 46, 34, and 40%, respectively, and were not significantly different from one another (P greater than .05). Although a high incidence of uterine filling defects and unilateral tubal blockage was observed (19.2%), the incidence of an abnormal HSG finding that significantly decreased fecundity was only 2.8%.

CONCLUSION

In women with no history of tubal or uterine disease, routine HSG before initiation of donor insemination is of limited value for identifying decreased treatment fecundity.

The effect of laparoscopic ablation or danocrine on pregnancy rates in patients with stage I or II endometriosis undergoing donor insemination

The effect of treatment on stages I and II endometriosis was evaluated in 61 women with laparoscopically proven disease who were undergoing therapeutic donor insemination. Only treatment cycles completed after diagnostic laparoscopy were used for analysis. To evaluate fecundity, we performed life-table analysis on 343 treatment cycles of therapeutic donor insemination in 67 patients with stage I or II endometriosis and compared it with 212 cycles in 43 patients with no female infertility factors. Average monthly fecundity and cumulative conception rates over six cycles were calculated for each group. A significant difference was found when patients with laparoscopically proven normal anatomy were compared with those with endometriosis (P = .002). The fecundity did not differ significantly between stage I and stage II endometriosis (P greater than .05). Neither ablation during laparoscopy nor medical treatment with danocrine improved the fecundity of patients with early-stage endometriosis (P greater than .05).

Immunohistochemical detection of type I, III, and IV collagen in endometriosis implants

OBJECTIVE

To determine if types I, III, or IV collagen are present in ectopic endometrium and to determine which type(s) of collagen are present in the connective tissue surrounding ectopic endometrial implants.

DESIGN

Paired intrauterine and ectopic endometrial samples were obtained for study at the time of laparoscopy from women in the proliferative and secretory phase of the menstrual cycle. Connective tissue surrounding each ectopic implant was also obtained for study.

SETTING

Academic research environment with institutional review board approval.

PATIENTS

Six patients without endometriosis were used as controls. Ten additional patients with stage II or III endometriosis were studied. Only women on no medications participated in the study.

MAIN OUTCOME MEASURES

Immunohistochemical techniques were used to identify the presence of collagen in biopsied specimens.

RESULTS

Each collagen type studied was identified in the intrauterine endometrium of patients with and without endometriosis. All collagen types were also identified in each of the ectopic endometrial implants studied. The distribution of collagen in ectopic endometrial implants was similar to the distribution of collagen seen in intrauterine endometrium obtained from patients with or without endometriosis. Collagenous tissue that contained type I collagen was identified at the periphery of deep ectopic implants.

CONCLUSIONS

This study demonstrates the presence of type I, III, and IV collagen in the intrauterine and ectopic endometrium of patients with endometriosis. Type I collagen was the predominant collagen present in the surrounding collagenous tissue associated with deep, ectopic endometrial implants.

Endometriosis and associated pathology

The natural history of endometriosis, including the belief that it is a progressive disease, is reviewed with the help of a large, cross-sectional, prospective study and a smaller longitudinal study. Two studies are reviewed that address the role of growth factors in the development of endometriosis. These studies demonstrated that the peritoneal fluid of patients with endometriosis contained significant growth factor activity against human endometrial stromal cells. In a mouse model, macrophage-derived factors stimulated endometrial cell proliferation. The possible correlation between endometriosis and decreased bone mineral density, which was reported by an earlier study, is reviewed. Recent data, however, have shown no correlation between bone mineral density and endometriosis. Finally, several reports on the usefulness of endometrial antibodies and serum CA 125 levels in the diagnosis and treatment of patients with endometriosis are reviewed. These data suggest that both endometrial antibodies and CA 125 measurements may be useful in the diagnosis and treatment of patients with endometriosis.

The effects of prolactin on human sperm capacitation and acrosome reaction

OBJECTIVE

To study the effects of human prolactin (PRL) on human sperm capacitation and acrosome reaction.

DESIGN

Acrosome reactions were induced by the addition of follicular fluid (FF) and progesterone (P). Experiments were performed to determine time and dose-dependent effects of PRL on sperm capacitation, potentiation of the acrosome reaction, decapacitating effects, and potential for PRL to induce an acrosome reaction.

RESULTS

An average of 31.5% of spermatozoa underwent acrosome reaction with addition of FF and P. No time- or dose-dependent PRL effects on sperm capacitation or acrosome reaction were found (P greater than 0.05).

CONCLUSION

Prolactin does not play an important role in human sperm capacitation or acrosome reaction.

The effect of age on female fecundity

To determine the relationship between age and female fecundity, 210 women were studied prospectively. The subjects had negative infertility evaluations and were receiving therapeutic donor insemination. Life-table analysis was performed on 751 donor insemination cycles. For comparison, patients were divided into five separate age groups and into two separate groups, ages 19-34 and 35-45. Monthly fecundity and cumulative conception rates were calculated for each group. A significant difference was found when all age groups were compared (P = .05) and when those at or above age 35 and those below age 35 were compared (P less than .05). Frozen semen was used in 92% of all cycles. The average monthly fecundity of all patients treated with frozen semen was 16%. This study confirms a progressive decline in fecundity with age in a completely evaluated group of women undergoing therapeutic donor insemination and demonstrates that frozen semen can yield acceptable fecundity provided sufficient numbers of motile sperm are used for each procedure.

The nonstress test. Criteria for the duration of fetal heart rate acceleration

Although the most common definition of a reactive nonstress test is an acceleration in the fetal heart rate of 15 beats per minute (bpm) for 15 seconds, some investigators require that the fetal heart rate acceleration be maintained at 15 bpm above the baseline for the entire 15 seconds (long criterion), and others require simply that the acceleration be 15 seconds from the beginning until the return to the baseline (short criterion). In 1,241 nonstress tests (NSTs) there was a statistically significant difference in the number of reactive tests between the short and long criteria (1,108 [89%] vs. 985 [79%], P less than .001). This difference in percentage of reactivity may be important when comparing studies performed by various investigators. In comparing cesarean section deliveries for fetal distress we were unable to find a difference in the ability to predict a poor outcome between use of the short and long criteria. However, a type II error is possible since the number of poor outcomes was small. We now use the short criterion for NST interpretation.