Placement of the acetabular component

Ideal placement of the acetabular component remains elusive both in terms of defining and achieving a target. Our aim is to help restore original anatomy by using the transverse acetabular ligament (TAL) to control the height, depth and version of the component. In the normal hip the TAL and labrum extend beyond the equator of the femoral head and therefore, if the definitive acetabular component is positioned such that it is cradled by and just deep to the plane of the TAL and labrum and is no more than 4mm larger than the original femoral head, the centre of the hip should be restored. If the face of the component is positioned parallel to the TAL and psoas groove the patient specific version should be restored. We still use the TAL for controlling version in the dysplastic hip because we believe that the TAL and labrum compensate for any underlying bony abnormality. The TAL should not be used as an aid to inclination. Worldwide, > 75% of surgeons operate with the patient in the lateral decubitus position and we have shown that errors in post-operative radiographic inclination (RI) of > 50° are generally caused by errors in patient positioning. Consequently, great care needs to be taken when positioning the patient. We also recommend 35° of apparent operative inclination (AOI) during surgery, as opposed to the traditional 45°.

Investigation and management of an outbreak of Salmonella Typhimurium DT8 associated with duck eggs, Ireland 2009 to 2011

Salmonella Typhimurium DT8 was a very rare cause of human illness in Ireland between 2000 and 2008, with only four human isolates from three patients being identified. Over a 19-month period between August 2009 and February 2011, 34 confirmed cases and one probable case of Salmonella Typhimurium DT8 were detected, all of which had an MLVA pattern 2-10-NA-12-212 or a closely related pattern. The epidemiological investigations strongly supported a linkbetween illness and exposure to duck eggs. Moreover, S. Typhimurium with an MLVA pattern indistinguishable (or closely related) to the isolates from human cases, was identified in 22 commercial and backyard duck flocks, twelve of which were linked with known human cases. A range of control measures were taken at farm level, and advice was provided to consumers on the hygienic handling and cooking of duck eggs. Although no definitive link was established with a concurrent duck egg-related outbreak of S. Typhimurium DT8 in the United Kingdom, it seems likely that the two events were related. It may be appropriate for other countries with a tradition of consuming duck eggs to consider the need for measures to reduce the risk of similar outbreaks.

Investigation and management of an outbreak of Salmonella Typhimurium DT8 associated with duck eggs, Ireland 2009 to 2011

>Salmonella Typhimurium DT8 was a very rare cause of human illness in Ireland between 2000 and 2008, with only four human isolates from three patients being identified. Over a 19-month period between August 2009 and February 2011, 34 confirmed cases and one probable case of Salmonella Typhimurium DT8 were detected, all of which had an MLVA pattern 2-10-NA-12-212 or a closely related pattern. The epidemiological investigations strongly supported a link between illness and exposure to duck eggs. Moreover, S. Typhimurium with an MLVA pattern indistinguishable (or closely related) to the isolates from human cases, was identified in 22 commercial and backyard duck flocks, twelve of which were linked with known human cases. A range of control measures were taken at farm level, and advice was provided to consumers on the hygienic handling and cooking of duck eggs. Although no definitive link was established with a concurrent duck egg-related outbreak of S. Typhimurium DT8 in the United Kingdom, it seems likely that the two events were related. It may be appropriate for other countries with a tradition of consuming duck eggs to consider the need for measures to reduce the risk of similar outbreaks.

Anal fistula: an unusual presentation of tuberculosis in a migrant health care professional

We present a case of a young health care professional from the Indian subcontinent, who presented with a low anal fistula and underwent exploration, debridement and fistulotomy twice. The initial working diagnosis was Crohn's disease. However, Mycobacterium tuberculosis, fully sensitive to all first-line drugs was cultured from the specimens sent from the second surgical procedure. On initiation of anti-tubercular therapy the symptoms improved within 5 weeks. The origin of the patient, high index of suspicion for non-infectious reactivation of tuberculosis in migrant health care workers, importance of a proper history taking including previous exposure and diagnostic workup is stressed.

Drug expenditure in Ireland 1997-2007

Community prescribing accounts for approximately 85% of total drug expenditure. In 2007 spending on medicines under the Community Drugs Schemes exceeded Euro 1.74 billion, a five-fold increase over the decade 1997-2007. The year on year increase in spending on medicines is amongst the highest in Europe. The desire of the HSE to reduce or at least contain drug expenditure is appreciated and is consistent with approaches across other EU member states. Recent developments in drug pricing and reimbursement as outlined here may help to contain the drugs bill. However, the emergence of promising but expensive biologic agents for cancer therapy and other chronic conditions threaten any cost containment measures.

Methadone induced torsade de pointes in a patient receiving antiretroviral therapy

Adverse drug reactions account for approximately 5% of acute medical admissions. A 34-year-old male patient receiving antiretroviral therapy, methadone and flurazepam presented to the emergency room following collapse with associated loss of consciousness. Cardiac monitoring demonstrated marked Q-T prolongation followed by the cardiac arrhythmia, torsade de pointes. The patient made a full recovery following withdrawal of the antiretroviral therapy and a reduction in methadone dose. Methadone is a recognised cause of this potentially fatal cardiac arrhythmia which is more likely to occur when methadone metabolism is inhibited by drugs such as HIV tease inhibitors.

Upright, supine, or bipositional reflux: patterns of reflux do not affect outcome after laparoscopic Nissen fundoplication

INTRODUCTION

This study was undertaken to determine if the body position in which gastroesophageal reflux occurs before fundoplication--i.e., pattern of reflux--affects symptoms before or after laparoscopic Nissen fundoplication.

METHODS

A total of 417 patients with gastroesophageal reflux disease (GERD) underwent pH studies, and the severity of reflux in the upright and supine positions was determined. The percent time with pH less than 4 was used to assign patients to one of four groups: upright reflux (pH < 4 more than 8.3% of time in upright position, n = 80), supine reflux (pH < 4 more than 3.5% of time in supine position, n = 73), bipositional reflux (both supine and upright reflux, n = 163), or neither (n = 101). Before and after laparoscopic Nissen fundoplication, the frequency and severity of symptoms of reflux (e.g., dysphagia, regurgitation, choking, heartburn, chest pain) were scored on a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). For each patient, symptom scores before versus after fundoplication were compared using the Wilcoxon matched pairs test; comparisons of symptom scores among patients grouped by reflux patterns were made using Kruskal-Wallis test.

RESULTS

Before fundoplication, the patterns of reflux did not affect the frequency or severity of reflux symptoms. After laparoscopic fundoplication, all symptoms of bipositional reflux improved, and essentially all symptoms of isolated supine or upright reflux or neither improved.

CONCLUSIONS

Preoperatively, regardless of the patterns of reflux, symptoms among patients were similar. After fundoplication, symptoms of GERD improved for all patterns of reflux. Laparoscopic fundoplication imparts dramatic and broad relief of symptoms of GERD, regardless of the patterns of reflux. Application of laparoscopic Nissen fundoplication is encouraged.

The transverse acetabular ligament: an aid to orientation of the acetabular component during primary total hip replacement

Ensuring the accuracy of the intra-operative orientation of the acetabular component during a total hip replacement can be difficult. In this paper we introduce a reproducible technique using the transverse acetabular ligament to determine the anteversion of the acetabular component. We have found that this ligament can be identified in virtually every hip undergoing primary surgery. We describe an intra-operative grading system for the appearance of the ligament. This technique has been used in 1000 consecutive cases. During a minimum follow-up of eight months the dislocation rate was 0.6%. This confirms our hypothesis that the transverse acetabular ligament can be used to determine the position of the acetabular component. The method has been used in both conventional and minimally-invasive approaches.

Morbidity, mortality and economic burden of renal impairment in cardiac intensive care

BACKGROUND

Moderate to severe impairment of renal function has emerged as a potent risk factor for adverse short- and long-term outcomes among patients presenting with cardiac disease.

AIMS

We sought to define the clinical, late mortality and economic burden of this risk factor among patients presenting to cardiac intensive care.

METHODS

A clinical audit of patients presenting to cardiac intensive care was undertaken between July 2002 and June 2003. All patients presenting with cardiac diagnoses were included in the study. Baseline creatinine levels were assessed in all patients. Late mortality was assessed by the interrogation of the National Death Register. Renal impairment was defined as estimated glomerular filtration rate <60 mL/min per 1.73 m2, as calculated by the Modified Diet in Renal Disease formula. In-hospital and late outcomes were compared by Cox proportional hazards modelling, adjusting for known confounders. A matched analysis and attributable risk calculation were undertaken to assess the proportion of late mortality accounted for by impairment of renal function and other known negative prognostic factors. The in-hospital total cost associated with renal impairment was assessed by linear regression.

RESULTS

Glomerular filtration rate <60 mL/min per 1.73 m2 was evident in 33.0% of this population. Among these patients, in-hospital and late mortality were substantially increased: risk ratio 13.2; 95% CI 3.0-58.1; P < 0.001 and hazard ratio 6.2; 95% CI 3.6-10.7; P < 0.001, respectively. In matched analysis, renal impairment to this level was associated with 42.1% of all the late deaths observed. Paradoxically, patients with renal impairment were more conservatively managed, but their hospitalizations were associated with an excess adjusted in-hospital cost of $A1676.

CONCLUSION

Impaired renal function is associated with a striking clinical and economic burden among patients presenting to cardiac intensive care. As a marker for future risk, renal function accounts for a substantial proportion of the burden of late mortality. The burden of risk suggests a greater potential opportunity for improvement of outcomes through optimisation of therapeutic strategies.

Limb length restoration during total hip arthroplasty: use of a caliper to control femoral component insertion and accurate acetabular placement relative to the transverse acetabular ligament

Current methods for restoring or preserving limb length following total hip arthroplasty largely depend on restoring the distance between a fixed point on the pelvis and femur. Each of these techniques allows length correction to be made by combining the effects of both acetabular and femoral height into a single measurement. These methods help to minimise inequality but are anatomically flawed, as they do not allow independent control of placement of the femoral and acetabular components which both contribute to leg length. To address this we present and evaluate a technique that uses a caliper to control the vertical placement of the femoral component and the transverse acetabular ligament to control the vertical height of the acetabular component. Limb lengths were measured in 200 patients who had undergone primary total hip arthroplasty using this technique. Using this method 94% had a postoperative limb length inequality that was 6mm or less (average, +0.38 mm). The maximum measured limb length inequality was +/-8 mm.

Self-reported difficulty in conceiving as a measure of infertility

BACKGROUND

This study aimed to explore the meaning and potential use of women's self-reported difficulties in conceiving as a measure of infertility in epidemiological studies, and to compare women's stated reasons for infertility with information in their medical records.

METHODS

Data were available from a population-based case-control study of ovarian cancer involving 1638 women. The sensitivity and specificity of women's self-reported infertility were calculated against their estimated fertility status based on detailed reproductive histories. Self-reported reasons for infertility were compared with diagnoses documented in women's medical records.

RESULTS

The sensitivity of women's self-reported difficulty in conceiving was 66 and 69% respectively when compared with calendar-derived and self-reported times taken trying to conceive; its specificity was 95%. Forty-one (23%) of the 179 women for whom medical records were available had their self-reported fertility problem confirmed. Self-reported infertility causes could be compared with diagnoses in medical records for only 22 of these women.

CONCLUSIONS

Self-reported difficulty conceiving is a useful measure of infertility for quantifying the burden of fertility problems experienced in the community. Validation of reasons for infertility is unlikely to be feasible through examination of medical records. Improved education of the public regarding the availability and success rates of infertility treatments is proposed.

A study of infertility treatment and melanoma

This study examined the possible association between melanoma and exposure to fertility drugs, specifically clomiphene citrate, human menopausal gonadotrophin (HMG) and human chorionic gonadotrophin (HCG). A cohort of 3186 women who attended a fertility clinic between 1 January 1980 and 31 December 1990 was studied; by January 1996, 14 women had been diagnosed with primary melanoma. Details of fertility treatment were extracted from the clinical records. The incidence of melanoma in the cohort resembled that of the female Queensland population (standardized incidence ratio = 0.89, 95% confidence interval [CI] = 0.54-1.48). Exposure to clomiphene citrate, HMG or HCG did not affect the incidence of melanoma. Women with infertile partners who were treated with fertility drugs were at increased risk of melanoma (odds ratio [OR] = 3.17, 95% CI = 1.01-9.98). Compared with women exposed only to clomiphene citrate and HMG, a lower incidence of melanoma was observed among those who received HCG as well (OR = 0.10, 95% CI = 0.02-0.42). Women exposed to two or more cycles of either clomiphene citrate (OR = 0.27, 95% CI = 0.08-0.94) or HMG (OR = 0.23, 95% CI = 0.07-0.84) had a significant reduction in melanoma risk compared with women exposed to no or one cycle. In summary, a woman's infertility per se was not found to be associated with melanoma, while exposure to fertility drugs was positively associated with melanoma in women with infertile partners and negatively associated in women with low doses of fertility drugs.

Dose response effect of cyclical medroxyprogesterone on blood pressure in postmenopausal women

OBJECTIVE

This study was designed to compare with placebo the dose-response effect of cyclical doses of the C21 progestogen, medroxyprogesterone acetate (MPA) on blood pressure (BP) when administered to normotensive postmenopausal women receiving a fixed mid-range daily dose of conjugated equine oestrogen (CEE).

MATERIALS AND METHODS

Twenty normotensive postmenopausal women (median age 53 years) participated in the study which used a double-blind crossover design. There were four randomised treatment phases, each of 4 weeks duration. The four blinded treatments were MPA 2.5 mg, MPA 5 mg, MPA 10 mg and matching placebo, taken for the last 14 days of each 28 day treatment cycle. CEE 0.625 mg was also administered once daily as open labelled tablets to all subjects throughout the study. Clinic BP was measured weekly with the mean values of weeks 3 and 4 of each phase used for analysis. Ambulatory BP was performed in the final week of each phase.

RESULTS

Compared with the placebo phase, end of phase clinic BP was unchanged by any of the progestogen treatments. There was a dose-dependent decrease in ambulatory daytime diastolic and mean arterial BP with the progestogen treatments compared with placebo (P < 0.05).

CONCLUSION

In a regimen of postmenopausal hormone replacement therapy with a fixed mid-range daily dose of CEE combined with a cyclical regimen of a C21 progestogen spanning the current clinical dose range, the progestogen has either no effect or a small dose-dependent reduction in clinic and ambulatory BPs over one treatment cycle.

Dose response effect of conjugated equine oestrogen on blood pressure in postmenopausal women with hypertension

OBJECTIVE

This study was designed to compare with placebo the dose-response of conjugated equine oestrogen (CEE) on blood pressure in hypertensive postmenopausal women.

DESIGN AND METHODS

Fourteen postmenopausal women with grade 1-2 hypertension participated in the study which used a double-blind crossover design. There were four randomised treatment phases, each lasting 4 weeks. The four treatments were CEE 0.3 mg, CEE 0.625 mg, CEE 1.25 mg and placebo. Each subject also received non-blinded medroxyprogesterone acetate (MPA) 10 mg for the final 14 days of each 28-day treatment cycle. Clinic blood pressure was measured weekly with the mean values of weeks 3 and 4 of each phase used for analysis. Ambulatory blood pressure was performed in week 4 of each phase.

RESULTS

Compared with placebo, clinic systolic blood pressure was reduced in the CEE 0.3 mg and CEE 0.625 mg phases (p < 0.05) and clinic diastolic blood pressure was reduced in the CEE 0.625 mg phase (p < 0.05). There was no significant effect of CEE on ambulatory blood pressure, although the blood pressure pattern was similar to clinic measurements.

CONCLUSION

In hypertensive postmenopausal women, daily CEE together with cyclical MPA has a variable effect on blood pressure depending on CEE dose. The "lower" and "middle" doses of CEE produced a small reduction in blood pressure which reached a nadir and tended to reverse with the "higher" CEE dose.

The effects of different types and doses of oestrogen replacement therapy on clinic and ambulatory blood pressure and the renin-angiotensin system in normotensive postmenopausal women

OBJECTIVE

The effect on blood pressure of oral replacement' doses of exogenous oestrogen may depend on the type and dose of oestrogen administered. This study was designed to compare with placebo the effect of once daily treatment with a 'natural' oestrogen, piperazine oestrone sulphate, in two different doses and a semisynthetic oestrogen, ethinyloestradiol, on clinic and ambulatory blood pressure and the renin-angiotensin system in postmenopausal women.

DESIGN AND METHODS

Twenty-four normotensive postmenopausal women (median age 54 years, range 47-60 years) participated in the study which used a double-blind crossover design. For each subject there were four randomized treatment phases, each lasting 4 weeks. The separate treatments administered once daily were 0.625 mg oestrone sulphate, 2.5 mg oestrone sulphate, 0.02 mg ethinyloestradiol and matching placebo. Clinic blood pressure, heart rate and weight were measured weekly with the mean values of weeks three and four of each phase used for analysis. Ambulatory blood pressure and biochemical measurements were performed in the final week of each phase.

RESULTS

Twenty-four subjects entered and 22 completed the randomized phases of the study. Compared with the placebo phase, end-of-phase mean clinic diastolic blood pressure was reduced in subjects taking the semisynthetic oestrogen (P < 0.01) but was unchanged in those taking the 'low' and 'high' dose natural oestrogen. Mean clinic systolic blood pressure was also unchanged by any of the oestrogen treatments. Ambulatory night-time systolic, diastolic and mean arterial blood pressures were reduced with the low-dose natural and semisynthetic oestrogen treatments compared with placebo (P < 0.01), whereas there was no significant effect of the oestrogen treatments on ambulatory daytime blood pressures. A reduction in clinic and ambulatory heart rate was observed with the high-dose oestrone and semisynthetic oestrogen treatments. There was a dose-dependent increase in plasma renin substrate and decrease in plasma renin concentration with all active treatments; however, there was no change in plasma renin activity or plasma aldosterone concentration.

CONCLUSION

In normotensive postmenopausal women, replacement doses of natural and semisynthetic oestrogen reduce night-time ambulatory blood pressure with either no change or a small reduction in clinic blood pressure. Reduction in blood pressure is not explained by reduced activity of the renin-angiotensin system but could have a component of reduced central sympathetic drive consistent with the decreased heart rate.

Contribution of the assisted reproductive technologies to fertility in males suffering spinal cord injury

This study reviews 19 couples referred between 1990 and 1997 for fertility treatment for anejaculatory infertility in the male partner following spinal injury. Using sperm obtained by assisted ejaculation procedures, 14 of the 19 patients (74%) achieved at least 1 pregnancy. Pregnancy rates per treatment cycle were 12.0% for timed intrauterine insemination, 38.9% for gamete intra-Fallopian transfer and 19.2% for intracytoplasmic sperm injection followed by uterine embryo transfer. Choice of the appropriate assisted reproduction treatment to match the available semen quality results in a high level of success in such patients.

Low-dose diuretic and/or dietary sodium restriction when blood pressure is resistant to ACE inhibitor

AIM

To compare the efficacy of indapamide (1.25 mg daily) and low-salt diet (<100 mmol/day) separately and in combination in essential hypertensive patients with inadequate BP response to perindopril.

DESIGN AND METHODS

Randomized double-blind, double-dummy, crossover design. The randomized treatments were indapamide 1.25 mg daily, sodium chloride 80 mmol daily, the combination of indapamide and sodium chloride and placebo. All patients received perindopril 4 mg daily and maintained a low-sodium diet.

RESULTS

19 patients entered and 17 completed the study. Prior to randomization, average clinic sitting blood pressure was 162/101 mm Hg and average 24-h urine sodium excretion was 157 mmol/day. Compared to the phase in which patients received perindopril with sodium repletion, clinic and ambulatory BPs were significantly reduced (p<0.01) in all the other phases. Indapamide had a greater effect on BP than dietary sodium restriction, and in combination their effects were additive. The effect of indapamide on ambulatory BP persisted throughout 24 h, but the effect of the low-salt diet was predominantly observed during waking hours.

CONCLUSIONS

In hypertensives with BP resistant to the angiotensin converting enzyme (ACE) inhibitor perindopril, the diuretic indapamide had greater additional efficacy and longer duration of action than dietary sodium restriction. In combination they had additive effects on BP.

Lacidipine, hydrochlorothiazide and their combination in systolic hypertension in the elderly

OBJECTIVE

To compare with placebo the efficacies of once-daily administrations of lacidipine and hydrochlorothiazide separately and in combination to elderly patients with systolic hypertension.

DESIGN AND METHODS

Nineteen elderly subjects (five men and 14 women, median age 71 years, range 62-79 years) participated in the study, which had a randomized double-blind crossover design. For each subject there were four treatment phases, each of duration 4 weeks. The initial treatments in each phase were 2 mg lacidipine once a day and 25 mg hydrochlorothiazide once a day, separately and in combination, and placebo. Doses of each agent could be doubled after 2 weeks in each phase if the patient's goal systolic blood pressure had not been achieved. The numbers of subjects administered the higher dose of each treatment were 13 for placebo, 14 for lacidipine, 11 for hydrochlorothiazide and eight for lacidipine plus hydrochlorothiazide.

RESULTS

End-of-phase mean clinic blood pressures were 164/85 mmHg with placebo, 159/82 mmHg with lacidipine, 157/84 mmHg with hydrochlorothiazide and 152/82 mmHg with lacidipine plus hydrochlorothiazide. Systolic blood pressure was significantly reduced during all active treatment phases compared with placebo and that for the lacidipine plus hydrochlorothiazide phase was also significantly less than those for both of the other active treatment phases. There was no difference between sitting and standing blood pressure for any phase. Factorial analysis of the main effects of treatment indicated that the effects of lacidipine and hydrochlorothiazide on clinic blood pressure were additive and also that heart rate was higher when hydrochlorothiazide had been administered. Ambulatory blood pressure monitoring confirmed the pattern of the responses of blood pressure and showed that administration of hydrochlorothiazide had a significantly greater effect on systolic blood pressure and a longer duration of action than did administration of lacidipine. There was no difference in the frequency of adverse effects among any of the phases.

CONCLUSIONS

In treating elderly systolic hypertensives the diuretic hydrochlorothiazide is a more effective antihypertensive agent with a longer duration of action than is the calcium channel antagonist lacidipine. In combination the effects of these two drugs on blood pressure are additive.

Multicenter feasibility study of a new coaxial falloposcopy system

We compared falloposcopy employing a new coaxial system with traditional laparoscopic chromotubation and hysterosalpingography in a prospective, multicenter clinical trial at five tertiary infertility centers. Based on findings at hysterosalpingography or laparoscopic chromotubation, the 16 women (22 tubes) in group 1 had a presumed diagnosis of proximal tubal obstruction, and the 4 (7 tubes) in group 2 had unexplained infertility. Cannulation was successfully achieved in 83.3% of tubes. In group 1, 85% (17/20) of visualized tubes were patent and 35% (7/20) were normal. In group 2, 40% (2/5) of visualized tubes were abnormal. Management was changed in 52.4% of women as a result of falloposcopic findings. Falloposcopy with this new coaxial system allows improved visualization with less bulky and less traumatic instruments. The system provides valuable information regarding the fallopian tube lumen that correlates poorly with that obtained with more traditional techniques.

National trends in gynaecological endoscopic surgery

Endoscopic or minimal access surgery promises less postoperative pain and decreased hospitalization. It is also a more reliable diagnostic tool than some conventional diagnostic procedures. The Medicare database was analyzed over 4 sequential financial years (1991-1992 to 1994-1995) to assess trends in utilization of endoscopic procedures in the private sector. Hysteroscopy is slowly replacing dilatation and curettage as a diagnostic procedure. Endometrial ablations are decreasing. A higher proportion of adnexal procedures and ectopic pregnancies are being managed endoscopically. Laparoscopically-assisted hysterectomies are slowly increasing. However data from the last 2 financial years suggests that the trend to endoscopic procedures is stalling with laparotomy still being extensively used. This may indicate an increased need for education and workshops by responsible organizations to extend the potential benefits of endoscopic surgery to more patients.

Second time around: a study of patients seeking second assisted reproduction pregnancies

OBJECTIVE

To investigate the outcomes of subsequent cycles of IVF-ET, GIFT, and frozen ET in patients who have already achieved at least one assisted reproductive technology (ART) pregnancy.

DESIGN

Retrospective cohort.

SETTING

Private infertility clinic, Brisbane, Queensland, Australia.

PATIENTS

From 1985 to 1992, 4,680 patients underwent 13,106 ART oocyte retrieval cycles. One thousand nine hundred twenty-two patients achieved a pregnancy, and 784 returned for a second pregnancy. These 784 return patients were divided into two subgroups: group A (288 patients) took home at least one baby from their first pregnancy; group B (496 patients) had an unsuccessful first pregnancy.

MAIN OUTCOME MEASURES

Pregnancy rate (PR), cumulative PR, pregnancy outcome.

RESULTS

Patients returning for second and third ART pregnancies had an increased chance of success. Pregnancy rates increased from 31.0% per transfer for patients attempting their first GIFT pregnancy, to 34.7% and 42.7% per transfer for patients attempting their second and third GIFT pregnancy. Cumulative PRs increased with subsequent pregnancy attempts. Groups A and B did not differ in PR, age, or indication of infertility but had significantly different live birth rates. The pregnancy outcomes of frozen ETs depended on the outcomes of the original cycle from which the embryos were derived.

CONCLUSIONS

This study has important implications for the counseling of patients returning for subsequent ART pregnancies.

Successful in vitro fertilization and pregnancy in a patient with autoimmune chronic active hepatitis and cirrhosis

Fertility is reduced in women with chronic active autoimmune hepatitis (AIH) and pregnancy is hazardous. This report describes a 33 year old woman with AIH and cirrhosis in whom a successful pregnancy was achieved following in vitro fertilization/embryo transfer. Disease exacerbation during pregnancy was controlled by azathioprine and an increased dose of prednisone, and a healthy child was delivered by Caesarean section at 36 weeks gestation. Since the perinatal care of preterm infants and the obstetric care available to women with complicated medical problems has improved markedly in recent years and since active disease can be controlled by adequate immunosuppressive therapy, we propose that it is justified to allow these patients access to in vitro fertilization programmes.

The diagnostic accuracy of a microlaparoscope

The performance of microlaparoscopy has been limited until recently. The introduction of a 2-mm laparoscope for diagnostic and minor procedural work may represent a technologic advance. Before such systems are used widely, their diagnostic accuracy must be validated. Twenty patients underwent laparoscopy first with a 2-mm microlaparoscope and then immediately with a 10-mm laparoscope. All cases were videotaped. The fiberoptic system in the 2-mm laparoscope gave pictures of sufficient diagnostic accuracy so that no pathology was missed and minor procedures could be performed.

Gynaecological surgery after endometrial ablation

OBJECTIVE

To determine the number of patients requiring further gynaecological surgery after endometrial ablation.

DESIGN

A retrospective 20-26-month follow-up of private patients who underwent endometrial ablation, tracking subsequent surgical procedures through the Medicare database. Data were analysed on a national and State basis.

SETTING AND PARTICIPANTS

1853 private patients who had had an endometrial ablation from 1 April 1991 to 30 September 1991. Seven different groups of subsequent gynaecological surgical procedures were investigated.

MAIN OUTCOME MEASURES

The need for subsequent endometrial ablation, hysterectomy (by any means) and other forms of gynaecological surgery within the defined time period.

RESULTS

After initial ablation, 382 patients (21%) required further gynaecological surgery: 10% required hysterectomy; 6% required repeat ablation; and 5% of patients required other gynaecological procedures related to the uterus. These rates for further procedures were generally higher than reported previously after transcervical hysteroscopic endometrial ablation or resection.

CONCLUSIONS

Endometrial ablation is associated with a significant medium and long term failure rate, necessitating further intervention. This failure rate may have been previously underestimated, and our higher rate may still be an underestimate.

Comparative tissue tolerance of a new endodontic sealer

An experimental radiopaque resin root canal sealer was tested for tissue biocompatibility in rat connective tissue. The controls were four widely used sealers: Sealapex, Kerr's sealer, AH-26, and Roth's sealer. Polyethylene tubes were filled with the sealers and allowed to set for 24 hours in 100% humidity. Each sealer was implanted in the connective tissue of Sprague-Dawley rats and removed after 3, 10, 20, 30, and 60 days, fixed, and histologically prepared for light microscope evaluation. At each time period there was practically no difference in the reaction of all the sealers. By 60 days, the total picture was one of well-tolerated biocompatibility.

The predictive value of idiopathic failure to fertilize on the first in vitro fertilization attempt

OBJECTIVE

To investigate the subsequent performance of patients with idiopathic fertilization failure on the first in vitro fertilization (IVF) cycle.

DESIGN

A retrospective study of 2,322 consecutive patients undergoing their initial IVF cycle.

SETTING

Advanced infertility treatment in an IVF/general infertility clinic.

PATIENTS

In 5 years, 94 couples with unexplained failed oocyte fertilization had 270 cycles of treatment. Each couple's performance was tracked through subsequent cycles of treatment.

INTERVENTIONS

In vitro fertilization with husband and donor sperm.

MAIN OUTCOME MEASURE(S)

Investigated retrospectively after 5 years of data collection.

RESULTS

Sixty-five couples of the original 94 had a second IVF attempt. Fifty of these successfully fertilized oocytes with husband's sperm and 4 with donor sperm. Nineteen of the 65 couples who continued treatment achieved a pregnancy, and only one couple had continuing fertilization failure.

CONCLUSIONS

The prognosis in the study group was surprisingly favorable despite the initial failed IVF treatment cycle.

Multiple-sited (heterotopic) pregnancy after in vitro fertilization and gamete intrafallopian transfer

Pregnancies occurring simultaneously in different body sites (heterotopic pregnancies) are a rare condition thought to occur in 1 of 30,000 spontaneous pregnancies. Individual cases may occur after in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). In the past 4 1/2 years, our unit has performed 6,204 IVF/GIFT or pronuclear stage transfer cycles of treatment. Ten such pregnancies proven by surgical, ultrasound, and histological diagnosis have occurred. In the same period 640 IVF, 355 GIFT, and 6 pronuclear stage transfer clinical pregnancies were achieved. This suggests that the incidence of heterotopic pregnancy after assisted reproduction is closer to 1 of 100 pregnancies. Clinicians managing early complications of IVF, GIFT, and/or pronuclear stage transfer pregnancies should be aware of this relatively high incidence of concomitant intrauterine and extrauterine pregnancy.

Patient age and success in a human IVF programme

Previous studies suggest that at around 40 years of age, pregnancy rates achieved by IVF programmes fall and pregnancy loss rates increase. The actual age at which this occurs has not been clearly delineated. This study of 2,692 patients including 94 aged 41 or over shows that satisfactory pregnancy rates can be achieved up to and including age 40. As age 40 is approached the pregnancy loss rate increases to around 40%. In the 41 years and over group the pregnancy rate was poor at 6% (6/94) and the pregnancy loss rate very discouraging at 83% (5/6).

Performance of patients with a "frozen pelvis" in an in vitro fertilization program

It is now possible to identify and study the performance of different subgroups of patients in in vitro fertilization (IVF) programs. Patients with severe pelvic adhesions due to pelvic inflammatory disease (PID) or endometriosis were classed as having a frozen pelvis if less than or equal to 20% of total ovarian surface was visible and if the rest of the ovary was bound down with significant adhesions. IVF offers the only hope of pregnancy for these patients. Fifty-one treatment cycles in 23 such patients were matched against 51 cycles in 48 patients with adhesion-free ovaries. The study group had a significantly higher number of cancelled oocyte retrievals because of poor estradiol (E2) response. They also had a significantly lower rate of E2 rise and a lower peak value of E2 before and after the administration of human chorionic gonadotropin. These patients took longer to respond to a hyperstimulation regime, and when a response occurred they formed fewer follicles, as measured with the use of ultrasound. Lower numbers of oocytes were obtained from this group, but the fertilization rate of oocytes was the same for both groups. One pregnancy occurred in the study group and 11 in the control group. It is possible that disruption of ovarian blood supply or mechanical factors due to the pressure of significant adhesions prevent a good follicular response in patients with a frozen pelvis.

A laparoscopic approach to a program of gamete intrafallopian transfer

Gamete intrafallopian transfer (GIFT) provides an effective method of achieving pregnancy in infertile women with normal fallopian tubes. Laparoscopic approach to ovum pickup and tubal catheterization provides a simple and rapid means of performing the operation. Equipment used to facilitate this process is described, and techniques of tubal catheterization are discussed. A clinical pregnancy rate of 27% is reported in a series of 71 treatment cycles. The application of GIFT in conjunction with in vitro fertilization is discussed, especially the use of excess gametes to provide embryos for freezing. The use of GIFT as a research and investigative tool may provide further insight into the causes for idiopathic infertility.

Cross-over trial of superovulation protocols from two major in vitro fertilization centers

A study was undertaken as a controlled comparison of two different superovulation induction protocols currently in use in major Australian in vitro fertilization (IVF) clinics. Thirty patients each from the Monash University and the Royal Women's Hospital (RWH) IVF programs were stimulated for ovulation induction by the other program. Once timing for oocyte retrieval was scheduled, all care reverted to the program from which the patient first came. Results given as pregnancies per patient commencing stimulation were: RWH patients on Monash protocol, 27%; RWH control patients, 15%; Monash patients on RWH protocol, 7%; Monash control patients, 13%. In the year preceding the trial pregnancy rates were 16.9% at Monash and 10.6% at RWH. Stimulation protocols were also compared with respect to each of administration, cost, and patient stress. The results of this cross-over trial demonstrated major differences between the two ovulation induction protocols studied, although it was not possible to conclude that differences in pregnancy rate were due to stimulation alone.