Laparoscopic abdominal cerclage after radical vaginal trachelectomy

BACKGROUND

The incidence of cervical cancer (CC) in Slovenia in 2011 was 13.2 per 100,000 women. The treatment of early stages of invasive cervical carcinoma involves several surgical techniques. In this article the authors would like to present a new combination of two methods which help to preserve fertility and to improve pregnancy outcome. The first procedure, radical vaginal trachelectomy (RVT), begins with laparoscopic pelvic lymphadenectomy. All suspicious lymph nodes are sent to frozen section. If those lymph nodes are negative, the procedure continues vaginally. Almost the entire cervix is removed with parametria and vaginal cuff. Permanent cerclage stitch is applied and covered with vagina on what is left of uterus. Second procedure, laparoscopic abdominal cerclage (LAC), begins with pneumoperitoneum. Mersilene tape is introduced in the abdominal cavity and placed through the visceral peritoneum at the isthmic part of the uterus with a Berci's needle. It is knotted and remains permanently.

MATERIALS AND METHODS

For the first procedure all the patients with confirmed cervical carcinoma (FIGO Stage IA₁, IA₂, and IB₁) and with the desire for fertility were recruited. For the second procedure, all the patients after RVT and after miscarriage after 14th week of gestation were recruited.

RESULTS

RVT was performed in 15 patients and laparoscopic abdominal cerclage in three of them (21.5%). All three patients achieved pregnancies and after 36th weeks of gestation delivered by cesarean section (100%).

CONCLUSIONS

RVT alone is an indication for LAC. Considering its success, LAC should be performed before any miscarriage.

Age, oestradiol and blastocysts can predict success in natural cycle IVF-embryo transfer

The aim of this study was to evaluate the influence of maternal age and oestradiol concentrations on blastocyst development and live birth rates in natural cycle IVF-embryo transfer. This observational study included 397 natural cycles with IVF embryo transfer for female infertility with embryo transfer on day 5. The cycles were divided into two groups according to the woman's age (<39 and > or = 39 years of age), and into two groups according to oestradiol concentrations on the day of human chorionic gonadotrophin (HCG) administration (0.4-0.49 nmol/l and 0.5-1.2 nmol/l). Comparison between the cycles in younger versus older age groups showed significant differences in blastocyst development rate, live birth rate per embryo transfer and live birth rate per cycle (55 versus 29%, 23 versus 3% and 13 versus 2% respectively) (P < 0.001). Comparison between cycles with lower versus higher oestradiol concentrations showed no significant differences in blastocyst development rate, live birth rate per embryo transfer and live birth rate per cycle (47 versus 49%, 18 versus 18%, and 11 versus 10% respectively). Advanced maternal age negatively predicts the success of natural cycle IVF, while low oestradiol concentrations on the day of HCG administration (ultrasound criteria fulfilled) do not negatively predict blastocyst development and success of natural cycle IVF.

Small uterine septum is an important risk variable for preterm birth

OBJECTIVE(S)

To evaluate whether a uterus with a small septum (arcuate uterus or class VI according to the American Fertility Society (AFS) classification) behaves similarly to a uterus with a larger septum (septate or subseptate uterus or AFS class V).

STUDY DESIGN

Observational study included 826 singleton deliveries to 730 women with a history of hysteroscopic resection of the uterine septum. Data on deliveries were obtained from the National Perinatal Registry of Slovenia (NPIS). Multiple gestations were excluded. We analysed and compared perinatal outcomes before and after hysteroscopic resection in two groups of women: in women with a small uterine septum (Group A) and in those with a larger uterine septum (Group B). Data on the septum length were obtained during hysteroscopic resection by comparing the length of the 1.4-cm long yellow tip of the electric knife to the length of the resected septum. A small uterine septum was defined as having a length of 1.3-1.5 cm.

RESULTS

The preterm birth rate in Group A (n=420) was 33.9% before and 7.2% after hysteroscopic resection (P<0.001); the preterm birth rate in Group B (n=406) was 36.5% before and 8.0% after hysteroscopic resection (P<0.001). The very preterm birth rate in Group A was 12.5% before and 3.1% after hysteroscopic resection (P<0.001); the very preterm birth rate in Group B was 15.0% before and 2.9% after hysteroscopic resection (P<0.001). After surgery, we registered a decreased need for neonatal intensive care, as well as a significant decrease in stillbirth and neonatal death rates in both groups of patients.

CONCLUSION(S)

Similarly to a large uterine septum, a small uterine septum or arcuate uterus is an important hysteroscopically preventable risk variable for preterm birth.

Blastocyst formation--good indicator of clinical results after ICSI with testicular spermatozoa

BACKGROUND

The aim of this study was to evaluate the role of blastocyst culture in patients with azoospermia.

METHODS

In 98 cycles embryos were cultured for 2 days and in 128 cycles for 5 days to reach the blastocyst stage; a maximum of two of the most developed embryos were transferred in each group.

RESULTS

There was a negative correlation between a high (>/=20 IU/l) male serum FSH and embryo development, manifested as embryos not reaching the morula stage on day 5 (r = 0.387; P < 0.05). After prolonged culture, 23% of embryos reached the blastocyst stage. The pregnancy rates per transfer, and the abortion rates were approximately the same in the day 2 group and the day 5 group (20 versus 20% and 19 versus 18% respectively). After blastocyst transfer, a high clinical pregnancy rate (55%) and a low abortion rate (6%) were achieved, whereas the transfer of arrested embryos provided a low pregnancy rate (2%) and a high abortion rate (100%). If only blastocysts had been transferred on day 5, the clinical pregnancy rate per started cycle would have been approximately the same in both groups (13 versus 16%).

CONCLUSIONS

Blastocyst formation is a good indicator of clinical results after ICSI with testicular sperm.

Infertility treatment by in vitro fertilization in patients with minimal or mild endometriosis

PURPOSE

To estimate the clinical effectiveness of in vitro fertilization treatment in patients with minimal or mild endometriosis (stages I and II) in comparison to the patients with tubal infertility in terms of fertilization, pregnancy and livebirth rates.

METHODS

Retrospective analysis of the outcome of IVF-ET in 612 cycles of the patients with endometriosis (389 stimulated with HMG/HCG and 223 co-treated with GnRH-a) and in 7,339 cycles of the patients with tubal infertility (5,520 stimulated with HMG/HCG and 1,819 co-treated with GnRH-a). RESULLTS: Regardless of the type of ovarian stimulation, the fertilization rate per treated cycle was practically the same in both groups (endometriosis 81.4% vs tubal infertility 84.2%; p = 0.07). However, in the endometriosis group the pregnancy rate was higher (25.3% vs 18.9%; p = 0.000), and so was the livebirth rate (19.0% vs 14.2%; p = 0.003). Considering the type of ovarian stimulation, the fertilization rate in the endometriosis group was almost the same in the HMG/HCG (81.2%) and in the GnRH-a co-treated cycles (81.6%), and did not differ from that in the tubal infertility group (83.6% in the HMG/HCG vs 85.9% in the GnRH-a cycles). In the GnRH-a co-treated cycles the pregnancy rate and the livebirth rate were not significantly higher in the endometriosis group than in the tubal infertility group (27% and 20.2% vs 22.2% and 17.5%). In the HMG/HCG stimulated cycles the pregnancy rate was significantly higher in the endometriosis than in the tubal infertility group (24.3% vs 17.7%; p = 0.004), and so was the livebirth rate (18.4% vs 13.0%; p = 0.008).

CONCLUSION

In patients with minimal or mild endometriosis the IVF-ET procedure is at least as effective as in patients with tubal infertility.

Pretreatment evaluation of adnexal tumors predicting ovarian cancer

Kobal B, Rakar S, Ribic-Pucelj M, Tomazevie T, Zaletel-Kragelj L. Pretreatment evaluation of adnexal tumors predicting ovarian cancer. The objective of this study was to determine the ability of tumor marker assessment, gray-scale transvaginal with color Doppler ultrasonography to predict ovarian malignancy. One hundred thirty-four subjects with ovarian masses who entered the study prospectively underwent pelvic examination, tumor marker assessment and gray-scale transvaginal with color flow Doppler ultrasonography preoperatively. Malignancy predictors were statistically evaluated with stepwise multiple logistic regression, and the scores from the model were transformed to probability for having a malignant disease. The presence of neovascularization, intracystic papillary projections, elevated serum CA 125, and age over 45 years were significant predictors for malignancy. Positive predictive value (PPV) for the regression model was 89.0%, and negative predictive value (NPV) was 96.8%. Probability for malignancy ranged from 0.004 to 0.991 depending on which covariates were included. Logistic regression analysis of pretreatment diagnostic gray-scale and color Doppler ultrasonographic characteristics, together with CA 125 enabled a creation of probability assessment scale for individual estimation of ovarian mass, which may contribute to final clinical decision.

Subpopulations of human granulosa-luteal cells obtained from gonadotropin- or gonadotropin-releasing hormone agonist/gonadotropin-treated follicles in in vitro fertilization-embryo transfer cycles

PURPOSE

Our purpose was to find the differences in granulosa-luteal cells obtained from gonadotropin-versus gonadotropin-releasing hormone (GnRH) agonist/gonadotropin-treated follicles in in vitro fertilization-embryo transfer (IVF-ET) cycles.

METHODS

Granulosa-luteal cells were obtained from 45 follicles of women undergoing IVF-ET with gonadotropin releasing hormone (GnRH) agonist and human menopausal gonadotropin (hMG) and from 45 follicles of women with hMG IVF-ET cycles. Subpopulations of granulosa-luteal cells were observed by computerized image analysis in which human chorionic gonadotropin (hCG) was localized using immunoperoxidase staining.

RESULTS

The luteinized granulosa-luteal cells from hMG-treated follicles were larger than those from GnRH agonist/hMG-treated follicles. The hMG-treated follicles contained more hCG-stained cells, particularly those with cytoplasmic hCG localization.

CONCLUSIONS

We found differences in morphometric characteristics and hCG localization in granulosa-luteal cells obtained from hMG-versus GnRH agonist/hMG-treated follicles. We presume that the results indicate the influence and importance of luteal-phase support on the clinical pregnancy rate in GnRH agonist/hMG-treated IVF-ET cycles.

Safe and effective fluid management by automated gravitation during hysteroscopy

OBJECTIVE

The automated gravitational Vario Flow system with weighing-based electronic fluid deficit indicator was used in order to reduce the risk of fluid intravasation during continuous flow hysteroscopic procedures. Early experiences are reported.

METHODS

Between August 1996 and July 1997, the Vario Flow with fluid deficit indicator and alarm system was used in 203 hysteroscopic operations. Between January 1994 and August 1996 the Vario Flow without fluid deficit indicator was used in 240 hysteroscopic operations. In all, there were 443 hysteroscopic operations: 301 metroplasties, 20 endometrial ablations, 10 cases of lysis of synechiae, 58 myomectomies and 54 polypectomies. The data on fluid deficit before and after the introduction of the electronic fluid deficit indicator were similar.

RESULTS

Fluid deficit indicator was proved highly efficient in 203 operations. It provided the information on fluid deficit at any moment during hysteroscopic operations. Besides intrauterine pressure, the actual fluid deficit has become one of the leading parameters during our continuous flow hysteroscopic procedures.

CONCLUSIONS

We therefore conclude that by using an automated gravitational system with fluid deficit indicator and alarm system, the safety for patients during hysteroscopic procedures has been increased.

Subpopulations of human granulosa-luteal cells obtained during early timed and during normally timed follicular aspiration in in-vitro fertilization-embryo transfer cycles

OBJECTIVE

To find the differences between human granulosa-luteal cells obtained during early timed follicular aspiration to prevent severe ovarian hyperstimulation syndrome (OHSS) and during normally timed follicular aspiration.

DESIGN

Retrospective analysis of clinical laboratory data.

SETTING

In vitro fertilization unit, University Department of Obstetrics and Gynecology, Ljubljana, Slovenia.

PATIENT(S)

Twenty women undergoing IVF-ET at high risk for OHSS.

INTERVENTION(S)

Cells were obtained from the follicles of women who were stimulated with hMG and hCG during an early timed follicular aspiration of one ovary, 10-12 hours after hCG, and during a normally timed follicular aspiration of the contralateral ovary, 32-36 hours after hCG administration.

MAIN OUTCOME MEASURE(S)

Subpopulations of granulosa-luteal cells were observed by computerized image analysis in which hCG was localized using immunoperoxidase staining.

RESULT(S)

Early timed follicular aspirates contained no oocytes and only a scant number of granulosa cells. Granulosa-luteal cells were smaller than those from normally timed follicular aspirates. We identified three subpopulations in early timed follicular aspirates: nonluteinized, small luteinized, and medium luteinized cells. In normally timed follicular aspirates, four subpopulations were identified, including large luteinized cells. The normally timed follicular aspirates contained more hCG-stained cells. Three staining types of hCG localization were found: on the surface membrane, on the surface membrane and within the cytoplasm, and only within the cytoplasm of cells from normally timed follicular aspirates. Early timed follicular aspirates contained only cells with membrane hCG localization.

CONCLUSION(S)

We found differences in morphometric characteristics and hCG localization between human granulosa-luteal cells obtained during early timed follicular aspiration to prevent severe OHSS and during normally timed follicular aspiration.

Microsurgery and in-vitro fertilization and embryo transfer for infertility resulting from pathological proximal tubal blockage

The aim of this study was to evaluate the prognosis for the patients after the treatment of infertility resulting from proximal tubal blockage using microsurgical tubocornual anastomosis and in-vitro fertilization (IVF) and embryo transfer complementarily. A total of 59 microsurgical operations (1986-1992) for infertility resulting from pathological proximal tubal lesions were analysed. The cumulative live birth rate was 52% for tubocornual anastomosis, 58% for bilateral operations and 28% for two-site operations. In all, 35 singleton babies were born. Of the 32 operated patients who did not deliver within 2 years of surgery, 21 were treated by 66 IVF cycles; 12 babies were born. The live birth rate was 18% per cycle and 57% per patient. Combining both treatment methods the cumulative live birth rate was improved up to 69% in the group of tubocornual anastomoses, up to 75% in the group of bilateral operations, and up to 57% in the group of two-site operations. Complementary use of microsurgery and IVF and embryo transfer improves the prognosis for selected infertile patients with pathological proximal tubal blockage. In the absence of pregnancy, IVF and embryo transfer should be commenced 1 year after surgery.

An automated gravitational system for delivery of low-viscosity media during continuous-flow hysteroscopy

We constructed an automated gravitational system to control fluid dynamics during hysteroscopic operations. The new system allows linear regulation of intrauterine pressure by varying the flow by simply changing the height of the fluid-filled bag above the patient. The outflow from the automated gravitational system is also driven by gravity. Between January 1994 and June 1995 we performed 88 hysteroscopic operations: 10 myomectomies, 8 endometrial ablations, 3 polypectomies, 3 lysis of synechiae, and 64 transcervical metroplasties. With the Vario Flow system we obtained good visualization, and all operations were performed adequately in one attempt. No surgical or general complications were encountered. We presume that patient safety will be increased further with the second version of this system, which has a built-in electronic fluid deficit-control system.

Early timed follicular aspiration prevents severe ovarian hyperstimulation syndrome

PURPOSE

Early timed follicular aspiration (ETFA) of one ovary 10-12 hr after administration of chorionic gonadotropin (hCG) is an attempt to prevent severe ovarian hyperstimulation syndrome (OHSS). After the introduction of early timed follicular aspiration ETFA of one ovary in IVF/ET cycles at high risk for severe OHSS, no cases of severe OHSS were registered in the Ljubljana IVF/ET program. In the period before preventive ETFA (1984-1992) there were 16 cases of severe OHSS of 4798 IVF/ET cycles followed by 577 clinical pregnancies. After the introduction of ETFA (1992-1993) there were no cases of severe OHSS of 2289 IVF/ET cycles followed by 364 clinical pregnancies.

METHODS

We attempted to evaluate the significance of this observation by comparing two groups of female infertility IVF/ET cycles at high risk for severe OHSS. The occurrence of severe OHSS and clinical parameters in the two groups of IVF/ET cycles at high risk for severe OHSS were compared.

RESULTS

In the group of 106 IVF/ET female infertility cycles at high risk of severe OHSS with preventive ETFA, there were no cases of severe OHSS. In the control group of 92 IVF/ET female infertility cycles at high risk for severe OHSS with normally timed follicular aspiration (NTFA) of both ovaries, severe OHSS occurred in 16 cases. The difference in the occurrence of severe OHSS between the two groups is highly significant (P < 0.005), both in hMG/hCG- and in GnRHa/hMG/hCG-induced IVF/ET cycles. No difference in live birth rate (16 vs. 16%) between the two groups was noted.

CONCLUSIONS

Considering these results we conclude that ETFA is another successful option to decrease the incidence of severe OHSS in assisted reproduction. The preventive effect of follicular aspiration seems to depend on its timing.

Subpopulations of human granulosa-luteal cells in natural and stimulated in vitro fertilization-embryo transfer cycles

OBJECTIVE

To find out the differences between human granulosa-luteal cells derived from natural and stimulated IVF-ET cycles.

DESIGN

Cells were obtained from dominant follicles of 52 women with natural cycles in whom preovulatory hCG was given when the follicle was mature and from 50 dominant follicles of women undergoing IVF-ET with hMG and hCG.

SETTING

In Vitro Fertilization Unit, University Department of Obstetrics and Gynecology Ljubljana, Slovenia.

MAIN OUTCOME MEASURE

Four subpopulations of cells were observed by computerized image analysis in which hCG was localized using immunoperoxidase staining.

RESULTS

The nonluteinized granulosa cells from natural cycles were larger than those from the stimulated ones. In luteinized cell types, there was no difference in cell area between natural and stimulated cycles. Three staining types of hCG localization were found: on the surface membrane, on the surface membrane and within the cytoplasm, and within the cytoplasm alone. The hCG stained cells from natural cycles were larger than the ones from stimulated cycles. The natural developing follicles contained more hCG stained cells than the stimulated ones. The follicles with fertilizable oocytes had more cells with cytoplasmic hCG localization. Only in natural cycles was there was a correlation between follicular fluid hCG levels and the percentage of the hCG stained cells.

CONCLUSION

We found differences in morphometric characteristics and hCG localization between human granulosa and granulosa-luteal cells obtained from natural and stimulated IVF-ET cycles.

Influence of follicular phase duration on human granulosa-luteal cell subpopulations in natural and stimulated IVF-ET cycles

OBJECTIVES

To observe the granulosa-luteal cell subpopulations presented within follicular aspirates concerning duration of the follicular phase and the type of IVF protocol.

DESIGN

Cells were obtained from dominant follicles of 40 women with natural IVF-ET cycles, in which preovulatory hCG was given when the follicle was mature, and from 40 follicles of 32 women with hMG and hCG stimulated IVF-ET cycles. Granulosa-luteal cell subpopulations were observed by computerized image analysis in which hCG was localized using immunoperoxidase staining.

RESULTS

(1) The nonluteinized granulosa cells from natural developing follicles were larger than those from stimulated ones regardless of the follicular phase duration. (2) The size of each luteinized cell subpopulations was influenced neither by the two IVF protocols nor by the follicular phase duration. (3) The hCG stained cells from natural developing follicles were larger than the ones from stimulated follicles and their relative number in aspirates was higher. Cell areas and distribution were not influenced by the duration of follicular phase. (4) In stimulated conditions, hCG stained cells became larger if follicular phase was longer.

CONCLUSIONS

Duration of the follicular phase influences the immunocytochemical hCG localization and the morphometric characteristics of granulosa-luteal cell subpopulations presented within natural developing follicles and stimulated ones.

Risk factors for ectopic pregnancy after in vitro fertilization and embryo transfer

PURPOSE

To find the incidence of ectopic pregnancy (EP) in patients who conceived in the IVF-ET program, and risk factors affecting the occurrence of EP.

METHODS

We analyzed the effects of the indication for IVF, type of ovarian stimulation (hMG + hCG vs. GnRH + hMG + hCG), type of embryo transfer (transcervical intratubal, intrauterine in chest-knee position and intrauterine in lithotomy position) and number of embryos transferred on the occurrence of EP. EP was treated by laparotomy, prostaglandin E2 or laparoscopic surgery.

RESULTS

In 7991 stimulated and 92 natural cycles treated in the Ljubljana IVF-ET program between May 1983 and June 1994 we achieved 1059 pregnancies, of which 44 were ectopic (incidence 4.1%), the main risk being tubal factor infertility. There were 38 (86.3%) tubal, 3 (6.8%) heterotopic, 1 (2.4%) ovarian, and 2 (4.5%) cornual EP. In two patients multiple tubal EP occurred (1 twin, 1 triplet). Forty-two patients (95.4%) had tubal factor infertility, 1 (2.3%) unexplained, and 1 (2.3%) patient had male factor. The incidence of EP in patients with tubal infertility was 5.4%, in patients with unexplained infertility 2.0% and in those with male factor 0.9%. There appeared to be no correlation between the two superovulatory methods. With transcervical intrauterine ET the incidence of EP was 0 of 5 clinical pregnancies (CP); with intrauterine in chest-knee position it was 26 (3.5%) of 738 CP; with intrauterine in lithotomy position it was 17 (5.4%) of 316 CP. The difference between the two types of intrauterine ET is not statistically significant. The incidence of EP did not correlate with the number of embryos transferred. The average initial values of beta hCG performed 17 days after ET were significantly lower in patients with EP than in those with normal singleton pregnancy (157 +/- 143 mIU/ml vs. 408 +/- 148 mIU/ml).

CONCLUSIONS

EP can complicate the IVF procedure. The main risk factor is tubal infertility with or without previous tubal surgery. The low initial value of beta hCG has a strong predictive value in the diagnosis of EP.

Preventing severe ovarian hyperstimulation syndrome in an in vitro fertilization/embryo transfer program. Use of follicular aspiration after human chorionic gonadotropin administration

In 3,972 human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG)-stimulated menstrual cycles, severe ovarian hyperstimulation syndrome (SOHSS) developed in 10 patients (0.25%), while in 627 hMG-, hCG- and gonadotropin releasing hormone analog (GnRH-a)-stimulated cycles, 6 patients (0.95%) developed SOHSS. In cases of threatening SOHSS in the follicular phase (excessive estradiol values, multiple follicles), a preventive method was applied: follicular aspiration 12 hours after hCG administration and regular oocyte retrieval 36 hours after hCG (17 patients). The method of post-hCG aspiration in one ovary was effective, leading to the withdrawal of all signs of SOHSS within six days after the second aspiration. In hMG-stimulated, pretreated patients there were four deliveries of seven healthy infants (two singleton, one twin and one triplet), while one pregnancy in seven GnRH-a-stimulated and pretreated patients ended in a spontaneous abortion. Post-hCG aspiration is a quick, simple and effective method that prevents the development of SOHSS and permits pregnancy in the treated cycle. Although the pregnancy rate in patients who developed SOHSS was higher (100% per embryo transfer), one should also consider the high spontaneous abortion rate (33.3% for the hMG- and 50% for the GnRH-a/hMG-treated groups) and the fact that SOHSS is a life-threatening condition, demanding expensive, intensive care. According to our experience, post-hCG follicular aspiration is the treatment of choice in patients with signs of SOHSS.

The effects of gonadotrophin-releasing hormone agonist on follicular development in patients with polycystic ovary syndrome in an in-vitro fertilization and embryo transfer programme

The aim of the study was to evaluate ovarian response to gonadotrophin stimulation, with and without premedication with gonadotrophin-releasing hormone (GnRH) agonist, in patients with polycystic ovary syndrome. In all, 40 women included in the in-vitro fertilization/embryo transfer programme were divided into two groups. In the first group, buserelin, 500 micrograms/day s.c., was given until pituitary desensitization was achieved. Ovarian stimulation was performed by the combination of GnRH agonist and human menopausal gonadotrophin (HMG). The second group was treated using a conventional HMG and human chorionic gonadotrophin (HCG) protocol. Desensitization was achieved in 15.2 +/- 6.3 days (mean +/- SD) and the luteinizing hormone:follicle stimulating hormone ratio decreased from 2.84 +/- 1.54 to 0.60 +/- 0.35. Comparing the duration of stimulation, the number and size of all observed and aspirated follicles, oocytes recovered and fertilized and the number of embryos replaced, no statistically significant differences were found between the groups. The average oestradiol concentration on the day of HCG administration was lower in the group treated with premedication (P < 0.05). These data suggest that short pre-treatment with GnRH agonist can temporarily correct endocrine abnormalities of polycystic ovary syndrome but do not change the ovarian response to gonadotrophin stimulation and multiple follicular development.

Ectopic pregnancy following the treatment of tubal infertility

To evaluate the prognosis for the patient who becomes pregnant after infertility treatment, we analyzed the occurrence of ectopic pregnancy following reconstructive surgery and in vitro fertilization/embryo transfer (IVF/ET) for tubal infertility. The results of 474 microsurgical operations and the results of 2,119 stimulated IVF/ET cycles for tubal infertility in the Reproduction Unit of Ljubljana University Department of Obstetrics and Gynecology are presented. The ratio of patients who subsequently had only ectopic pregnancies to the number of operations was 12%. Ectopic pregnancies represented 28% of all pregnancies after surgery. In IVF/ET cycles for tubal infertility, ectopic pregnancy represented 2.8% of all pregnancies and 3 permiles of all transfers. There was one (0.5%) heterotopic pregnancy. The likelihood of live births (30%, one or more times) after surgery compensates the high risk for ectopic pregnancy. While the risk for ectopic pregnancy after IVF/ET is much lower than the risk after tubal surgery, it is still rather high compared with the risk in the normal population. In the cases with severe tubal lesions IVF/ET is preferable to tubal surgery. The results show the importance of considering ectopics when deciding upon treatment and in patients who become pregnant after treatment for tubal infertility.

Microsurgery and in vitro fertilization/embryo transfer for infertility resulting from distal tubal lesions

The live birth rates were analyzed after 688 microsurgical operations for infertility resulting from distal tubal lesions and after 885 in vitro fertilization cycles for tubal factor infertility at the Ljubljana University Department of Obstetrics and Gynecology. The cumulative live birth rate five years after surgery was 31% (17% cases lost to follow-up). The cumulative live birth rate after four in vitro fertilization cycles for tubal infertility was 40% (8% per treated cycle). With two options for treatment, operable cases had a better prognosis than did the inoperable ones. If pregnancy did not occur two to three years after surgery, the patients underwent in vitro fertilization. The complementary use of microsurgery and in vitro fertilization has substantially improved the prognosis for infertility resulting from distal tubal lesions.

[Surgical treatment of symmetrically developed uterine abnormalities]

Retrospectively 75 patients having undergone metroplasty for symmetric uterine anomalies were analysed. The main indication for operation was recurrent abortions and preterm deliveries (63 women) and primary sterility (12). Adnexal pathology which required microsurgical repair was present in 52 (57%) patients. The most frequent uterine malformations were uterus septus and subseptus (51), uterus bicornis (23) and uterus arcuatus (1). All metroplasties were performed according to the Bret-Palmer technique modified by authors. Indication for metroplasty was based on hysterosalpingography, laparoscopy and hysteroscopy in doubtful cases. Prior to metroplasty, 63 patients had 189 spontaneous abortions and 6 preterm deliveries without a living child, while 12 patients were primarily sterile. After operation 68 (90.4%) patients became pregnant and 65 (86.6%) of them delivered 92 healthy children. Pregnancy in 3 (4.0%) patients ended with repeated spontaneous abortions, while 7 (9.4%) remained sterile.

Transvaginal ultrasound or laparoscopy for oocyte retrieval (experiences in the Ljubljana IVF program)

At present, the less invasive ultrasound-directed techniques are the methods of choice for oocyte retrieval in most in vitro fertilization and embryo transfer (FIVET) centers. Among the ultrasound-direct techniques, the transvaginal follicle aspiration guided by transvaginal ultrasound for oocyte recovery is gaining popularity in many FIVET centers. This study compare cycles outcome following transvaginal ultrasound oocyte retrieval (105 cycles) to laparoscopic oocyte retrieval (218 cycles); no statistically significant difference could be demonstrated between the groups in all parameters evaluated but better clinical results have been obtained in transvaginal ultrasound group. The Authors conclude that transvaginal oocyte recovery represents an improvement and a simplification of the FIVET procedure.

Umbilical cord cortisol in breech delivery

Mixed umbilical cord blood samples were obtained in 31 cases immediately after vaginal breech delivery at term and in 31 cases immediately after vaginal vertex delivery at term. The total cortisol concentrations were determined using a direct radioimmunologic method (Amerlex cortisol kit). The mean umbilical cord total cortisol concentration was 790 +/- 363 nmol/liter in breech delivery as compared with 493 +/- 125 nmol/liter in vertex delivery. The difference was highly significant (p less than 0.0005). There was a highly positive correlation (r = 0.59, p less than 0.0005) between duration of labor and total cortisol concentrations in umbilical plasma after breech delivery. In contrast to that we found only a slightly positive correlation between duration of labor and total cortisol concentrations after vaginal vertex delivery (r = 0.23, p less than 0.10). Significant differences in pH values between breech and vertex deliveries (p less than 0.01) and a slight but significant correlation (r = 0.35, p less than 0.002) between umbilical vein pH values and umbilical total cortisol concentrations indicate that the increase in cortisol during vaginal breech delivery could be attributed partially to some hypoxic events. These results support the concept that the increase in cortisol in the umbilical cord plasma during labor reflects the fetal adrenal response secondary to stress in utero and contribute to our understanding of why an increased risk exists for the fetus during vaginal breech delivery of long duration.

The treatment of invasive carcinoma of the cervix at the Department of Gynecology and Obstetrics in Ljubljana

In this report the treatment of carcinoma of the cervix in the period from 1965 through 1972 at the Department of Gynecology and Obstetrics in Ljubljana, is presented. In that period 651 patients were admitted for treatment and 488 were operated; the operability was 73.8%. The primary mortality rate was 1.02% and the frequency of ureteral fistulas 1.93%. The 5-year survival rate were: for stage I 81.8%-94.5% for stage Ia and 76.2% for stage Ib, for stage II 57.83% and for stage III 28.38%. The treatment and mortality for cases with positive lymph-nodes is discussed, and the results of treatment are also presented.

[Results of the treatment of endometrial carcinoma (author's transl)]

The increased incidence of endometrial carcinoma in Slovenia from 1961 to 1970 is presented, as well as the five-year survival of patients treated from 1946 to 1949 and from 1965 to 1972. A retrograde analysis is made of 288 patients, of the structure of their carcinomatous stages, their age, mode of treatment, and their survival in relation to the kind of treatment, the development of the cancer, its histological structure, and the magnitude of changes in regional lymph nodes. Novak's merit for the use of the so-called old Wertheim in the surgery of endometrial carcinoma is particularly pointed out.