A. A. Templeton

The incidence, characteristics, and prognosis of patients whose infertility is unexplained

Review of the case records of 500 consecutive couples attending one Scottish infertility clinic revealed a group of patients whose infertility remained unexplained after completion of a standard protocol of investigations. The incidence of this condition in the clinic population was 24%. Various patient characteristics were examined, and no differences from patients with a detectable, organic cause for their infertility were found. Life-table analysis was used to provide a prognostic guide for such couples. About 34% of those with primary infertility and 21% of those with secondary infertility will remain infertile after 9 years of attempting to conceive.

Chromosome studies in human in vitro fertilization

SummaryThe chromosome constitution of 22 human preimplantation embryos from donor oocytes fertilized in vitro by donor sperm was studied to assess the contribution of lethal chromosome anomalies to the high failure rate of implantation of in vitro fertilized embryos after embryo transfer in infertile women. Evidence was found of nondisjunction, resulting in trisomy, monosomy, and nullosomy; structural abnormalities; haploidy; and triploidy. Despite the lethality of their chromosome complements, these embryos could not be distinguished morphologically from those with normal chromosomes.

Consequences of polyspermy in man

Polyspermy occurs with a frequency of about 12% under some hormonal regimens currently being used for in vitro fertilization and embryo transfer. Oocytes with three pronuclei usually show normal cleavage and are morphologically indistinguishable from embryos produced by normal fertilization. Chromosome studies and DNA measurements on dispermic embryos show that about one-half are triploid, the others having either a normal diploid chromosome complement or a severely depleted chromosome complement. The evidence suggests that these errors must arise at the first mitotic division of the oocyte. Aberrant spindle formation is implicated.

LAPAROSCOPIC SPERM RECOVERY IN INFERTILE WOMEN

Sperm recovery from the peritoneal fluid was attempted in a group of infertile women in whom it was anticipated that all routine investigations would be normal (commonly referred to as ‘normal infertiles’). Forty‐four couples were recruited into the study but in retrospect only 24 met the study criteria of normal semen, normal pelvis and appropriate timing. In 15 of these 24 patients, spermatozoa were covered from the peritoneal fluid, and so far seven have become pregnant. In the nine patients where spermatozoa were not recovered, none have so far become pregnant. There was no correlation between sperm recovery and the quality of the post‐insemination cervical mucus examination. This test allows more accurate assessment of the ability of spermatozoa to reach the site of fertilization.

A RAPID LUTEINIZING HORMONE RADIOIMMUNOASSAY FOR THE PREDICTION OF OVULATION

A rapid luteinizing hormone (LH) radioimmunoassay (total time 4 h) has been developed and used to measure the preovulatory LH surge in 22 patients. Ovulation, assessed by laparoscopy or mini laparotomy, did not occur until at least 32 h after the start of the LH surge. This rapid LH radioimmunoassay provides a simple method of predicting ovulation for the correct timing of oocyte collection or artificial insemination.

The development of a clinical test of sperm migration to the site of fertilization

In those patients whose infertility is unexplained after routine investigations, it is likely that there are defects of gamete transport, fertilization, or implantation. This paper describes the development of a test of sperm migration to the site of fertilization. A method of laparoscopic sperm recovery from the peritoneal cavity and fimbrial rinsings following insemination at midcycle is described. In all, 47 patients were studied, and spermatozoa were recovered in 55%. There was no difference in the success rate following artificial insemination or coital insemination. Successful sperm recovery could not be attributed to better semen quality or better timing of the procedure in the menstrual cycle. The spontaneous pregnancy rate in the positive sperm recovery group was significantly higher than in the negative group. A comparison was made between the results of the postcoital test and the results of laparoscopic sperm recovery. There was a poor correlation between the two tests. It is suggested that laparoscopic sperm recovery is useful in the investigation of and the further management of that group of patients whose infertility is unexplained.

ENDOGENOUS LUTEINIZING HORMONE SURGE IN WOMEN DURING INDUCTION OF MULTIPLE FOLLICULAR DEVELOPMENT WITH PULSATILE FOLLICLE STIMULATING HORMONE

In this study nine consecutive normally cycling women undergoing in‐vitro fertilization (IVF) were superovulated with clomiphene citrate followed by pulsatile ‘pure’FSH injected s.c. via a pump (28 IU every 3 h). All women displayed an endogenous LH surge, which was markedly attenuated in most of the cases (peak value 44·5 ± 5·9 U/l, duration 29·2 ± 1·2 h, mean ± SEM) as compared to spontaneous cycles. An increase in serum progesterone levels before the onset of the LH surge was seen in only one woman at a time when the LH values were low. During the LH surge serum progesterone levels increased significantly in all patients (12·7 ± 1·90 nmol/l vs 4·74 ± 1·57 nmol/l at the onset of the surge, mean ± SEM, P < 0·05) indicating follicular luteinization. Very high oestradiol levels in serum were found at the onset of the LH surge (7504 ± 898 pmol/1, mean ± SEM). Preovulatory oocytes were recovered from all women through a laparoscope 34–36 h after the beginning of the LH surge and embryos were replaced to them after IVF. One ongoing clinical pregnancy occurred. In contrast to results in monkeys, these results demonstrate for the first time that normally cycling women superovulated with clomiphene pulsatile ‘pure’FSH will display an endogenous LH surge. Although the surge is attenuated implantation can occur.

Characteristics of patients requesting reversal of sterilization.

With the increased number of female patients seeking sterilization and the good chance of successful reversal using modern microsurgical techniques, it can be anticipated there will be a rise in the number of patients requesting reversal of sterilization. We have studied the characteristics of 36 patients who requested reversal of sterilization at the Royal Infirmary, Edinburgh, in the last five years. The majority of patients requested reversal on the basis of a new relationship. Other reasons included sexual problems and child death. Eighteen of the patients had clear evidence of marital disharmony at the time of sterilization. Seven of the patients had been admitted to hospital with a drug overdose since being sterilized.

THE EFFECT OF LAPAROSCOPIC STERILISATION BY DIATHERMY OR SILASTIC BANDS ON POST‐OPERATIVE PAIN, MENSTRUAL SYMPTOMS AND SEXUALITY

A total of 530 patients was reviewed six months after laparoscopic sterilisation by diathermy (235 patients) or silastic bands (295 patients). In the immediate post‐operative period severe lower abdominal pain was more common in the patients who had silastic bands. There was one failure with diathermy and two with silastic bands. There were no differences in the nature or incidence of menstrual problems when the two methods were compared. In all, 40 per cent of patients reported an increase in menstrual blood loss and 26 per cent of patients an increase in menstrual pain, and this could not be attributed entirely to stopping oral contraception; 42 per cent of patients reported improvement in their sex lives after sterilisation, while 6.6 per cent reported deterioration mainly due to lack of libido. There was some regret about the operation in 5.1 per cent of patients.

Hysterectomy following sterilization

Summary. Using record linkage data derived from Scottish hospital discharge summaries, admissions to gynaecological units and hysterectomy rates have been studied following sterilization. The average annual gynaecological admission rate per 1000 women was 43·7 in the group of sterilized women and 21·5 in the control subjects. The average annual hysterectomy rate was 9·3 in the sterilized women and 2·5 in the control subjects. Although there were differences in age and pregnancy number between cases and controls, these did not account for the observed differences. This study was not able to determine whether the increase in gynaecological morbidity was due to the sterilization procedure or to the characteristics of the women sterilized.