Jack A. Goldman

Femoral neuropathy subsequent to abdominal hysterectomy. A comparative study

Abstract In a prospective study of two 5-yr periods two groups of patients undergoing pelvic operative procedures were compared. Iatrogenic femoral neuropathy occurred in 282 patients who underwent pelvic abdominal surgery in the first group of women, an overall incidence of 7.45%. The neuropathy was associated with the use of self-retaining retractors during surgery. Femoral nerve neuropathy occurred only in two patients in the second group in whom no retractors were used during operation. No other contributing factors were found. The duration of complaints ranged from 3 to 90 days. Spontaneous recovery occurred in 265 patients, while in 17 there were residual mild symptoms for up to 116 days. No serious sequelae have been observed. Prevention of this mostly mild yet annoying syndrome may be achieved if no retractors are used in gynecological operations, or, if they are necessary, due to difficult conditions at surgery or if the operation is long, they should be used with care and loosened from time to time. It is estimated that the incidence of iatrogenic femoral nerve neuropathy is higher than reported, since in very mild cases the patient fails to mention her complaints. The prognosis is usually rather good.

Ovarian cyst formation: a complication of gonadotropin-releasing hormone agonist therapy.

Since gonadotropin-releasing hormone (GnRH) analogs were introduced into clinical therapeutic use, several side effects directly related to the hypoestrogenic state have been reported. The authors have encountered a rather infrequent complication, namely ovarian cystic formations, when using these compounds for selected in vitro fertilization and embryo transfer (IVF-ET) cases. In 7 of 24 patients with Decapeptyl (D-Trp6-luteinizing hormone-releasing hormone [LH-RH], Ferring, Kiel, FRG) treatment, and in 5 of 22 patients treated with Buserelin (Superfact, Hoechst A.G., Frankfurt, FRG), solitary ovarian cysts developed during the down-regulation phase. Their growth did not change during ovulation induction with menotropins. Although the mechanism of ovarian cyst formation during GnRH agonist treatment is not clear, their presence does not appear to interfere with the fertility of these women.

Transvaginal ultrasonic needle-guided aspiration of endometriotic cysts before ovulation induction for in vitro fertilization

Controversy still exists concerning the optimal treatment of endometriomata in endometriosis and its related infertility. Forty-one women with endometriomata who failed to conceive during previous in vitro fertilization and embryo transfer (IVF-ET) cycles (protocol A) were readmitted for ovum pickup following transvaginal ultrasonic needle-guided aspiration of the endometriomata (protocol B). Following aspiration a significantly higher number of oocytes was recovered (P<0.0006); subsequently, more embryos were transferred, and significantly higher clinical pregnancy rates per cycle (P<0.0001) were achieved. This difference may be directly related to the reduction of extensive ectopic endometrial tissue (endometriomata) with improved ovarian response, follicular accessibility, and most probably, improved oocyte quality.

Age and pregnancy rates in in vitro fertilization

The influence of women[s age on the results of in vitro fertilization (IVF) was analyzed in 1801 women undergoing the procedure. Advancing age was found to be related to significant reduced success rates from an average of 30.1% per transfer below the age of 36 years to 15.9% per transfer at 37 years or more (P<0.001). The decrease was related to a reduction in oocyte production (five at 25 years or less, four below the age of 40 years, three at 40 years or more, and two in the 43 to 47-year group) and probably-due to reduced implantation. It is concluded that a womans age must be considered an important prognostic factor when IVF is suggested.

The value of hysteroscopy in elderly women prior to in vitro fertilization-embryo transfer (IVF-ET): A comparative study

Two hundred eighty-four hysteroscopies were performed in 312 (91%) candidates for in vitro fertilization and embryo transfer (IVF-ET) who were divided into two groups. Group I consisted of elderly women over 40 years, and group II of women below this age. Although visualization revealed uterine abnormalities in 29.9% of all patients, abnormal findings were significantly increased in the former group in comparison to the latter (P<0.001). This difference was attributed mainly to uterine rather than cervical pathology. Furthermore, in elderly women agerelated uterine pathology such as submucous myomata, endometrial hyperplasia, and polyps were more prominent, while in younger patients other uterine lesions such as adhesions and tubal ostia occlusion were more common. Moreover, treatment prior to IVF-ET resulted in 7 clinical pregnancies (8.9%) in group I and in 41 clinical pregnancies (19.9%) in group II, all of which failed in one to three cycles previously. It seems that hysteroscopic evaluation may reduce the IVF-ET failure rate due to intrauterine abnormalities in elderly as well as young patients, thus it becomes an absolute prerequisite for all patients scheduled for an IVF program.

Intrapartum Management of Insulin-Dependent Diabetes Mellitus (IDDM) Gestants: A comparative study of constant intravenous insulin infusion and continuous subcutaneous insulin infusion pump (CSIIP)

Two groups of insulin-dependent diabetes mellitus (IDDM) parturients were managed according to different intrapartum protocols and compared with a control group of normal women in labor. Thirty-seven patients received conventional intensified insulin therapy during pregnancy and intravenous continuous insulin infusion during labor. Twenty-eight women were managed by continuous subcutaneous insulin infusion pump (CSIIP) throughout gestation and this therapeutic approach was continued during labor. When the two glucose control techniques were compared, CSIIP was superior to achieving and maintaining intrapartum optimal metabolic control, reducing significantly the incidence of acute fetal distress, thus lowering the cesarean section rate and neonatal hypoglycemia. Consequently we concur with the recommendation that firm prepartum as well as intrapartum diabetic control is mandatory for successful management of labor in IDDM patients.

Abdominal complications following ultrasonically guided percutaneous transvesical collection of oocytes for in vitro fertilization

Ultrasonically guided transvesical oocyte aspiration is a safe and efficient method in most in vitro fertilization (IVF) units. It entails very rare severe complications, even though transvesical punctures performed may unintentionally pierce the bowel or even major blood vessels. Nevertheless, mild complications are rarely noted and reported. During a 9-month period 140 ovum pickups were performed: 102 by transabdominal ultrasound-guided puncture and 38 by means of laparoscopy. In the former group, abdominal pain (11.6%), exacerbation of previous pelvic inflammatory disease (2.9%), mild hemoperitoneum (2.9%), urinary tract infections (5.8%) and transient macroscopic hematuria (5.8%) occurred following the procedure. In the latter group, abdominal pain followed in 7.8%; no urinary tract complications were noted in women undergoing laparoscopic ovum aspiration. In spite of the fact that ultrasonically guided transvesical oocyte collection is an atraumatic method with rare complications, they should be reported in order to draw attention to their not-so-rare occurrence and with the aim of their prevention.

The impact of embryo quality on pregnancy outcome in elderly women undergoing in vitro fertilization-embryo transfer (IVF-ET)

Most IVF-ET units limit the procedure to women below age 38. Nevertheless, demands for infertility treatment, including IVF therapy, are more frequent nowadays. We compared 46 cycles for ovulation induction for IVF in 46 women aged 40 or more (Group I) to 51 induced cycles for this procedure in younger women of mean age 30.2 years (Group II). Cancellation rates due to early luteinization or ovulation were significantly higher in group I than in group II (28.2 and 17.6%, respectively) (P<0.001). Also, significantly higher abortion rates were observed in older women (62.5%), in comparison to the younger control group, (25%), (P<0.001). It is suggested that the high abortion rate considered to be due to genetic factors in older women, may possibly also be due to the aging uterine environment. Furthermore, while embryos with fragmentations may often produce clinical pregnancies in the young, the aging uterus in the elderly woman does not encourage the development of clinical pregnancies in such embryos. Consequently the higher abortion rate in the elderly woman.

Very early pregnancy wastage in in vitro fertilization and embryo transfer (IVF-ET)

The occurrence and incidence of early pregnancy wastage in an in vitro fertilization and embryo transfer (IVF-ET) program have been studied in 750 patients. In 297 (39.6%) a pregnancy was diagnosed; of these, 14.8% were biochemical and 24.8%, clinical pregnancies. In the latter group 23.6% aborted, while 75.8% had clinical ongoing pregnancies. The mean embryo quality score of the biochemical pregnancy group was similar to that of the clinical ongoing pregnancy group but statistically different from that of the clinical abortion group (P<0.005). Furthermore, the clinical ongoing pregnancy rate in women with previous biochemical pregnancy was 24.7%, a significantly higher percentage compared to clinical ongoing pregnancies achieved in IVF-ET cycles (P<0.05). It is possible that biochemical pregnancy does not represent an index for infertility but rather an intact stage of reproduction leading toward implantation. The high clinical pregnancy rate in subsequent cycles may probably serve as an encouraging sign or a marker for future clinical pregnancy.

The impact of spermatic vein ligation on the male factor in in vitro fertilization-embryo transfer and its relation to testosterone levels before and after operation

Criteria for improved semen quality after varicocele operations are not clear, as they do not express sperm fertilization capacity, its most important qualification. Twenty-two couples, 12 with mechanical female infertility (group I) and 10 with normal female fertility (group II), in whom the husband had subfertile semen in the presence of varicocele, and who had failed preoperative in vitro fertilization-embryo transfer (IVF-ET) attempts, were readmitted for the IVF-ET procedure following the repair of varicocele. In group I, a 20% pregnancy rate was achieved after the operation, while no pregnancies occurred before surgery. In group II, four pregnancies (40%) were achieved after operation. Plasma testosterone (T) levels demonstrated a significant increase in 50% of the patients in both groups after surgery, resulting in a concurrent improved fertilization, cleavage, and pregnancy rates.