Maria Matheus de Sala

Effect of Inseminated Volume on Intrauterine Insemination

AbstractPurpose: Intrauterine insemination (IUI) is a method for the treatment of marital infertility involving the intrauterine or fallopian deposition of washed spermatozoa, depending on the amount of inseminated semen. In view of the divergent opinions about the inseminated volume, the objective of this study was to compare the two techniques (3.0 mL or 0.5 mL) in two groups of patients. Methods: We performed 164 cycles of ovulation induction followed by IUI. The patients were divided into two groups according to the technique used. Group low volume – 50 cycles and 0.5 mL of inseminated semen; Group high volume – 114 cycles and 3.0 mL of inseminated semen. The cycle was monitored on the basis of endometrial thickness and follicular development measured by transvaginal ultrasound. Human chorionic gonadotrophin (hCG) was administered in the presence of a follicle measuring 18 mm in mean diameter. The procedure was performed after sperm washing using a discontinuous PureSperm® gradient, 40 h later. Results: We obtained a similar clinical pregnancy rate for the two groups (14.0% for Group low volume and 15.7% for Group high volume). There was one abortion in each group. We detected no interference by any etiology of infertility or by the total motile recovered sperm with pregnancy rate. Conclusions: The results did not demonstrate superiority of one method over the other, with both therapeutic alternatives being satisfactory for the treatment of infertile couples.

A New Method for Sampling Maternal Blood in the Placental Intervillous Space

The intervillous space (IVS) is part of the histofunctional unit of the human placenta and by being a fetal-maternal exchange interface is an important subject of study for the understanding of fetal physiology, especially in nutritional investigations. A method developed for the collection of IVS blood has permitted to evaluate the fetal-maternal exchanges in an effective manner. Two disadvantages of this method, however, are the mixing of IVS blood and fetal blood and marked hemolysis. In the present study we introduce and describe some modifications of this method using a single stylet for the perforation of the chorionic plate which simplifies collection and reduces the chance of mixing and hemolysis of the samples obtained.

Prospective evaluation of renal artery resistance and pulsatility indices in normal pregnant women.

To establish normal values for renal artery resistance index (RI) and pulsatility index (PI) during gestation and, by comparison with non‐pregnant controls, to determine if pregnancy affects these indices.

Avaliação do Tratamento Clínico da Endometriose

Objetivo: o objetivo do presente trabalho e apresentar um perfil das pacientes com endometriose, estadio e resultados do tratamento entre as pacientes atendidas no nosso Servico. Metodos: foram revistos 155 prontuarios medicos de pacientes portadoras de endometriose atendidas no periodo de 1991 a 1996 segundo um protocolo preestabelecido. Resultados: a media de idade das pacientes foi de 31 anos, sendo que a maioria era branca e com ciclos menstruais regulares. Os sintomas mais observados foram a dismenorreia, dor pelvica e infertilidade, sendo esses sinais e sintomas de grau leve na maioria dos casos. Os metodos diagnosticos utilizados foram a laparoscopia ou ultra-sonografia. Houve concordância entre a ultra-sonografia e a laparoscopia em 96% das vezes. Em 28% dos casos houve necessidade de realizacao de laparotomia para elucidacao diagnostica e/ou tratamento. O achado de endometrioma ocorreu em 37% das vezes e em apenas 74% das biopsias das lesoes houve a confirmacao de endometriose pelo estudo anatomopatologico. Houve melhora significativa com o tratamento clinico independente da droga utilizada, com melhora dos sintomas em cerca de 50% delas. Foram realizadas tecnicas de fertilizacao assistida em 34 pacientes, das quais 80% foram fertilizacao in vitro (FIV), com taxa de 27% de gravidez/paciente. Conclusoes: o metodo diagnostico de escolha deve ser a laparoscopia, embora a ultra-sonografia apresente um alto indice de concordância. O estudo anatomopatologico das lesoes deve ser utilizado como metodo auxiliar no diagnostico, pois ele nao e positivo em todos os casos. O tratamento clinico com reproducao assistida e uma boa opcao terapeutica, principalmente com o uso de FIV.

Avaliação da Cavidade Uterina: Estudo Comparativo entre Histerografia, Histerossonografia e Histeroscopia

Purpose: to compare the methods used to investigate the endouterine cavity by testing the sensitivity and specificity of X-ray hysterography and sonohysterography compared with hysteroscopy (gold standard). Methods: we carried out a prospective study with 18 patients who, due to symptoms such as irregular menstrual cycles, unexplained postmenopausal uterine bleeding and ultrasound disturbance, were candidates for uterine cavity investigation by X-ray hysterography, sonohysterography and hysteroscopy. Results: sonohysterography sensitivity and specificity were 90 and 87.5%, respectively. Positive and negative predictive values were 90 and 87.5%. For X-ray hysterography, sensitivity, specificity, positive and negative predictive values were 70, 75, 77.7 and 75%, respectively. Conclusion: the use of saline instilation into the endometrial cavity in order to enhance the acuracy of the vaginal ultrasonography seems reliable as a mean to distinguish lesions in the uterine cavity, thereby facilitating the identification of candidates for diagnostic or operative hysteroscopy. X-ray hysterography produces results inferior to hysterosonography.

Avaliação da Reserva Ovariana: Comparação entre a Dosagem do FSH Basal e o Teste do Clomifeno

Purpose: to assess ovarian reserve by FSH determination on the 3rd day of the menstrual cycle compared to the clomiphene test and to correlate the results with the ovarian response to controlled hyperstimulation with gonadotrophins for in vitro fertilization. Methods: a total of 49 patients older than 30 years who had been presenting a clinical picture of infertility for at least 1 year were selected. All patients were evaluated for ovarian reserve by the clomiphene citrate test and 26 of them were later submitted to controlled ovarian hyperstimulation with gonadotrophins. Of these 26 patients, 18 showed a good response to ovarian hyperstimulation and 8 showed a poor response. Mean (+ SD) FSH values were calculated for the determinations on the 3rd and on the 10th day and for their sum in the group of patients who responded favorably to ovarian stimulation, and were later correlated with the ovarian response after gonadotrophin stimulation. Results: employing a FSH value > 16.1 IU/mL on the 10th day (mean plus 2 SD) for the prediction of a poor ovarian response in the clomiphene test, the sensitivity, specificity, and positive and negative predictive values of this parameter were 50, 100, 100 and 81.8%, respectively. Considering the clomiphene test to be positive when the sum of the FSH values determined on the 3rd and 10th day plus 2 SD was > 22.6 IU/mL, we obtained 62.5% sensitivity 100% specificity, 100% positive predictive value, and 85.7% negative predictive value. A single FSH determination of 10 IU/mL on the 3rd day of the cycle for the prediction of a poor ovarian response showed 87% sensitivity, 100% specificity, 100% positive predictive value and 94.7% negative predictive value. Conclusion: in the present study, a single FSH determination on the 3rd day of the cycle showed to be more sensitive than the clomiphene test for the evaluation of ovarian reserve.

Tumor placentário diagnosticado durante a gravidez: relato de caso

The most frequently nontrophoblastic tumor of the placenta found is chorioangioma, with an incidence of about 1%. When they are small, they do not significantly affect the fetus, but the large ones can cause intrauterine growth restriction, polyhydramnios, premature delivery, congestive heart failure and fetal death. The authors report a case of chorioangioma in a 28-year-old woman, second gestation, whose diagnosis was established at the 32nd week by ultrasound and confirmed by the anatomopathological examination. Ultrasonography evaluations showed chronic fetal distress and the delivery was performed at 36 weeks. The newborn results were satisfactory with Apgar 9-10 and fetal weight 2.460 g.

Tumores pélvicos em mulheres na pós-menopausa

Purpose: to evaluate clinical and ultrasonic findings in patients with pelvic tumors at postmenopause and to correlate them with the final diagnosis. Patients and Methods: thirty-six postmenopausal women with pelvic tumor diagnosis were prospectively evaluated through clinical examination and endovaginal ultrasonography. Clinical follow-up with no surgical procedures was indicated for anechoic cystic tumors with or without thin unique septation and volume under 50 cm3. Needle aspiration was indicated for tumors with the same aspect, and volume of 50 to 100 cm3, whereas exploratory laparotomy was performed in the remaining patients. Diagnosis defined two groups of patients: benign (28) and malignant (8) pathologies. Results: anechoic cystic tumor with or without a thin septum indicates benignity (p = 0.0091). Tumors with solid areas indicate malignancy (p = 0.0024). Ascites correlates with malignancy (p = 0.0278). Heterogeneity, thick capsule, thick septa, and papillary projections predominated in malignancies but without no statistical significance (p > 0,05). Tumor volume indicates malignancy, with a median of 85.2 cm3 in benign tumors and 452.5 cm3 in malignancies (p = 0.0048), with a cutoff at 295 cm3 (sensitivity = 83.3% and specificity = 85.2%). Following this protocol, all malignancies were submitted to surgery and 11 benign tumor patients were treated with a conservative protocol (39.3% of all benign patients). Conclusion: conservative management is an adequate protocol for women with anechoic pelvic tumors with low volume, with or without single thin septum and without ascites. Differentiation between benign and malignant of complex and/or high volume tumors requires complementary investigation.

Uso da bromocriptina associado a hiperestimulação ovariana controlada em pacientes más respondedoras

OBJECTIVE: to assess the ovarian response of poor responsive patients, submitted to the bromocriptine method. PACIENTS AND METHODS: a prospective clinical trial for the in vitro fertilization (IVF) program was performed in 10 poor responsive patients. Endocrinologically normal ovulatory women under 38 years old, who had previously failed in IVF due to poor response to ovarian stimulation with the traditional protocol, were submitted to the bromocriptine method in 12 cycles. They were given bromocriptine, a dopaminergic agonist, in the preceding cycle in order to stop the prolactin production. When the medication was removed at the beginning of the stimulation cycle, an elevation of seric prolactin by a rebound phenomenon was found. This optimized its seric concentration, improving the quality of oocytes and embryos. Serum prolactin and estradiol concentrations, number of follicles, number and quality of oocytes and cleaved embryos, fertilization and pregnancy rates were analyzed. RESULTS: there was a reduction in the dose of gonadotropin administered and in the duration of ovarian stimulation and an improvement in follicular recruitment, oocyte retrieval, embryo morphology, fertilization, and ongoing pregnancy rates. Fertilization rate was 77.7%, pregnancy rate was 44.4% and live baby rate was 25%. CONCLUSION: this study suggests that the bromocriptine method enhanced follicular recruitment and embryonic development, resulting in increased fertilization and pregnancy rates when compared with the traditional protocol for poor responsive patients. Studies with a large number of patients are necessary to confirm these results.

Comparação entre três escores embrionários como fator prognóstico do sucesso em fertilização in vitro

PURPOSE: to evaluate three embryo scoring systems specific for 3-day embryos and to correlate them with positive in vitro fertilization outcome. METHOD: retrospective study of the In Vitro Fertilization Program of the University Hospital, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo. A total of 137 patients submitted to the transfer of 439 embryos were evaluated. The main outcomes measured were pregnancy and implantation rates. RESULTS: a significant difference in the three scoring systems was observed between pregnant (n=53) and non-pregnant (n=84) patients (p<0.0001). In the first embryo scoring system, in which cell number alone was used, higher pregnancy (70%) and implantation rates (42%) were observed when embryos with a mean blastomere number higher than 8 were transferred. Scoring system 2, based on a total four-point score (cleavage stage, blastomere number, fragmentation and symmetry), showed increased pregnancy (52.8%) and implantation rates (31%) for scores above 2. Scoring system 3, based on cell number and morphological criteria, also showed higher pregnancy and implantation rates with increasing average scores of the transferred embryos. CONCLUSION: the three scoring systems assessed in 3-day embryos were positively correlated with pregnancy and implantation rates.